Patient Case Study Enhancing Intraoperative Intervention

In this care study, the intraoperative journey of a fictitious patient will be critically analysed, and a panoramic view of patient care will be facilitated by values of the National Health Service and enhance a holistic approach. The use of a fictitious patient allows maintenance of confidentiality in line with professional’s standards (College of Operating Department Practitioners, 2009). For clarity and to enhance structure the fictitious patient shall be referred to as Mrs Bird.

Mrs Bird is a 45-year-old female who has been experiencing abdominal cramps and heavy bleeding. She visited her GP presenting her symptoms which were consistent episodes of urinary, abdominal distention, chronic lower back pain and dyspareunia. Her GP prescribed her some non-steroidal anti-inflammatory drugs to relieve the cramps and bleeding, however even with taking the medication she was constantly in pain and bleeding. Her GP made an appointment for her to go visit a gynaecologist for further examination. An examination was conducted on her pelvis and a uterine mass was found, following this discovery a son-hysterography was performed and the diagnosis of uterine fibroids was confirmed. Uterine fibroids are benign tumours of the smooth muscle of the uterus, they grow under the influence of the hormone oestrogen and most often seen after the first menstrual cycle and tend to shrink after menopause. Fibroids are very common in Afro-Caribbean women and they can cause severe complications such as difficulty in getting pregnant and risk of miscarriage or premature delivery (Royal College of Obstetricians and Gynaecologists, 2016).

Uterine fibroids can be treated using different approaches such as hysterectomy, conservative surgical therapy, anti-hormonal agents, uterine artery embolization and anti-inflammatory painkillers (NHS, 2018). The treatment approach will be determined by the healthcare professionals based on the individual overall health, medical history, and extent of the disease, tolerance of specific medications, opinion or preferences (NHS,2018). After a thorough discussion between Mrs Bird and the gynaecologist it was agreed that abdominal hysterectomy will be performed and this was due to the size of the uterine fibroid, however according to The National Institute for Health and Clinical Excellence (NICE) (2007) abdominal hysterectomy should be considered as a last option for fibroids and that woman should be told about other surgical treatments such as laparoscopic and vaginal hysterectomy. The American College of Obstetricians and Gynaecologists (2016) supports this by recommending vaginal hysterectomy as the first choice when possible because of its advantages such as less intraoperative blood loss, less postoperative pain, shorter hospital stays, rapid recovery and less complications compared to abdominal approach which is associated with longer hospital stay, increased risk of infection, greater pain and longer recovery, however some laparoscopists argued that laparoscopy should be used for the preceding indications (Garry et al, 2004 & McPherson et al, 2004).

It is stated by The American College of Obstetricians and Gynaecologists (2016) there are factors such as the size and shape of the uterus and vagina, accessibility of the vaginal passage, available hospital resources and the surgeons training and experience which may influence the route of the hysterectomy. Hence, abdominal hysterectomy is mostly performed if the fibroid is large, if there is insufficient access to the vagina or there are any suspected diseases outside the uterus (Reich, 2007). The uterus is a female reproductive organ that lies in the middle of the body within the pelvis between the bladder and rectum. It is responsible for several reproductive functions including implantation, gestation, labor and delivery. The uterus reacts to the hormonal milieu within the body and allows adaption to the different stages of a woman, reproductive life (NHS, 2015).  It also reflects changes in ovarian steroid production during menstrual cycle displaying rapid growth, activity during pregnancy and child birth (NHS, 2015).  The size of an ovary depends on a woman’s age and hormonal status (NHS,2015). After hysterectomy surgery, bleeding from the vagina is normal and usually lasts for a few weeks, periods will stop leading to surgical sterility after total hysterectomy (NHS, 2015). Hysterectomy is a major procedure and is associated with physiological and psychological changes in a woman’s life, women will no longer menstruate and not being able to conceive.   Although Mrs Bird had stated that she will not have no children in future, she was worried about how the procedure would affect her sexual life, however, according to Lonnee-Hoffmann and Pinas (2014) hysterectomy does not necessarily change a women’s sexuality, but some women may find they have a lack of sexual desire caused by anxiety, fatigue and fear of pain. Emotional effects vary from person to person some women may feel better because they will no longer experience pain, bleeding or fear of cancer, although some may feel sad because of loss of menstrual cycle or their inability to bear children (NHS, 2016)

