Enhancing Surgical Safety: Best Practices for Surgical Site Marking

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“What constitutes the best practise in surgical site marking: An extended critical review of

literature?”

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Executive Summary

This paper aims at the analysis on best practices for surgical site marking among patients

during preoperative conditions to reduce wrong site surgeries. The incidence of wrong site

surgery is observed to be escalated annually among world population. According to Simons

et al (2008) stresses that only 48% of surgeons regularly mark their surgical sites. Surgical

confusions are one of the poorly studied clinical research areas. Wrong site surgery is defined

by (Mulloy, 2008) as surgery conducted in wrong body parts, wrong organs or wrong surgical

procedure performed. Surgical training and practising includes the both technical and non-

technical skills. Most of the surgical errors are caused due to human factors which accounts

for non-technical errors. Human factors such as lack of situation awareness, poor decision

making, lack of communication and team work accounts up for the non-technical errors

during surgery. Due to the raising rates of wrong site surgeries and its associated fatalities

and medical complications, the research intent was based in search of best methods for

surgical site making since medical errors during surgery accounts for 8% of annual death in

UK and fatalities due to surgical errors are forecasted to escalate in future. According to

(Joint Commission, 2015), there are generally the three important segments in UP such as

pre-strategy check, site stamping, and a period out. From 2006, each recovering center,

walking thought working environments, and office-based surgery exercises sanction by the

Joint Commission are obliged to utilize the UP and all assurance workplaces oblige

adherence to the UP for reimbursement. From 2015, the CMS insisted that every hospitals,

clinics and nursing homes should have good surgical systems to offer a safe surgery agenda

with a specific end goal to get repayment. Despite of having such universal regulations, the

incidence of wrong site surgery keep on increasing.

Colon, rectal and ostomy surgeons regularly mark the surgical sites to reduce the wrong site

surgeries. This study employs qualitative research design using secondary research methods.

practise based extended critical review of literature was chosen as the research design. The

ultimate reason for selection of this model is to identify the best methods for surgical site

marking from the available medical literature and to critically review which method is widely

used in current medical practise. Growing source of information available in the form of

electronic records and medical research databases have reduced the pain of researchers and

healthcare practitioners for identification and selection of ideal method which is retrieved

effectively at reduced cost of time and money. This study is conducted as a preliminary

research to observe the best method for surgical site marking practise to prevent the wrong

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site surgery. A systematic review using PICO model was used in this study to analyse the

best practices in the surgical site marking. Journals were extracted from medical research

literature databases such as COCHRANE, EMBASE, PUBMED, PUBMED CENTRAL and

MEDLINE. Out of 15 articles retrieved only 10 met the inclusion criteria of the study. Most

of the journals have addressed that bio absorbable tissue marking system with additional

imaging studies increase the effectiveness of surgical site marking practices to reduce the

wrong site surgery. The study concludes that CT scan guided hook wire positioning or

marking method was observed to have increased safety, efficacy, speed and reliability for

localisation of surgical sites.

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Table of Contents Executive Summary ................................................................................................................... 2

Chapter 1: Introduction .............................................................................................................. 6

Background ............................................................................................................................ 6

Rationale of the present study ................................................................................................ 6

Scope of the present study ..................................................................................................... 7

Significance of the present study ........................................................................................... 7

Research Design..................................................................................................................... 8

Research Aim and Objectives ................................................................................................ 8

Research Aim ..................................................................................................................... 8

Research Objectives ........................................................................................................... 8

Research question .................................................................................................................. 9

Structure of the Dissertation .................................................................................................. 9

Chapter 2: Search and Review Strategy................................................................................... 10

Search criteria ...................................................................................................................... 10

Types of clinical studies................................................................................................... 10

Nature of the study population ......................................................................................... 10

Nature of interventions .................................................................................................... 11

Kind of research outcome measures .................................................................................... 11

Primary outcomes ............................................................................................................ 11

Secondary outcomes ........................................................................................................ 11

Search methods employed in the present study ................................................................... 11

Databases used for search .................................................................................................... 12

Searching for alternate resources ......................................................................................... 12

Data collection ..................................................................................................................... 12

Choice of earlier studies................................................................................................... 12

Extraction and Management of Data ............................................................................... 13

Evaluation of bias in current research .............................................................................. 13

Evaluation of heterogeneity ................................................................................................. 13

Sample size ...................................................................................................................... 13

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Quality of the evidence .................................................................................................... 13

General Agreements and Disagreements ......................................................................... 13

Research tool ........................................................................................................................ 14

PICO Model ..................................................................................................................... 14

Chapter 3: Presentation of Literature and Initial Discussion ................................................... 15

Overview about Wrong Site Surgery ................................................................................... 15

Impact of wrong site surgery ............................................................................................... 16

PICO analysis on best practices in surgical site marking .................................................... 17

1. Thakar & Mearse (2012) .............................................................................................. 17

2. Person et al (2012) ....................................................................................................... 18

3. Colwell and Gray (2007) ............................................................................................. 19

4. Shah et al (2011) .......................................................................................................... 20

5. Harman and Benjamin (2013) ...................................................................................... 20

6. Mears et al (2009) ........................................................................................................ 21

7. Bergal et al (2011) ....................................................................................................... 23

8. Suzuki et al (2014) ....................................................................................................... 24

9. Hoang (2012) ............................................................................................................... 26

10. Li et al (2014)............................................................................................................. 27

Chapter 4: Discussion and Future Implications ....................................................................... 29

Discussion ............................................................................................................................ 29

Chlorhexidine vs Iodine based skin preparations for surgical site marking ........................ 29

Stomal site marking and its effectiveness ............................................................................ 29

Bio absorbable Tissue marker .............................................................................................. 30

Relationship between willingness and demographics for surgical site marking ................. 30

Future Implications .............................................................................................................. 31

Chapter 5: Conclusion and Limitations ................................................................................... 32

Conclusion ........................................................................................................................... 32

Limitations ........................................................................................................................... 33

References ................................................................................ Error! Bookmark not defined.

