are, unfortunately, part and parcel of our surgical discipline. Indeed, they are perhaps one of the most challenging parts of our working lives. Paradoxically, a lack of exposure during residency training can leave less experienced surgeons feeling ill‐equipped to deal with them. A variety of emotional responses are triggered when surgical complications arise. Depending on experience, these may include feelings of failure, guilt, shame, anxiety, or embarrassment. For some, a natural instinct is “fight or flight,” while others choose to “bury their head in the sand,” or worst of all – blame others. Although the equine surgical patient may be harmed and the first victim of a surgical technical error, the surgeon may also be the second victim in emotional terms [1], particularly when serious complications arise.
It is usually a humbling experience that we should learn from. The ideal approach when complications arise is to accurately diagnose the nature of the problem, analyze the cause, treat it to the best of our ability using an evidence‐based approach, and learn from it. Rapid disclosure of adverse events to the horse owner with good professional communication and thorough documentation will help avoid litigation or, at the very least, prepare for it. The art of communication will help the experienced surgeon navigate these knotty situations, and junior surgeons and residents should listen well and consult and learn from more experienced colleagues. Talking to a colleague about the surgical error [1] may also help to reduce the emotional burden incurred by the surgeon implicated.
The word complication is derived from the Latin word complicare for a fold, the opposite to smooth – the desired outcome following a surgical intervention. F.D. Roosevelt’s statement “A smooth sea never made a skilled sailor” is fitting for surgery and surgeons! The words complication and adverse event, although they have different meanings, are often used interchangeably. Adverse events have been defined as “an unintended injury or complication resulting in prolonged length of hospital stay, disability at the time of discharge, or death caused by healthcare management and not by the patients’ underlying disease” [2]. Adverse events may cause preventable equine patient harm, prolong hospitalization, and increase costs. It is interesting that most adverse events in human hospitals are associated with surgery [3]. Furthermore, surgeons should note that non‐operative management errors were more frequent than errors in surgical techniques and included monitoring, incorrect or delayed treatment, diagnostic error. or delay [4]. Complications may be a consequence of an adverse event, but an adverse event may occur without complication.
Careful surgical planning (patient, surgical theatre, and equipment) and communication with the surgical team, intraoperative technique, and perhaps most important, non‐operative management, should keep complications to a minimum.
Unfortunately, evidence‐based information on complications in equine surgery is not always available, as some of the equine surgical complications are extremely rare and treatment depends on the creativity and experience of the attending surgeon at the time. This is often the real‐life situation!
Future efforts to improve patient safety should target research on the leading causes of potentially preventable equine patient surgical harm, identified from collected data on the frequency, severity, and preventability of adverse events. The Clavien‐Dindo classification of surgical complications, now widely employed in human surgery, or variations thereof, would be a useful tool for grading complications in future equine studies [5].
A text book addressing this subject is timely, unique, and fills an important niche and will be an invaluable and comforting “go‐to” resource, particularly for less experienced junior surgeons, to provide guidance on decision‐making in challenging cases. It will provide access to the experience of many expert surgeons. Niels Bohr stated that “an expert is a person who has made all possible mistakes in a small field!” Hopefully, this body of work will inspire and pave the way for new research studies on this topic to move this important surgical field forward.
Professor Sheila Laverty MVB DACVS DECVS.Faculty of Veterinary Medicine, University of Montreal, St. Hyacinthe, Canada
References
1 1 Wu, A. (2000). Medical error: the second victim. The doctor who makes mistakes needs help too. B.M.J. 320 (7237): 726–727.
2 2 Brennan, T.A., Leape, L.L., Laird, N.M., et al. (1991). Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N. Engl. J. Med. 324: 370–376.
3 3 Baker, G.R., Norton, P.G., Flintoft, V., et al. (2004). The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. J.A.M.C. 170: 1678–1686.
4 4 Anderson, O., Davis, R., Hanna, G.B., et al. (2013). Surgical adverse events: A systematic review. Am. J. Surg. 206 (2): 253–262.
5 5 Dindo, D., Demartines, N., and Clavien, P.A. (2004). Classification of surgical complications: a new proposal with evaluation in a cohort of 6,336 patients and results of a survey. Ann. Surg. 240 (2): 205–213.
Preface
As surgeons we read and learn with enthusiasm about surgical treatments and techniques and enjoy performing those on our patients aiming to achieve a successful outcome for them. That successful outcome is the result of many factors including good knowledge and technique, mentorship, interaction with peers, experience and, of course, the availability of evidence‐based literature and resources. Publications in the form of textbooks and journals play a central role in our individual training and progression, and will remain as key in the further evolvement of equine surgery and formation of new equine surgeons. As residents we feel thrilled and enormously satisfied when we observe how application of those surgical treatments translates into survival of our patients. It is with great satisfaction when as surgeons we remove gloves, gown and mask at the end of a surgical procedure that has been completed effectively. The satisfaction is bigger when the patient gets discharged from the hospital and increases further when we learn from owners, trainers or referring veterinarians that the patient has successfully returned to their previous or intended use. However, as surgeons we all learn that many hurdles are to be cleared in the pre‐, intra‐, and postoperative periods to reach that successful outcome. On occasions, there are unforeseen circumstances or factors that we may not be able to control or that escape our individual experience.
We all have experienced surgeries that do not go according to plan, despite having cautiously read and memorized all steps of the surgical procedures. Not uncommonly, we encounter individual variations, intraoperative incidents or situations that may escape the standard descriptions in the literature. Surgical steps may be carefully followed without guarantee that they will translate into results as described in textbooks or papers. In the postoperative period, we are vigilant of our patients hoping for a steady recovery to hospital discharge and successful return to previous use. We monitor our patients closely with special attention to detect early signs that may alert us to occurrence of complications or deviation from the uneventful recovery path. This represents a source of stress for the responsible clinician and especially for residents when they are questioned by their mentors about unexpected signs, possible complications, reasons, and how those could have been prevented and be treated at the time. The stress also extends to client communication, as the effect of those complications on the outcome of that particular patient may not be readily described in the scientific literature. All these bumps along the way can be referred to as complications that jeopardize the well‐desired successful outcome for our patients. Although we will not be able to save all patients, the science to accurately predict, diagnose, and manage complications, in addition to training and experience, hopefully give the surgeon the ability to adapt to those less‐than‐ideal situations while providing the means to achieve the best successful outcome for that patient.
The editors are delighted to present