Every person who must undergo any major surgery needs a careful and detailed pre-operative assessment (Johnson and Porter, 2008). According to the National Institute for Health and Clinical Excellence (2003) elective patients attend a pre-admission clinic which will involve a medical history, a nursing assessment, the provision of written or verbal information and medical tests. Adult patients undergoing elective surgery are required to have some relevant tests done such as x-rays, electrocardiograms, full blood count, kidney and lung functions tests (NICE, 2016).  By performing these tests, healthcare professionals will be able to recognise patients who are high risk, arrange necessary investigations, assess patient’s fitness for treatment and implement procedures for fasting and administration of medicines (Association of Anaesthetists of Great Britain and Ireland, 2010). During preoperative assessment the patient’s care pathway must be completed, this allows any problems that may influence the result of the surgery to be resolved and to avoid long hospital stay for the patients (Royal College of Anaesthetists, 2018). Jenkins and Burch (2012) support the aim of the carefully planned care by also stating that it reduces risks and complications for the patient. During the preoperative assessment phase, consent for treatment is discussed with the patient, it is vital that the patient understands the information given about the surgery, its risks and the care involved before he or she gives consent (The Royal College of Surgeons of England, 2016). For consent to be legally valid, it must be competent, voluntary and informed (Corfield and Pomeroy, 2008). In some circumstances where an adult is incapacitated to understand the consent process, such as patients with a brain injury, dementia or learning disabilities they may require a surrogate or proxy decision maker (Bernat and Peterson, 2006).  Children who are under the age 16 years will have their parents or legal guardians make the decision for them, however some children who may achieve enough understanding of the intervention proposed are deemed as Gillick competent meaning they can give consent (Royal College of Nursing, 2017). Although they can give consent, The British Medical Association opposed by stating that their parent or legal guardians can sometimes overturn the child’s decision for certain reasons, for instance family values, preferences, expectations and beliefs plays a big role in decision-making. However, Department of Health (2004) stated that consent cannot be overridden by the parents or legal guardians, but the courts can override the decision.

During intraoperative phase standards of care must be sustained, patients should be treated fairly and as individuals ensuring that their needs are met. Older patients are often substantially different from those of younger patients, it is evident that the elderly patients are much more at risk of morbidity and mortality after surgeries compared to younger patients (AAGBI, 2013). Older patients and younger adult patients should be treated with the same level of dignity and care, however when caring for the elderly patient’s additional time maybe required during preparation of surgery (AAGBI, 2013). Children should receive care that is integrated and co-ordinated around their needs and the needs of the family. Children are usually accompanied by parents and play therapists as they help to distract them (Pritchard, 2009). Some patients have learning disabilities or mental health issues, and some may find new environments stressful, so it preferable if the person with them is familiar (Pritchard, 2009). Before Mrs Bird was taken to theatre, the surgeon visited her in the day surgery unit to ensure that she had arrived and ready for surgery. The visit from the surgeon can minimise anxiety, reinforce emotional support and reassures the patient and family members.  Back in the operating room a team brief was carried out, briefing and debriefing is a procedure which is carried out before and at the end of operating list, it enables the surgical team members to communicate, collaborate and identify potential hazards during surgery (NPSA, 2011). The process promotes patient safety by allowing team members to reflect on themselves and their work using immediate feedback (Royal College of Surgeons, 2017)). Team members start by introducing themselves and their job roles, staffing issues, changes to the list, equipment and instrumentation are communicated and time for the list if confirmed. It is recommended by NPSA (2009) for all members of the surgical team to be present during briefing as this ensures a shared understanding and preparation for anticipated problems.  According to Makary et al (2006) most incidents that occur in the health sector are through communication breakdown between healthcare professionals due to unclear understanding of the plan and what is expected of them.