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Chapter 1: Introduction

Background

Wrong site surgery is one of the major clinical issues in healthcare industry. Such adverse life

threatening events increases the complexity in health care industry. Conducting a surgery at

wrong site is known as wrong site surgery. According to Mulloy (2008) wrong site surgery is

a preventable type of medical error. This is devastating error for patients and produces a

negative impact over the medical team. Generally, legal penalties are imposed for surgeons

who performed wrong site surgery. As reported by Panesar (2011) have also argued that

nearly 4.2 million patients are undergoing surgeries in England and 1 per 10000 surgeries

leads to adverse effects in the same. 3-16% of total surgeries lead to adverse medical

complications and 0.8% leads to fatal death. The rate of surgical errors was estimated to

increase per year. So, this study is intended to analyse the best practices to eradicate wrong

site surgery by identifying best practises in surgical site marking.

Rationale of the present study

Surgical training and practising includes the both technical and non-technical skills. Most of

the surgical errors are caused due to human factors which accounts for non-technical errors.

Human factors such as lack of situation awareness, poor decision making, lack of

communication and team work accounts up for the non-technical errors during surgery. Due

to the raising rates of wrong site surgeries and its associated fatalities and medical

complications, the research intent was based in search of best methods for surgical site

making since medical errors during surgery accounts for 8% of annual death in UK and

fatalities due to surgical errors are forecasted to escalate in future. Though the advanced

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digital equipments assists medical surgery, the deaths occur for one patient per 100 cases in a

300 bedded hospital was reported by Kelly (2012). Many surgeons report that incomplete

patient assessment and wrong diagnosis in X-ray or Scans accounts for wrong positioned

surgery. This study mainly focuses on the best method through the literature search in

available research databases and from online sources such as research articles, journals etc.

Scope of the present study

As indicated by the Organization for Medicinal services Exploration and Quality (2015), the

Joint Commission created and executed a systematic protocol applicable universally. In order

to avoid surgeries at incorrect Site, Wrong Methodology, and Wrong Individual Surgery in

2004, likewise alluded to as the universal protocol Convention.

According to (Joint Commission, 2015), there are generally the three important segments in

UP such as pre-strategy check, site stamping, and a period out. From 2006, each recovering

center, walking thought working environments, and office-based surgery exercises sanction

by the Joint Commission are obliged to utilize the UP and all assurance workplaces oblige

adherence to the UP for reimbursement. From 2015, the CMS insisted that every hospitals,

clinics and nursing homes should have good surgical systems to offer a safe surgery agenda

with a specific end goal to get repayment. Despite of having such universal regulations, the

incidence of wrong site surgery keep on increasing. From the reports of Mulloy (2008)

highlights that only 52% of surgeries in preoperative conditions are avoidable. So, this study

is devoted to analyse the literature by overlooking about various practices applied for the

prevention of wrong site surgeries.

Significance of the present study

Surgical site marking is the initiative amended to reduce the amount of Wrong Site Surgery.

From the reports of Simon et al (2007) stresses that only 48% of surgeons regularly mark

their surgical sites. Surgical confusions are one of the poorly studied clinical research areas.

The overall aim of this project was analyse the best methods for preventing surgical errors

and ideal method for the surgical site marking. Various research studies in this area are

targeted on the risk factors which accounts for wrong site surgery yet there exists a gap in

literature on identification of best practises for the surgical site marking to prevent wrong site

surgeries.

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Research Design

To conduct the present research investigation, practise based extended critical review of

literature was chosen as the research design. The ultimate reason for selection of this model is

to identify the best methods for surgical site marking from the available medical literature

and to critically review which method is widely used in current medical practise. Growing

source of information available in the form of electronic records and medical research

databases have reduced the pain of researchers and healthcare practitioners for identification

and selection of ideal method which is retrieved effectively at reduced cost of time and

money. This study is conducted as a preliminary research to observe the best method for

surgical site marking practise to prevent the wrong site surgery. Due to the convenience and

less time needed for accessing the literary archives, the current research is designed as

secondary research. In this method, data is gathered from summary of medical research

sources like books, reviews, consensus reports and raw or original findings from various

research articles and journals directed towards various methods for surgical site marking.

Although, the need of clinicians is different from the need of the researchers and other non

clinical professionals, this model will be very much beneficial in making preliminary

researches so that based on the findings of the present study further research investigations

can be directed in primary research designs. Thus, in this study, research articles and medical

sources are retrieved from MedLine, PubMed, PubMed Central are employed and critically

reviewed.

