Improving surgical results: Three low-tech approaches

Even in our competitive globalized economy, America has retained its leadership in biomedical research and medical innovation. Although it takes years for basic research to be translated into clinical advances, patients are already benefiting from many new diagnostic tests, genetically engineered drugs, and medical devices that would have been considered fantastic just a few years ago.

Like other areas of medicine, advances in surgery are often driven by technology; laparoscopic hernia repairs and robot-assisted radical prostatectomies are just two of many examples.

Despite these major gains, we need more progress. American medicine is the best in the world, but American health lags behind some less advanced countries in important areas ranging from infant mortality to life expectancy. Technology alone can't close the gap, and innovative technology is often extremely expensive. The public must do more to prevent disease through lifestyle changes, ranging from smoking cessation to diet and exercise. And it's refreshing to see that doctors are developing some low-tech, low-cost ways to improve care. Three of these developments promise to improve surgery by using simple interventions before, during, and after operations.

Warming up

Walk into a concert hall before the program begins, and you'll see musicians playing scales and running through difficult passages. Walk into a stadium before the game starts, and you'll see athletes stretching, jogging, and practicing their skills before competition begins. But walk into a surgeon's lounge, and you're likely to see doctors catching up on paperwork and phone calls before they scrub for surgery.

Research may change that. Scientists in Arizona and Washington studied 46 surgeons with varying levels of experience. Some of the doctors were asked to perform warm-up exercises that mimicked the motions used in minimally invasive surgery before being tested on surgical simulators, while others were tested without warming up. The warm-up exercises appeared to improve both manual dexterity and mental focus. In addition to improving performance on tasks that were similar to the warm-ups themselves, the exercises improved performance on unrelated surgical tasks. Both surgical residents and more experienced staff surgeons benefited from warm-up exercises; doctors who were fatigued from a night on call and those who were starting fresh improved to a similar degree.

The researchers concluded that short-term preoperative warm-up exercises can improve both surgical proficiency and cognitive arousal (mental concentration). It's a logical interpretation of the results, but more research and experience will be needed to learn if warm-ups before real operations will improve surgical performance. Still, because surgery is so demanding and the stakes are so high, surgeons might be wise to develop warm-up routines even before new results are available.

Checking it off

Talk to an airline crew before they board a jetliner, and you'll learn that they go through an elaborate checklist prior to passengers buckling in. It's been a fact of life in the aviation trade for decades, and its role in safety seems obvious. Obvious or not, checklists are newcomers in the operating room; they have found a champion in Harvard Medical School's Dr. Atul Gawande, and they are already paying off in improved patient safety.

In 2005, the World Health Organization (WHO) launched the Safe Surgery Saves Lives campaign. The program includes a checklist designed to ensure that all members of the surgical team share full understanding of the patient, the planned operation, and the steps that can reduce errors and complications.

The checklist contains 19 items divided into three stages. The sign-in phase occurs before anesthesia is administered; key elements include verifying the patient's name and drug allergies, the body part to be operated on, and the availability of properly functioning equipment and adequate supplies. The time-out phase occurs during a mandatory pause before the first incision is made. Each member of the surgical team confirms his or her name and role, and the lead doctors and nurses review essential elements of the procedure. Finally, during the sign-out phase before the patient leaves the operating room, the responsible surgeon, nurse, and anesthesiologist review essential details of the operation and key elements of the postoperative care. During each stage of the checklist, all items are verified aloud and confirmed by each member of the team.

It's a logical plan, but does it work? To find out, researchers compared the clinical outcomes of 3,955 adult patients whose operations used the checklist with 3,733 patients whose operations did not. The operations were performed in eight cities around the world in hospitals with a wide range of economic circumstances and technical sophistication. Despite this diversity, the checklist was highly effective, reducing deaths by 47% (from 1.5% to 0.8%) and in-hospital complications by 36% (from 11% to 7%). Similar results were obtained in a subsequent study of six hospitals in the Netherlands.

The WHO estimates that surgical complications result in about 500,000 preventable deaths worldwide each year. This simple surgical checklist is an important step in reducing that number.

Airing out

Read about the early days of battlefield medicine, and you'll learn about Florence Nightingale's heroic efforts to improve care through sanitation, hygiene, and fresh air. "It is the unqualified result of all my experience with the sick," she wrote, "that second only to their need for fresh air, is their need of light." Surgical care has improved enormously over the past 150 years, and research is shedding light on the possibility that supplementary oxygen may help prevent surgical wound infections.

Postoperative infections of the surgical incision are common. About 5% of all operations are complicated by wound infections, but since the colon and rectum are teeming with bacteria, as many as 10% to 20% of colorectal operations result in infections. It's a serious problem because these complications double the length of hospitalizations and the risk of postoperative death. Surgical wound infections are also expensive, draining the U.S. economy of about $1.8 billion a year.

Although Nurse Nightingale didn't know a thing about how oxygen-free radicals kill bacteria or how oxygen helps the body's immune cells polish off germs, she seemed to understand that oxygen helps fight infection. And in 2000, doctors in Austria and Germany tested the theory that supplementary oxygen could help prevent wound infections following colorectal surgery. Five hundred patients volunteered for the study; all received the standard treatments that prevent infection. Half the patients breathed 30% oxygen during their operations and for two hours afterward, and the other half breathed 80% oxygen for the same period of time. The extra oxygen worked, cutting the postoperative infection rate from 11.2% to 5.2%.

A 2005 study of 300 Spanish colorectal surgery patients reported similar benefits for supplementary oxygen, and a 2009 meta-analysis of trials involving over 3,000 patients linked supplementary oxygen to a 25% reduction in infections. However, a 2009 Danish study of patients undergoing a variety of operations did not find any benefit from oxygen therapy. None of the trials reported any adverse effects of high-dose oxygen, and since the therapy was usually administered in the operating room or recovery suite, extra cost was low.

A brief course of high-dose oxygen therapy won't solve the problem of surgical wound infections, but it may help. And if it becomes part of standard care, it will take its place alongside other methods of proven benefit. These include bowel cleansing in preparation for colorectal surgery, clipping rather than shaving hair from the incision site, cleansing the skin with a chlorhexidine-alcohol antiseptic scrub rather than the standard povidone-iodine antiseptic before the incision, administering a preventive antibiotic at the time of surgery, and keeping the patient's body temperature up to normal during and after surgery.

Like supplementary high-dose oxygen, all of these steps are simple and inexpensive — and they work. Add surgical warm-up exercises and surgical checklists, and doctors will have a thoroughly modern, thoroughly low-tech way to improve surgical results.