The roles and responsibilities of the operating room are diverse, members of the surgical team have different levels of qualifications and experience. The surgeon is usually the head of the team who is responsible for the intervention and performs the actual surgery who can have assistants working under their instructions and supervision (RCS, 2018). The role of the scrub practitioner can be undertaken by a qualified nurse or ODP with responsibilities to prepare the instruments and equipment for surgeons and to be aware of the surgeon’s preferences during the procedures, however the qualified scrub practitioner can also undertake the role of being a circulating practitioner together with an operating room support worker (AORN, 2012).Circulating practitioner role is important as they help and support the scrub practitioner by preparing the theatre , ensuring the operating room environment is clean and tidy and stock the operating room after operative list (AORN, 2012). The anesthesiologist role is vital as one their responsibilities are to assess a patient’s medical readiness for surgery, however during intraoperative phase they are responsible for medical management and anesthetic care of the patient throughout the surgery (AAGBI, 2005). Sometimes, student ODP’s, student nurses and medical students are present in the operating room, they usually work alongside a qualified practitioner or their appointed mentors. Students work within their limitations under the supervision of their mentors as it is required of them by the professional body they will be registered with upon completion of their training. In 2003, a non-medical perioperative practitioner role working as the surgeon first assistant was redefined to that of the advanced scrub practitioner (PCC,2007). /The roles of the advanced practitioners are now well recognised and widely used within operating theatres and it is undertaken by a healthcare practitioner who is evidently competent and skilled to aid the surgeon while not performing surgical intervention (PCC, 2007). This role has evolved over the years however, it is vital that the practitioner remains accountable for his or her actions while undertaking this role and must act lawfully (NMC 2008, HPC 2008). It has been reported that practitioners are being pressured to undertake the role of the surgical first assistant and being expected to perform the role of the scrub practitioner at the same time (AFPP, 2014). The law states that whoever provides care is responsible for the care given and Dimond (2011) also states that it is the duty of the healthcare practitioner to refuse to undertake the role of a surgical assistant and scrub practitioner to ensure patient safety by adhering to the laws and regulations set by professional bodies which has the power to maintain their registration or remove them.

#It is acceptable for a scrub practitioner to undertake dual role nonetheless, they cannot perform the role of a scrub practitioner and SFA at the same time (HPC, 2004). The law states that every healthcare practitioner is accountable and responsible to undertake a role or task and answer to an individual or body regarding its undertaking (HPC, 2008). The aim of professional accountability is to maintain standards of practice, prevent inappropriate practice to ensure public safety (RCN, 2008). The PCC (2012) guidelines states that if an employer considers that a dual role is required, the decision should be endorsed by a policy that fully supports this practice. Practitioners undertaking the dual role may require knowing the legal and ethical implications of the dual role before undertaking it (Royal College of Surgeons of England, 2011). At present, the Bolam Test is the standard of care to which the practitioner would be measured against if their role is questioned. The Bolam Test was established in the case of Bolam v Friern hospital Management Committee (1955), (2015) and the case of Wilsher v Essex (1988), 92013) which established how the clinical responsibility of the practitioners concerned would be determined and how practitioners may find that they would be measured against such findings.

After the briefing was completed the patient was sent for to come to the operating theatre, at this point all necessary information about the patient had been discussed such as any known allergies, additional equipment required, any other health problems that will implicate the surgical procedure and postoperative management. While waiting for the patient, the scrub practitioner performed handwashing which is done prior to commencing any surgical or invasive procedures (WHO, 2009). Hands are washed according to the hand washing policy and the infection control practice in the operating department policy. According to Pratt et al (2007) effectiveness hand hygiene reduces the potential carriage of pathogens on the hands and prevents infection that can compromise the patient safety. Management of items used during a surgical procedure is one of the core roles of the scrub practitioner (AFPP, 2007), therefore instrument count was done by the scrub practitioner and the circulator following the policy of recording and documentation. It is stated by the AFPP (2011) that it is the responsibility of the scrub practitioner to do the count with another member of the surgical team and the count must be audible to the other team members to decrease the risk of incorrect count. Counting and recording of surgical instruments is done in order to avoid retaining of items in the patient’s wound as it is a potential source of infection and potential psychological damage to the patient as the patient may require undergoing more surgery (WHO, 2009). The errors in managing surgical items may result in litigation leading the patient to claim that the surgical team was negligent in its duties and may sue the hospital (Woodhead 2005, WHO 2009).