Research Aim and Objectives

Research Aim

The chief aim of the present study is to identify best methods to prevent wrong site surgery

thereby analysing the effective method for surgical site marking that assists the surgeons.

Research Objectives

Following are the research objectives intended for the present study;

1. To analyse the impact of wrong site surgery and its adverse effects

2. To identify the importance of surgical site marking in preventing wrong site surgery

and its associated fatalities.

3. To observe the best and effective method for surgical site marking

4. To discuss the effectiveness of the method from various medical research databases,

journals, research articles and other online sources

5. To conclude and discuss based on the methods addressed in the literature.

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Research question

The research question addressed for the present study is “what is the best method for

surgical site marking?”

Structure of the Dissertation

Evidence based study always needs a conceptual framework preparation to conduct a

systematic research investigation over a research problem. The current evidence based

research investigation is typically classified into five chapters that can be observed and

explained below. The present research framework represented below offers a clear picture

about this whole study

Figure 1: Framework of the Research Study

Chapter 1 – Introduction and Background: The aims and objectives, scope, research

questions, limitations and significance etc. of the study are elaborated in this chapter.

Chapter 1: Introduction

Chapter 2: Search and Review strategy

Chapter 3: Presentation of Literature(PICO model)

Chapter 4: Disucssion of findings

Chapter 5: Conclusion

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Chapter 2 – Search and Review strategy: Legitimate writing with respect to the imperative

issues and point of exchanges are composed in this part.

Chapter 3 – Presentation of literature using PICO model: The third chapter includes the

display of gathered literature using PICO model

Chapter 4 – Discussion and findings: All the data collected in the previous chapter are now

analysed here with the help of literature archives, records and databases.

Chapter 5 – Conclusions and Recommendations: Final chapter concludes the findings of the

research from the literature search

Chapter 2: Search and Review Strategy

This study employs practical based critical review of literature to assess the best practises in

surgical site marking. Evidence based research generally attempts to identify, evaluate and

describe the best practise for a specific problem. This concept was developed by Cochrane

(1909). The main purpose of EBR is not limited to group knowledge derived from clinical

experience and physiological rationale under the heading of best available evidence, nor is it

to develop hierarchies of evidence. This thesis aims at adopting evidence based research for

analysing the best practises in surgical site marking

Search criteria

Types of clinical studies

This report uses various kinds of clinical research designs such as randomised clinical trial,

semi experimental designs, studies involving systematic clinical trials, studies focusing on

quasi-experimental set ups, controlled experimental set ups and also the interrupted time

series analysis.

Nature of the study population

The study focuses on best practises for surgical site marking and so the participants who

undergo all kinds of surgeries were chosen. Besides patients, nurses or clinicians, health care

workers such as operation room technicians, health care managers and other health care

professionals were also chosen. Studies which focus on the stakeholders such as health care

insurers who are involved to avoid wrong surgical procedures.

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Nature of interventions

Studies which encompasses the patient identification, site of the surgery, procedure used for

surgery such as laparoscopy etc., documentation and communication methods employed by

health care team members such as doctors, nurses and other carers.

Kind of research outcome measures

There are two kinds of research outcomes. They are namely primary and secondary.

Primary outcomes

The sources which cite the incidence of wrong site surgery rates are generally used. This

enlists all sub criteria such as wrong side, wrong procedure and wrong patient surgery. These

outcomes are primarily used based on inclusion and exclusion criteria.

Secondary outcomes

This study does not include the secondary outcomes of research. Also, articles which lacks

primary outcomes and possess only secondary outcomes also rejected in the present study.

Few reported secondary outcomes such as utilisation of health service resources, mortality

rates, and behavioural aspects of health care professionals and also resource burden for health

care service provider teams are included in the research.

Search methods employed in the present study

Systematic reviews related to the surgical site marking practises, databases which enlist the

research journals focusing the surgical practise efficacy and safety. Various primary research

studies are identified from the bibliographic sources of such systematic reviews, relevant

sources and methods. As pointed out by Fiander (2012), final literature search strategies are

very iterative to develop for the current study. In this method, search strategies are screened

by authors, strategies, relevant results. Besides exploring the Medical Subject Headings

(MeSH) and other aspects related to vocabulary of search, none other strategies were

included while performing search in databases. This study is not limited to languages and

literature search was conducted from the period of July to Sep 2015. Recent research

publications from the period of 2008 to 2015 were used for the present analysis study.

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Databases used for search

Medical research databases such as MEDLINE, EMBASE, PUBMED, CENTRAL (Cochrane

Central Register for controlled studies), grey literature, dissertations and thesis were

employed in the present study.

S. No Databases used for the present study

1 MEDLINE

2 EMBASE

3 CENTRAL

4 EPOC

5. CINHAL

6. ProQuest

7. Virtual Health Library

8. LILACS

9. PAHO

10. WHOLIS

Searching for alternate resources

1. Besides conducting literature searches from the above databases, grey literature

findings are also gathered in the present study. The procedure adopted for the search

was

2. Screened individual articles and also conference papers

3. Reviewed list of publications from bibliographic sources

4. Literature sources are also gathered by contacting authors to review or to clarify about

the findings of their study

Data collection

Choice of earlier studies

After conducting an independent screening on title and its corresponding abstracts, it is

analysed whether the gathered articles meet the inclusion and exclusion criteria successfully.

