What is a surgical complication

Surgical complications (SC) are constantly on our minds. We toil and sweat to prevent them; we do not sleep at night worrying about them; and we suffer mental anguish when they do develop. The notion of complications is deeply impregnated in the surgeon’s blood: the word ‘‘complication’’ says what it means to any surgeon, and there is no need to re-invent the concept by applying pseudo-philosophical nomenclatures. A patient undergoes an elective inguinal hernia operation: today, in 2008, we expect an uneventful operation and postoperative course; and we all know that if anything goes wrong then it is a complication (lists of all potential complications are available in excellent texts), and complications may be ‘‘minor’’ or ‘‘severe’’; ‘‘surgical’’ or ‘‘medical’’; ‘‘technical’’ or of ‘‘judgment’’; of ‘‘commission’’ or ‘‘omission’’; ‘‘infective’’ or not; ‘‘avoidable’’ or ‘‘unavoidable’’; associated with negligence or not, or ‘‘maybe.’’ Even a car accident after the hernia operation might be considered a ‘‘complication,’’ if the patient had been allowed to drive home under the influence of anesthetic drugs. As much as I appreciate the authors’ [1] effort to educate us about complications, I find their approach rather naive—particularly the search for a definition of surgical complication on PubMed. Typically, for members of the Nintendo generation ‘‘whatever is not found on a superficial ONLINE search does not exist,’’ but what about looking at the many excellent books dedicated to surgical complications published around the world for the last 100 years? That the authors may not be optimally qualified to address the issue of defining ‘‘complication’’ is exemplified in the example they provide of the ‘‘high-risk aneurysm repair’’: the ‘‘risk of operative repair’’ has nothing to do with the ‘‘60% risk of rupture,’’ which depends on the aneurysm’s size. Thus the rupture is a complication of the aneurysm itself not of its operative repair, as implied. ‘‘Who...must judge the results (of operation) undesirable?’’ the authors ask; but they do not provide an answer. Obviously those who analyze and define complications cannot be nurses, administrators, or internists—not even experts in clinical ethics. They have to be independent surgical experts in the field! The authors suggest that ‘‘A complication in the UK may not be count as a complication in India and a complication in 2007 may have not have been in 1807.’’ Here the authors confuse the notion of ‘‘standard of care’’— which has been (hopefully) constantly changing since 1807 with the ‘‘quality of care’’ (e.g., complications). But a complication is still a similar complication in rural India or Yorkshire, with the difference being only that when it develops in India it could be termed ‘‘unavoidable.’’ Thus, the rate of wound infection in India may be 30% versus 10% in the UK—but a complication is a complication! The ‘‘full definition’’ of SC offered by the authors:’’...any undesirable, unintended and direct results of an operation...which would not have occurred had the operation gone as well as could be reasonably be hoped’’ is far from being ‘‘full.’’ It is painfully limited in scope and hazy. The etiology of SC is not limited to the technical performance of operation—what about a wound infection developing after a perfect operation because the surgeon forgot to administer prophylactic antibiotics? And does anyone know about any SC that was ‘‘desired’’ or ‘‘intended’’? Finally, what about the ‘‘non-direct’’ results of an operation? For example, a patient undergoes an M. Schein (&) Marshfield Clinic, 906 College Avenue W, Ladysmith, Wisconsin 54848, USA e-mail: Mschein1@mindspring.com