Responding to, reflecting on, and moving forward from a surgical complication

I am nearing the end of preparing the gastric conduit for an esophageal replacement during a long and complicated esophagectomy. I staple the left gastric pedicle along the lesser curvature. The orientation of the stomach does not look right. It dawns on me that, yes, I did the unthinkable. I stapled the right gastroepiploic pedicle—the blood supply for the gastric conduit. Her stomach is now unusable.

As much as I wanted to mentally kick myself and retreat from the world and the gravity of my error, I still had a patient with an open abdomen who needed an esophagectomy and an alternative replacement. In such situations, there is no time to retreat, rationalize, and ponder; there is only time to humbly admit the mistake and find a solution. In the face of a serious error, the surgeon needs to respond by accepting that he or she has made a mistake—without excuse, defense, or rationalization—and quickly return to caring for the patient. In this particular situation, the solution was to create a pedicled segment of jejunum to serve as an interposition between the proximal esophagus and remnant distal stomach.

Once the error has been physically resolved to the best of the surgeon’s ability, he or she should proceed as follows:

  • Be transparent with the patient, your colleagues, and yourself. Transparency is essential not only because the patient and family have the right to know the truth about the complication, but also because discussing complications with your colleagues serves as a foundation for lessons in how to prevent and compensate for such errors.
  • Create a moment of pause the next time you encounter a situation similar to the one that led to the error. I will forever remember stapling the right gastroepiploic pedicle to the gastric conduit, and from that incident forward, both my assistant and I have checked, double-checked, and triple-checked the orientation of the stomach and the anatomy before dividing what we believe is the left gastric pedicle. This simple tactic, “the pause”, serves as an effective checkpoint to prevent errors.
  • Reflect on the error. One of my mentors likes to keep a “little black book” in which he writes down lessons and thoughts for improvement after every case. He calls these entries his “black book thoughts”. As surgeons, we all need to have a means of reflecting on and, importantly, documenting our black book thoughts for posterity. This process allows us to accept what we have done, be transparent with ourselves, reflect on errors, develop error-prevention strategies, and ultimately forgive ourselves.
  • Forgive yourself. It is impossible to be an effective clinician and surgeon working with the weight of regret and the fear of repeating mistakes. Our prior errors should live with, but not hinder, us. We must be able to forgive ourselves so that we can continue to do the right thing and take care of our future patients. It is a chance to heal not only the patient, but also ourselves.

Acknowledgement
The author would like to acknowledge Sara S. Kim, MD, a first-year general surgery resident at the University of North Carolina-Chapel Hill, for her assistance with this essay.

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