Closer inspection was performed for full open access articles. Studies which failed to match

inclusion criteria are rejected for the analysis. No disagreements arose between inclusion and

exclusion criteria for the gathered data.

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Extraction and Management of Data

Data gathered through the above listed sources are assessed using the above checklist for

selection criteria. Collected data has essential information about the participants, intervention

employed in the study for wrong site prevention, methods, results, experimental settings etc.

Evaluation of bias in current research

Revman (2011) approach was recruited for evaluation of bias in the present study. Shape and

effect of intervention used in the study, incomplete outcome data, previously specified data

intervention. It was identified randomised clinical trials, controlled studies, studies with

similar baseline traits, outcome measurements and knowledge of allocated interventions does

not exhibit bias over theme of research.

Evaluation of heterogeneity

Substantial changes in the study findings that are anticipated over various kinds of

heterogeneity like type of setting, type of intervention, study design and methodological

issues.

Sample size

10 articles were chosen for the present study

Quality of the evidence

Less number of articles was chosen for the study and so the quality of the evidence will be

little bit low

General Agreements and Disagreements

It is commonly aware of any other systematic reviews that specifically evaluated the

effectiveness of either the Universal Protocol for preventing WSS (JHACO 2003) or the

commonly used WHO Surgical Safety Checklist in reducing the incidence of WSS. However,

we were aware of a number of retrospective studies that were of interest to this review. In

particular, Kwaan (2006) examined a series of WSS to determine whether the Universal

Protocol, emphasising preoperative verification, site marking and ’time-out’ practices might

have been preventive. Based on the authors’ retrospective judgement, rather than a

prospective clinical implementation and evaluation of the protocol’s effectiveness, they

determined that approximately 38% of cases identified would have been unlikely to have

been prevented by implementation of the Universal Protocol. While interesting, this finding is

subject to the biases inherent in the retrospective judgement of the authors, and should be

interpreted with caution

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Research tool

PICO Model

The present study employs PICO model as an effective tool. Generally, evidence based

research studies employ the PICO model to generate the questions. The acronym for PICO is

Population, Intervention, Comparison and Outcome. This method is deployed as effective for

searching strategy in medical research.

Population

1. What are the most important traits of the target population described in the present

study?

2. Are the study participants related to the demographic variables such as age, sex and

race?

3. What is the experimental setting of the present study?

4. Who has performed the diagnosis in the case?

5. Does the study enlists few population which are ought to be excluded from the study?

6. Does the study involve any subset population, if so how it is handled by the

researchers?

Interventions

1. Does the study observe any variations in the intervention for eg: intensity of disease,

dosage, delivery mode, health care provider who delivers the dosage, duration of

delivery, frequency of delivery?

2. Whether study includes all kind of variations and meets the inclusive criteria?

3. How the trials are conducted in the documented study?

4. How the clinical trials managed to give the intervention and combined dosage?

Comparisons

1. Compares the chief outcome of the study with other findings

2. This comparison is essential for the decision making process

3. Primary outcomes of the study are reviewed with other types of outcomes and if

sufficient studies are identified, a strong conclusion can be reached based on the

effects.

Outcomes

1. Primary outcomes are the two or three outcomes from among the main outcomes that

the review would be likely to be able to address if sufficient studies are identified, in

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order to reach a conclusion about the effects (beneficial and adverse) of the

intervention(s).

2. Secondary outcomes including the remaining main outcomes (other than primary

outcomes) and also the extra outcomes are also used for describing the effects of

variables subjected to the study

3. Ensure that outcomes cover potential as well as actual adverse effects.

4. Consider outcomes relevant to all potential decision makers, including economic data.

5. Consider the type and timing of outcome measurements

Chapter 3: Presentation of Literature and Initial Discussion

Overview about Wrong Site Surgery

Lack of communication is the main blunder adding to WSS. In an orderly audit, Hempel et al.

(2013) distinguished 125 experimental studies and four clinical practice rules distributed

from 2004 through 2013 that reported reasons for WSS. Their examination uncovered that

essential underlying drivers of wrong-site surgery were because of 1) correspondence issues,

for example, mistaken data and misperceptions of data, 2) not taking after arrangements, 3)

not performing wellbeing strategies in an important manner, 4) deficient approaches, and 5)

the absence of procedural institutionalization added to WSS occasions. As a result of this

proof blend, the scientists prescribed that an institutionalized convention to forestall WSS be

produced though wellbeing couldn't care small clinics directing surgeries.

By 2005, communication was cited as the major cause of WSS accounting for 70% of WSS,

followed by “deficits of procedural compliance (64%), leadership (46%), competency and

credentialing (29%), availability of information (28%), organizational culture (23%),

orientation and training (20%), patient assessment (18%), care planning (17%), staffing

(10%), environmental safety/security (10%), and continuum of care (5%)” (Joint

Commission, 2013, p. 5). Mulloy (2008) discovered comparable results when inspecting the

viability of the 'AORN Right Site Surgery Toolbox' and the UP among 519 enlisted medical

attendants and 325 non-enrolled medical caretaker surgical expert respondents. An

underlying driver investigation of WSS was directed and uncovered three repeating

correspondence hazard circumstances: 1) correspondence disappointments with the patient

and among individuals from the surgical group, 2) correspondence disappointments amid the

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preoperative appraisal of the patient, and 3) correspondence disappointments when checking

the right agent site. Mulloy (2008) found that 91% of enlisted medical caretakers and 73% of

non-enrolled attendant - surgical professionals reported the AORN toolbox was useful. Dunn

(2006) examined 455 WSS records and observed that in 80% of the cases, insufficient

correspondence was the underlying driver of the occasion. Stahel et al. (2010) found that out

of 27,370 self-reported antagonistic events, 85% of WSS occasions were because of lapses in

judgment while 72% were because of inability to perform a surgical 'time-out' preceding cut.