The patient was brought into the operating room, she was transferred from the trolley onto the operating table by five members of staff, two on each side and the anaesthetist supporting the head. When positioning a patient safe principal must be applied and taking in consideration of unconscious patients, physiological effects, surgical and anesthetic related factors (Goodman, 2012). If the patient is positioned poorly, patient’s health may be implicated causing injuries which may result in long-term functional restrictions (Goodman, 2012). There are supporting devices which can be used to help position and maintain patient’s position therefore, when transferring and positioning Mrs Bird, a pat slide and sliding sheets were used to move her effectively to avoid causing any damage to the patient nor themselves. When moving elderly patients extra care should be incorporated as they are at more risk of impaired skin integrity, as people get older the skin decreases the ability of epidermal barrier which prevents water loss resulting in elderly patient to be more prone of getting pressure ulcers than young patients (AFPP, 2007).

The patient was put in supine position which is the mostly used position when performing abdominal surgery however, some surgeons prefer the patient in lithotomy position using stirrups which will allow access to the vagina (Beesley & Pirie, 2005). Her head was placed on a gel donut headrest to prevent neck strain, arms were tucked on the sides supported by armrests to prevent ulnar nerve damage, alternatively arms can be put on arm boards at a 90-degree angle. In addition, during preassessment factors contributing to development of DVT such as age, body mass and mobility were discussed, precautions of flowtrons boots were put in place to avoid risk of developing DVT.  Flowtron boots or ted stockings stimulates the flow of the blood through the deep veins (Arnold, 2002).  Maintaining of temperature during operation time is vital as they are various causes for hypothermia in surgery such as open abdominal and chest surgery and length of surgery therefore, Mrs Bird was covered with a blanket to maintain her temperature, privacy and dignity, warming devices were available such as bair hugger as it is important to maintain body temperature especially for elderly patients. Older patients are prone to the development of hypothermia because their body lose heat more rapidly than younger persons (NICE, 2008). Day 2006, Kempainen and Brunette 2004) stated that children are also at risk of developing hypothermia as they are unable to generate heat in response to hypothermia. Hypothermia has its effects, it can increase the risk of surgical site infection, length of hospital stays which will result in subsequent costs for the hospital (Paulikas, 2008).

The second part of the WHO checklist which was carried out this is done before skin incision, the Who checklist is a tool that is used to promote safety in the surgical setting, it incorporates validated checklists to be reviewed by the surgical team before induction of anaesthesia, skin incision and before the patient leaves the operating room. It helps to minimise the risks of error by involving the entire team and encouraging team members to point out a possible error without fear of ridicule (NPSA, 2009). Team members confirmed they all knew each other, the surgeon confirmed the name of the patient, procedure intended, and no anticipated events and blood loss was expected. At this point, the surgeon performed a pelvic check for confirmation of size and shape for the uterus, it also helps with the type of incision.  The vagina was cleansed using povidone-iodine however, it has the potential to cause irritation postoperative therefore, normal saline is recommended as it is mild but effective and will not cause harm on the skin (NICE, 2008). The patient was put in dorsal lithotomy position and a Foley catheter was inserted into the bladder for straight drainage as this reduces the size of the bladder and prevents incidental bladder damage when entering the lower abdomen (NHS, 2007). The surgical site should be cleansed using safe and effective antiseptic products, the cleansing of the site reduces the risk of surgical wound infection (Allen, 2009). However, factors such as procedure type, patient assessment, allergies and contradictions should be considered when selecting the skin prep (AORN, 2015). The choice of antiseptic should be primarily based on the surgeon’s preference, knowledge of the product efficiency and ease of use. Povidone-iodine or chlorhexidine are the most suitable solutions to use for skin preparation, in this case the surgeon’s used povidone-iodine to prepare the abdominal surgical site as it is efficient and does not impede wound healing (NICE, 2008). The patient was draped using the single-use drapes, to provide a barrier between the surgical site and other parts of the patient’s body and nonsterile areas of the operating table. Drapes reduces the risk of infection (AFPP, 2007).

