Surgical documentation: worth its weight in gold

Documenting surgical procedures performed can be very important and even cost and lifesaving.

Regrettably writing operation notes and documenting procedures is considered a menial task and delegated to the junior most member of the operative team in most places in India. As a result it leaves much to be desired.

I recently operated on a young woman who had as per her discharge undergone a Whipple's surgery ( an operation in which the gall bladder, lower part of the bile duct, head of the pancreas, first part of small intestine and sometimes part of stomach is surgically removed) more then a decade ago at a prominent cancer centre  in Bengaluru.

Whipple's operation

She presented with fever and jaundice and her MRI showed presence of gall bladder and stones in the bile duct with no apparent surgical connection between bile duct and intestines that one expects to be present after such a procedure. This flummoxed us as this picture is unexpected after a Whipple procedure.

Fortunately, the patient was able to procure the detailed records from a decade ago which had clearly documented that the procedure performed was not a Whipple procedure but an unconventional one where the gall bladder was retained and surgically connected to the intestine. This made the picture clear and we were successfully able to sort the problem by performing a second surgery to remove the gall bladder, remove the remaining bile duct and stones and establish a connection between the bile duct and intestine. This successfully relieved her jaundice and she made a full recovery.

I have no hesitation in admitting that it is the detailed record that allowed us to solve the puzzle which otherwise despite requiring multiple and costly scans could still have left us in some doubt before the surgery. The documentation provided us a clear roadmap regarding what to expect and formulate a plan to deal with it beforehand.

As a rule I make it a point to write operative notes on my own. Being the lead surgeon,  I have the experience and insight to document all the necessary details that could be needed later. Writing the notes immediately ensures that details are fresh in memory and not forgotten. 

I often find  myself lamenting this lack of attention to detail when I see patients who have previously undergone surgery with only sketchy or woefully inadequate details available regarding the operative findings and nature of the surgery. These omissions can lead to escalated costs and make reoperative surgery difficult like groping in the dark.

This is a shout out to my surgical colleagues to pay attention to documenting clearly all surgical details ...it could save your patient a lot of angst, cost and even their lives.