Surgical blunders take a mixed bag of structures.

From DeVine et al., (2010) systematic review of 433,528 spinal surgical cases in

Pennsylvania to focus the occurrence of surgical slips. There were 427 occurrences of WSS

with 70% identified with wrong-side surgeries, 56% to 'close misses', 14% to wrong

area/level surgeries, 9% to wrong systems, and 8% to the wrong patient. The discoveries

demonstrated that WSS is the consequence of breakdowns in correspondence identified with

erroneous surgical site confirmation and off base correspondence between the surgical group.

It additionally demonstrated that WSS came about because of inability to confirm

understanding data preceding surgery. The clinical proposals of this precise survey

recommend that the Joint's utilization Bonus alone is lacking to anticipate WSS. From this

survey, the clinical proposals place that notwithstanding the Joint Commission there are

intraoperative pictures taken after the surgical site is imagined. Preoperative pictures are then

contrasted with these pictures in the space to guarantee the right level of spinal surgery.

Impact of wrong site surgery

Wrong-site surgery is a possibly annihilating circumstance for both the patient and specialist

(Robinson et al 2009). It however keep on being a worry especially in orthopedics, in spite of

real activities to address the issue, for instance the "work through your initials" battle by the

Canadian Orthopedic Affiliation, the "sign your site" activity by the AAOS, the "SMaX"

activity and the Imperial School of Specialists' and NPSA direction. By February 2010, all

doctor's facilities in the UK ought to have actualized utilization of the agenda (PSF 2015). In

any case, consequences of an overview show that more than 60% of units were assessing or

inspecting whether the agenda had any kind of effect by AAOS (2009). Just 29% of clinics

found had distinguished an approach to record the agenda was utilized and having an effect

(NPSA 2013). An absence of vigorous confirmation advancing the agenda's utilization,

briefings and debriefings can never again be refered to as a purpose behind moderate

appropriation of this activity.

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In a recent study conducted by deVries EN et al (2012) uncover that huge decreases in

surgical mortality and horribleness can be made through utilization of agendas. The main

drivers of wrong-site surgery are multi factorial. Be that as it may, highlighting unmistakably

in an investigations' portion incorporate breakdown in correspondence between surgical

colleagues, nonattendance of confirmation in the operation room and of a confirmation

agenda, off base stamping or assent, readiness of the wrong side, inaccurate hanging, patient

offering an explanation to the wrong name and disappointment of a formal 'time-out' system.

In an examination of wrong - site surgery close misses and genuine events, evaluations in

which close misses were recognized that did not advance on to real wrong-site events were

altogether more inclined to report consistence with exercises, for example, quiet ID,

preoperative compromise conventions, documentation of surgical site on assent structure,

support of the specialist in preoperative confirmation and cooperation of all surgical

colleagues in formal time-out systems.

PICO analysis on best practices in surgical site marking

This review throws on systematic overview for identification of best practices in surgical site

marking from the literature using PICO model.

1. Thakar & Mearse (2012)

In a prospective randomised clinical study conducted by Thakkar and Mearse (2012) have

reported that it is very crucial to employ surgical marking to reduce wrong site surgery. In

this study, two different kind of solutions were used namely chlorhexidine based and other

one is iodine based in skin preparations. The study employed both qualitative and quantitative

research approaches to observe the best solution that provides visibility to the surgeons. The

study recruited twenty patients and ten surgeons for assessing the visibility of the marked

site. Results from statistical data clearly remarked that chlorhexidine based solutions used for

surgical site marking was highly visible to the surgeons rather than iodine based site

markings. The study finally concluded that iodine based solutions used for surgical site

marking can reduce the wrong site surgery by increasing the visibility to the surgeons.

Patient 10 surgeons and 20 patients were recruited in this study.

Patient populations who undergone total hip arthroplasty

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were selected.

Intervention Chlorhexidine and Iodine based solutions for marking the

surgical site.

Comparison Both the solutions were marked with random three letters

with respect to the surgeon’s initial in skin according to

manufacturer’s guidelines. These markings were

photographed digitally before and after the skin

application. These initials and skin markings were

recognised by orthopaedic surgeons.

Outcome The statistical results confirmed that mean and standard

deviation of chlorhexidine based solutions used for surgical

site marking is higher than iodine based solutions with

(59.8 ± 15.7 U versus 14.9 ± 11.4 U, respectively; p <

0.0001). Surgeons were less probable to identify

chlorhexidine based sites than iodine. Since surgeons

identified 296 letters out of 300 marked in iodine whereas

only 209 out of 300 letters marked in chlorhexidine. So, it

can be concluded that iodine based solutions can be used

for surgical site marking.