Entry into the abdomen is usually by either a lower midline or transverse incision, the surgeon made a midline incision of 10-15cm using a number 10 blade, midline incisions are preferred because they allow adequate exposure of the cervix and vagina (Halm et al, 2009). A thorough anatomical check was performed when the abdomen was entered, this included the liver, gallbladder, stomach, kidneys and aortic lymph node. He requested for retractors which were placed on the right and left of the abdomen and    the bowel was packed out of the pelvis into the upper abdomen with two warm moist swabs in order to prevent serosal injury (reference). At this point, the self-retaining retractors were fixed in placed allowing good exposure of the pelvic structures, the scrub practitioner handed the kocher clamps which were used to grasp the uterus and placed along the ovarian round ligaments. The uterine incision was done on each side starting at the round ligaments, these were clamped with tonsil clamps, elevated and sutured using zero vicryl ties and then cut. To avoid back bleeding the uterine holding clamps were put in place and the pelvic peritoneum was opened, the round ligament peritoneal incision is carried from each side across the front of the uterus at the vessel uterus fold, this allows the bladder to be pushed in the midline inferiorly off the cervix. If the surgeon suspects bladder damage at any time during the operation, the bladder should be filled with a sterile coloured solution as this will quickly identify a cystotomy (Rodriguez and Payne, 2001). The surgeon bluntly dissected the retroperitoneal space posterior to the round ligament to allow visualization of the iliac vessels on the pelvic wall and ureter. Prior to surgery a decision about retaining or removing ovaries should be discussed with the patient therefore in Mrs Bird case, the ovaries were being retained. In general, it is recommended that if the ovaries are normal and the woman is 50 years of age or older, they should be removed however, in younger woman removal of ovaries will reduce their estrogen and androgen hormone level and it is not done routinely unless there is obvious gross ovarian pathology or strong family history of ovarian cancer (Parker, 2011).  As the ovaries were being preserved, the uteroovarian ligaments were clamped then cut using mayo scissors and ligated with zero vicryl. The surgeon clamped the ligaments as close to the uterus a possible to reduce ovarian blood flow disruption and ovarian hypofunction. After each clamp the tissue was cut and ligated with absorbable zero-vicryl because of its tensile strength which is around 65% at 14 days post-implantation as well the absorption competes in 56-70 days. Absorbable vicryl sutures are suitable to use in general soft tissue approximation and vessel ligation because they cause only slight tissue reaction and maybe used in the presence of infection (Ethicon, 2005). The hysterectomy can be performed with the complete removal of the cervix however, retaining the cervix maybe elected in some patients based on the theory that the cervix is important for orgasm or pelvic wall support (Parker, 2011).  As, Mrs Bird cervix was left the endocervical canal was excised to prevent later bleeding from retained endometrium. The paracervical fascia was separated with Metzenbaum scissors and long tissue tooth forceps, the surgeon removed the uterus with the use of a number 10 blade. The surgeon inspected the pelvis and obtained haemostasis because it is important for the body as it stops bleeding and helps to defend our body from infections (Taylor and Campbell, 2005). As soon as the uterus was removed, the scrub practitioner handed the surgeon a betadine-soaked sponge which he inserted into the upper vagina to decrease vagina bacterial contamination of the pelvis as the vaginal cuff was left open. The surgeon’s assistant irrigated the pelvis with warm normal saline as the surgeon was preparing to close the abdomen. At this moment the scrub practitioner performed second instrument count as it is stated by NPSA (2009) that a second count should occur before wound closure begins. The count was audible to the other team members, the scrub practitioner reported the second count correct to the surgeon, it is the responsibility of the scrub practitioner to tell the surgeon the outcome of the count however in a case of the count is incorrect, it is the surgeon responsibility to decide what to do about unaccounted items (WHO 2009, NPSA 2009).  A Jackson Pratt drain was attached to the wound to remove dead spaces, foreign objects or harmful materials that may possibly lead to wound healing complications (Baxter, 2003). When closing the peritoneum, the surgeon used 2-0 Monocryl CT-1 suture because of its tensile strength, and complete absorption, however some believe the peritoneum does not require suturing if the posterior fascia is securely closed (Parell and Becker, 2003). Closure of the fascia and subcutaneous tissue, he used PDS II because of its lasting strength and adequate support, is it also stated that PDS II are well suited for use in younger and healthy patients (Ethicon, 2005). The surgeon chose to use staples to close skin as staple closure are routinely used for standard abdominal closure however some advantages of using staples are easy to use, effectiveness and minimal damage to the skin (Baxter, 2003). The surgeon administered local infiltration of ½ lidocaine with a dilution solution of vasopressin, infiltration can be done subcutaneously before or after suturing the skin however, according to (Ferne and Sevarino, 2001) administration of local anesthetics into the wound during closure produces significant analgesia and is associated with a reduction in postoperative analgesia. Local infiltration is used to help decrease operative blood loss, decrease postoperative pain, reduces opioid consumption and speed patient recovery (Ferne and Sevarino, 2011)

