Intraoperative Consultation as an Instrument of Quality Management

It is not easy to collect data and analyze intraoperative decision making, the subtleties anesthesia, and technical surgical endeavors. As a result, the operation has historically been a ‘‘black box’’ in the field of surgical health services research. Preoperative risk factors and postoperative occurrences are described in extensive detail, but operative decision making is rarely studied. Within this context, in this issue of the World Journal of Surgery, Petersen et al. report a unique approach to surgical quality improvement focusing completely upon the operation [1]. In short, an attending surgeon provided an intraoperative consultation for every operation over a 6-month period. Routine intraoperative consultation did not frequently affect intraoperative clinical decision making. Conversely, when a ‘‘tactical’’ intraoperative consultation was initiated, intraoperative decision making changed over 50% of the time. Overall, it seems that having a second surgeon in difficult cases significantly changes the operation. The comprehensive focus on the operation is one unique aspect of the initiative described in the article. Previous pioneering work has studied the surgical technique and patient outcomes, but this work has gone further by affecting not only technical aspects of the operation but also the more complex issue of intraoperative decision making [2–4]. Obviously, such a comprehensive program has many potential logistical impediments. For example, many surgeons may not be willing to either consult or to request consultation. Similarly, surgeon reimbursement for such efforts may threaten the cost effectiveness of such an initiative. Conversely, as the authors mention, there may be significant opportunities to design an efficient and effective program specific for each institution. For example, a program may focus on intraoperative consultation during emergency operations. Considering the high rates and costs of complications after these operations, such a program may be cost-effective [5, 6]. Advances in surgical technology have introduced the concept of intraoperative real-time consultation by clinical experts residing at remote sites from the operating room. Obviously, with high-resolution real-time video access and communication, high-level discourse between surgeons can occur. In addition, expert surgeons can assess the operative field and advise on clinical decision making and technical issues. Further, with robotic surgery, real-time hands-on technical assistance may potentially be given from remote sites [7, 8]. Although such possibilities offer significant promise, they also present significant logistical issues. As a result, a program such as the one described in this article, one that involves extensive cooperation among surgeons within a single institution, has many potential advantages. Obviously, whether intraoperative consultation improves outcomes remains to be determined. As mentioned in the article, particularly in the setting of tactical consultations, intraoperative decision making frequently changed. Whether it was ‘‘for the better’’ or ‘‘for the worse’’ needs to be determined. If nothing else, a collaborative program such as the one described may go far to propagate a culture of safety within the operating room. This alone would be a significant achievement. M. J. Englesbe (&) Department of Surgery, University of Michigan, 2926A Taubman Center, Ann Arbor, MI 48109-5331, USA e-mail: Englesbe@umich.edu