2. Person et al (2012)

In a systematic survey study conducted by Person and his colleagues (2012) on analysing the

impact of stomal site marking in pre-operative conditions on 105 participants using quality of

life survey questionnaires observed that stoma site marking procedure has been observed to

reduce the wrong site surgery, enhancing their autonomy and also reduces the rate of clinical

complications in patients during post-operative conditions. This study employs quantitative

research design to assess the survey responses. Data gathered through survey responses are

analysed statistically through chi squared test with significance p<0.05.

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Patient 105 patients were selected which includes 60 men and 45

women. Patients suffering from colostomy, ileostomy and

urostomy are chosen. Approximately 70% of the variables

are above age 50 and rest 30% were above age 70. Among

105 patients, 49 patients had colostomies, 47 patients had

ileostomies and 9 patients had urostomy. In this study, 57%

of stomas were permanently marked whereas 43% were

marked temporarily.

Intervention Stomal site marking is used as clinical intervention to

reduce the wrong site surgery and its associated post-

operative complications.

Comparison The study compares the effectiveness permanent and

temporary Stomal marking among chosen target

population. In this study, patients are classified into four

groups. They are permanent, temporary, marked and

unmarked.

Outcome Statistical results suggests that patients who had permanent

stomal marking during preoperative conditions had

enhanced quality of life with reduced post-operative

clinical complications such as leakage, skin irritations, lack

of fitness, need for customised pouches and pain.

3. Colwell and Gray (2007)

In a systematic review analysis conducted by Colwell and Gray (2007) have reported that a

wide range of potential risk factors such as age, comorbidity status, smoking, suture choice

affects the preoperative complications. Upon analysing the six articles, authors concluded

that reduced number of evidences suggest that stomal marking has decreased the preoperative

conditions.

Patient 6 articles with reviews, randomised clinical trials, evidence

based studies.

Intervention Stomal site marking for reducing the wrong site surgeries

Comparison Out of 6 studies, only 3 studies emphasised the

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effectiveness of stomal site marking before surgery. In all

these studies, participants who received stomal site

marking obtained high scores in reduced postoperative

complications.

Outcome Author concludes that most of the articles emphasised that

stomal marking will reduce the postoperative complications

and decreases the incidence of wrong site surgery.

4. Shah et al (2011)

In a survey study conducted by Shah and his colleagues (2011) analysed the surgical site

marking and surgical timed out procedures. The study employed quantitative research design

with open ended survey questionnaire among chief paediatric surgeons and operation theatre

heads. The survey results are analysed using Chi squared test. 84% of the chief surgeons are

satisfied with surgical site marking procedures for nasal surgery and endoscopy.

Patient The present study included operation room directors and

surgeons of paediatric hospital with 167 child patients.

Intervention Various kinds of surgical site marking are compared with

respect to the satisfaction of the surgeons.

Comparison Site marking procedures for ventilation tube, adenostillar,

endoscopy, and nasal surgery and ear tube placement

surgeries were compared.

Outcome Statistical analysis were conducted by chi squared tests

depicts that elderly surgeons most likely prefer site

marking using markers for bilateral myingotomy placement

whereas 84% of surgeons prefer surgical site marking.

5. Harman and Benjamin (2013)

In a prospective study conducted by Harman and Benjamin (2013) have emphasised the

effectiveness of new method in surgical cavity using bio absorbable 3 dimensional tissue

marker. This study employs quantitative research method to estimate the effectiveness of bio

absorbable tissue marker namely BioZorb TM implanted during lumpectomy among patient

populations. The current study stresses that preoperative imaging studies such as X-ray,

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mammography, CT-scans and magnetic resonance imaging (MRI scans) shall assist the bio

absorbable tissue marker in surgical site marking process. In this study, 16 participants were

selected. These tissue markers are classified into two types namely marker made up of

titanium and PLA. The selected patients who undergo lumpectomy had imaging studies such

as mammogram, MRI and CT scans and followed by the implantation of tissue markers prior

to lumpectomy. The results suggest that tissue markers easily absorbed with the tumours and

clearly delineated the margins of the malignant tumours.

Patient 16 patients undergoing breast conservation surgery were

chosen in this study.

Intervention Patients undergoing lumpectomy are selected in this study

and intervened with tissue marker BioZorb

Comparison Every patient has previous imaging studies in lymph nodes

near the surgical site. In each case, tumour and tissue flats

in surgical cavities. The effectiveness of these markers is

evaluated among 16 participants.

Outcome The results suggest that malignant tumours are clearly

marginalised with tissue markers in every patient. Besides

surgery, it was also found to help radiation therapy among

breast cancer patients.

6. Mears et al (2009)

The main aim of this study is to analyse the withstanding capacity of solution preparations in

surgical site marking. Frequently, chlorhexidine based solutions and iodine solutions are used

for surgical site marking. Site marking preparation that withstands large period requires

additional scrubbing. In this study, 5 types of cadaveric skin flaps were employed. Each

sample was marked with two rows with nine various types of skin markers. One of skin

markings was treated with chlorhexidine based skin marking preparations and other row was

treated with the iodine based solution. Using imaging software, the digital photograph of skin

NotesMonkey

flaps including snaps taken before and after the site marking was assessed for greyscale

region. The variations in the greyscale region contrast were statistically evaluated using

multiple regression analysis method using SPSS and significance of p<0.05 was estimated for

difference in greyscale contrast among rows and markings in skin flaps.

