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World Journal of Surgery

, Volume 43, Issue 3, pp 798–805 | Cite as

Decision-Making in the Emergency Laparotomy: A Mixed Methodology Study

  • Louise HendraEmail author
  • Tim Hendra
  • Stephen J. Parker
Original Scientific Report
  • 70 Downloads

Abstract

Introduction

More than 30,000 emergency laparotomies take place annually in England and Wales (Symons et al. in Br J Surg 100(10):1318–1325, 2013; Shapter et al. in Anaesthesia 67(5):474–478, 2012). They are associated with high morbidity and an average inpatient 30-day mortality rate of 11%. Inextricably linked to outcomes is the decision-making process of whether or not to operate (NELA Project Team First patient report of the National Emergency Laparotomy Audit. RCoA, London, 2015; Crebbin et al. in Aust N Z J Surg 83(6):422–428, 2013). A mixed-methods study was undertaken to investigate decision-making in the emergency laparotomy and influencing factors.

Methods

Semi-structured interviews were undertaken amongst general surgeons, exploring the decision-making process. Results helped guide design of an online survey, consisting of vignettes and subsequent questions. Respondents were asked to decide whether or not they would perform a laparotomy for each vignette and the results compared to grade, risk attitudes and reflective practice. Responses were analysed for effect of previous positive and negative experiences and for consistency.

Results

Interviews revealed multiple important factors when considering whether or not to perform an emergency laparotomy, broadly categorised into patient-related, surgeon-related and external factors. A total of 116 general surgeons completed the survey: 12 SHOs, 79 registrars and 25 consultants. Non-consultants were 10.4% (95% CI ±9.7%) more likely to perform an emergency laparotomy than consultants (p = 0.036) on multivariate analysis. No association was observed between operative practices and risk attitudes (p = 0.22), reflective practice (p = 0.7) or previous positive or negative experiences in univariate (p = 0.67) or multivariate analysis. Surgeons were not proven to be either consistent nor inconsistent in their decision-making.

Conclusion

The decision to operate or not in an emergency laparotomy directly effects patient outcome. This study demonstrates a difference in decision-making and risk attitudes between consultants and their juniors. To address this, formal teaching of models of decision-making, influencing factors and vignette-based consultant-led discussions should be introduced into surgical training.

Notes

Acknowledgements

This research was undertaken as part of the third year of the MSc in Surgical Sciences or Edinburgh Surgical Sciences Qualification (ESSQ) www.essq.rcsed.ac.uk.

Compliance with ethical standards

Conflict of interest

The authors have no potential or real conflict of interest to declare.

Supplementary material

268_2018_4849_MOESM1_ESM.pdf (1.1 mb)
Supplementary material 1 (PDF 1146 kb)
268_2018_4849_MOESM2_ESM.docx (92 kb)
Supplementary material 2 (DOCX 92 kb)
268_2018_4849_MOESM3_ESM.tiff (416 kb)
Supplementary material 3 (TIFF 415 kb)
268_2018_4849_MOESM4_ESM.docx (83 kb)
Supplementary material 4 (DOCX 82 kb)

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Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  1. 1.General Surgery DepartmentRoyal Bournemouth HospitalBournemouthEngland, UK
  2. 2.Poole Hospital NHS Foundation TrustPooleEngland, UK
  3. 3.General Surgery DepartmentSt Mary’s HospitalNewport, Isle of WightEngland, UK

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