Lessons learned by personal failures in aneurysm surgery: what went wrong, and why?
OBJECTIVE
To analyse the intraoperative complications of a single neurosurgeon, with emphasis on devastating intraoperative incidents, and how they possibly could have been avoided.


METHODS
All the patients operated upon by the author between 1986 and 2002, i.e. 252 patients with 270 craniotomies for 294 aneurysms, were included. All intraoperative events that possibly could have influenced the clinical outcome were recorded prospectively.


RESULTS
A total of 16 cases (6.3% of all the patients) with serious intraoperative incidents were identified. In 11 cases (3.6% of all aneurysms), an intraoperative rupture occurred that was judged to have had mild to severe consequences for the patient. In another four patients (1.6% of all patients), all with unruptured, large aneurysms (>15 mm) of the carotid or middle cerebral arteries, a major vessel occlusion occurred inadvertently. In one patient with a large, unruptured MCA aneurysm, a clip slipped after the closure of the wound, causing a fatal intracerebral haemorrhage. These events had a severe impact on the clinical outcome. In retrospect, most of these incidents could, and should have, been avoided.


CONCLUSIONS
It is recommended to start the training of new aneurysm surgeons on patients with small, supratentorial, unruptured aneurysms, followed by ruptured aneurysms in all other supratentorial locations than the anterior communicating artery (ACOM), which is the supratentorial location that should be the last step in the training of independent aneurysm surgeons.
Wester
Knut
K
Section for Neurosurgery, Department of Surgical Sciences, University of Bergen, 5021, Bergen, Norway. knut.gustav.wester@helse-bergen.no
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002343:Carotid Artery, Internal / Q000473:pathology / Q000601:surgery; D002561:Cerebrovascular Disorders / Q000209:etiology; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology / Q000517:prevention & control; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D007431:Intraoperative Complications / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000473:pathology / Q000601:surgery; D009493:Neurosurgery / Q000193:education; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000401:mortality; D009664:Norway; D017063:Outcome Assessment, Health Care / Q000379:methods; D019106:Postoperative Hemorrhage / Q000401:mortality / Q000517:prevention & control; D011446:Prospective Studies; D011859:Radiography; D013345:Subarachnoid Hemorrhage / Q000401:mortality / Q000517:prevention & control; D013663:Teaching / Q000592:standards; D017211:Treatment Failure; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D055815:Young Adult