The study followed standard procedures for surgical site marking. Nine different type of skin

markers such as Sandel 4-in-1 marker (skin, wide) (Sandel Medical Industries, LLC,

Chatsworth, Calif); (2) Waterproof Permanent Marker-Mini, Fine Tip (Viscot Medical LLC,

East Hanover, NJ); (3) OP-marks mini markers (OP-marks, Inc, Bogart, Ga); (4) OP-marks

mini max (OP-marks, Inc); (5) Accu-line wide body (Accu-line Products, Inc, Hyannis,

Mass); (6) Sharpie super permanent marker (Sanford Corporation, Oak Brook, Ill); (7)

Securline surgical skin marker no. 1000 (Precision Dynamics Corporation, San Fernando,

Calif); (8) HMS Twin-Tip broad (Hospital Marketing Services Co, Inc, Naugatuck, Conn);

and (9) HMS Twin-Tip fine (Hospital Marketing Services Co, Inc). A single line mark 50mm

long was made in every row using nine different skin marker pens.

After marking, each skin flaps are photographed using digital camera with 10.1 megapixel

camera and 100 mm macro lens of Canon camera, USA. The important camera settings

include the speed of shutter 1/60 seconds and F stop value as 4.0. These images are analysed

for greyscale contrast regions using Adobe Photoshop CS2. Using this software, the images

are converted into 256 grayscale levels. The differences between the grayscale regions before

and after the marking are assessed using statistical software STATA 10 developed by

STATACORP. The results clearly depicts that chlorhexidine based solutions has less

grayscale regions than iodine based solutions and concludes strongly that iodine based

solutions has high grayscale regions than chlorhexidine and additionally marking sites treated

with chlorhexidine erased soon than iodine. The main limitations of this study are the present

study employed cadaveric skins than live skin; no literature evidence exists for different

reactivity over the various kinds of markers. All specimens in this study has exhibited light

discolouration. Dark pigmentation is expected among one of the solutions used for the site

marking

Patient/Population Five skin flaps from the different cadavers are chosen for

this study.

Intervention Surgical site marking and its efficiency was assessed using

five skin flaps from various cadavers.

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Comparison Nine different markers such as Sandel 4-in-1 marker (skin,

wide) (Sandel Medical Industries, LLC, Chatsworth, Calif);

(2) Waterproof Permanent Marker-Mini, Fine Tip (3) OP-

marks mini markers; (4) OP-marks mini max (5) Accu-line

wide body (6) Sharpie super permanent marker; (7)

Securline surgical skin marker no. 1000; (8) HMS Twin-

Tip broad and (9) HMS Twin-Tip fine are used to draw

straight marking lines in 50mm long and digitally

photographed and converted into the grayscale to evaluate

the contrasts in the withstanding time for long time.

Outcome Upon conducting the multiple regression analysis using

STATA observed that presently available skin markers gets

easily erased with chlorhexidine based solutions than

iodine based solutions. However, such erasing of site

marking could be prevented by improving the marker

technology. Authors conclude that no marker is susceptible

to the chlorhexidine or iodine based skin preparation

solutions. It can be effectively used for scrubbing method.

So, chlorhexidine based solutions needs additional efforts

than iodine based solutions while using surgical site

marking among patients.

7. Bergal et al (2011)

Bergal et al (2011) has conducted a nonrandomised clinical trial among 200 participants to

evaluate the willingness of patients to undertake surgical site marking. 200 patients

undergoing orthopaedic surgery are recruited in this study. Participant’s data such as age,

gender, type of the procedure and history of previous type of orthopaedic surgeries and

smoking status of patients. The study results displays that mean age of the patients is 48 and

time lapse between surgical site marking enrolment and surgery. The main results conclude

that there was no significant relationship between patients involvement in surgical site

marking which is regarded as unreliable. Authors finally concluded that patient’s

demographic variables are entirely unrelated with the demographical variables such as age,

gender, income, smoking status etc.

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Patient/Population In this study 200 patients who had undergone orthopaedic

surgery are recruited.

Intervention All the demographic details of the participant patients are

retrieved and their willingness to site marking are also

noted.

Comparison The overall response rate is 68%. There was no statistical

significant difference noted with the willingness with

respective to the willingness of preoperative surgical site

marking procedures.

Outcome Authors concluded that patient’s demographic variables fail

to show significance with willingness to take up the

surgical site marking procedures. The study achieves only

68% compliance rate and with less likelihood for surgical

site marking and demographic variables, reduction of

wrong site surgery using surgical site marking procedures

possess only less chances. So, it may not be a better option

to reduce wrong site surgery.

8. Suzuki et al (2014)

The chief aim of the research investigation conducted by Suzuki and his colleagues (2014)

evaluated the clinical and technical efficacy of CT-guided hook wire marking for conducting

video assisted thoracic surgeries to remove pulmonary lesions. The current study is designed

as quantitative experimental research design and employed 154 patients undergoing thoracic

surgery as participants. The study population encompasses 75 men and 79 women with the

median age as 62 years. The age groups of participant population range from 23 to 89 years.