When choosing wound dressing there are factors that should be considered such as wound healing process, infection, absorption and protection of the surrounding areas (McCullock and Kloth, 2010).  The surgeon’s wound dressing preference was to use soft dressing as these dressings are used for uncomplicated wounds which are closed by primary intention. He used four non-stick gauze which rests on the surface of the wound then, applied abdominal pads on top which helps with wound absorption and a paper tape was applied to immobilise the wound area and support the dressing (Baxter, 2003). The choice of dressing is important as it plays a huge part in wound healing however, authors like Posnett et al (2009) argued that some type of wound dressings can cause surgical site infection due to the person reacting to the type of dressing therefore, this can have a significant effect on quality of life for the patient because they will be  associated with considerable morbidity, extended hospital stay and is a drain on NHS resources (Plowman et al, 2001). If a patient suffers from surgical site infection he or she needs to establish if the system infection control procedures has failed them or a reasonable standard of care was not followed to avoid infection occurring.  Surgical site infection is mostly caused by contamination of an incision with microorganisms from the patient’s own body during surgery (Fredricks, 2001). The National Institute for Health and Clinical Excellence (NICE) (2008) stated that 5% of patients undergoing a surgical procedure in the UK result in surgical site infection however, Tanner et al (2008) stated that surgical site infection presents after patients have been discharged from hospital. The National Institute for Health Clinical Excellence (NICE) (2008) put in place precautions to reduce infection in operating theatres by restricting the number of people in theatre and minimising the activity of those present. If healthcare practitioners, by exercising these safe recommendations stated both the patients and staff are protected from infection and the organisation cost will be reduced and used for other purposes.

At the end of the procedure, the scrub practitioner performed the last count of the instruments and items used during the operation, correct count was reported to the surgeon. The specimen was handed to the circulator practitioner and placed it in the specimen container which was labelled with the patient’s name, date of birth, NHS, number, surgeon’s name, type of specimen and the date. When handling specimens, all staff must adhere to the standard precautions following the local policy as this will decrease the potential risk and adverse events (AFPP, 2011).  AORN (2013) stated that it is the responsibility of the requester to ensure that specimens and forms are correctly labelled following the correct standard procedure. Time out and debriefing was performed before the staff members left operating room, this allows the practitioners to reflect on their work and identify any areas they could improve on in future and share ideas to implement in order to deliver safe and effective care to the patients. The surgical team members worked together as a team and a successful outcome was delivered by communication and collaborating with each other. In this day, hysterectomy has remained one of the most performed surgical procedure and remains an effective intervention for many women with a variety of benign gynaecological symptoms and disorders. Abdominal hysterectomy remains the default procedure for women unsuitable for both vaginal and laparoscopic approaches, particularly those with very large fibroids (American College of Obstetricians and Gynaecologists, 2018).

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