The study assesses both technical and clinical efficacy based on medical records, imaging

studies, surgical success rate and finally postoperative surgical complications. The study

defines accomplishment of technical success as successful hook wire marking on pulmonary

lesions without dropping the marker before video assisted thoracic surgery and surgical

success rate was achieved by negative surgical margins upon pathological examination after

VATS among patients. The study finally concludes that CT hook wire marking achieved

97.5% of technical success and surgical success was reported as 98% with 158 /161 surgeries.

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Patient/Population 154 patients with 161 pulmonary lesions who undertake

Video Assisted Thoracic Surgeries (VATS) are chosen for

the current study. Totally 75 men and 79 women were

selected with age group 23 to 89 years with median age as

62 years.

Intervention CT guided hook wire for surgery is widely employed for

the localisation of lesions after conducting the PET/CT

imaging studies. This method employs kopans spring

localisation needles which consist of hook wire and an

introducer needle. A radiopaque skin marker is generally

used for this aseptic procedure. Achieving technical

success in this procedure includes estimation of pathway

for CT guided hook wire marking to avoid the vascular

structures carefully and marking the site using radio opaque

marker. The distance from lesion to marker is essential for

introducing the appropriate needle and hook wire.

Comparison The technical success rate was 97.5% (157/161). In three of

the four failed cases, another hook wire marker was placed,

and in the remaining case, VATS was performed without a

marker. The surgical success rate was 98.1% (158/161). In

the three failed cases, the margin was positive, so lung

lobectomy was performed in one case, and the other two

cases were observed carefully. Complication rates were as

follows: pneumothorax, 37.9% (61/161); focal

intrapulmonary haemorrhage, 34.8% (58/139);

haemoptysis, 0.6% (1/161); haemothorax, 0% (0/161); air

embolism, 0.6% (1/161); dissemination, 0% (0/161); and

death, 0% (0/161) by using CT guided hook wire site

marking method.

Outcome Authors conclude that CT guided hook wire site marking

achieved 97% technical and 98% surgical success rates in

VATS.

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9. Hoang (2012)

In a study conducted by Hoang (2012) has analysed the efficacy of CT guided hook wire

marking in detecting non palpable cervical lymph nodes. Authors describe that PET/CT

imaging studies greatly assists in detecting the metastasis among cancer patients. Non

palpable lesions from breast tissues are easily detectable using imaging studies and so site

marking performed using the assistance of imaging techniques largely help for the co-

localization of tumours or lumps during surgeries. This study has utilised non randomised

clinical trial using three subjects. Three patients each suffering from different type of

carcinoma are recruited in this study. Patient A was suffering from adenoid cyst carcinoma in

T2a stage, Patient B possess medical history of large B cell carcinoma and patient C is

suffering from high grade ovarian carcinoma in stage III c. All three study participants were

observed to be female with age ranging from 58 to 65 years with mean age as 61 years. All

patients received chemo and radiation therapy previously. Hook wire marking to remove

lesions are successfully performed for all patients. Mean intervention time taken for this

procedure is 9 minutes with the mean operation time of 75 minutes for each patient. Surgeons

do not report any mistakes during surgical resections such as wrong delineation of lesion

margins before surgery. The study also looked for postoperative complications among the

patients. Pathological findings reported that patient A had no lesions in lymph nodes, patient

B had follicular hyperplasia without the clinical features of lymphoma and finally Patient C

had metastatic carcinoma sharing similar morphology of ovarian carcinoma. The study finally

concludes that hook wire marking using CT/PET imaging techniques efficiently localises the

lesions and tumours before surgery and assists the surgeons. Also, the post-operative

complications were seemed to be less among patients.

Patient/Population Three female patients with medical history of malignancy

were selected. Mean age of patient is 61. Patient A was

suffering from adenoid cyst carcinoma in T2a stage, Patient

B possess medical history of large B cell carcinoma and

patient C is suffering from high grade ovarian carcinoma in

stage III c. All three study participants were observed to be

female with age ranging from 58 to 65 years. All patients

received chemo and radiation therapy previously and

suffering from advanced stages of cancer.

Intervention CT/PET guided hook wire surgical site marking method

NotesMonkey

was used as surgical intervention for guiding the surgical

removal of lesions and lumps.

Comparison Out of three participants, 2 patients were found to have

successful surgical resection by employing the CT/PET

guided hook wire surgery. Only one patient had metastatic

carcinoma after surgical resection. Moreover, postoperative

complications are also not observed during the CT guided

hook wire site marking method. So, this method was

observed to achieve 90% success in technical and surgery.

Outcome Preoperative CT guided hook wire site marking was

observed to be safe and effective method for surgeries. The

imaging techniques used for site marking enhances the

visibility of the surgical sites before the surgery.

10. Li et al (2014)

Li and his colleagues (2014) has analysed the effectiveness of hook wire positioning method

before the thoracoscopic surgery. This study employs 84 patients who undergo thoracoscopic

wedge resection from the period of January to December 2013. Study participants were

grouped into two classes. Bunch A comprised of 38 situations where the snare wire situating

method was not utilized, and the situating methodologies were intraoperative perception and

palpation. Class B comprised of 46 situations where the snare wire situating method was

used. The distance across of every knob was under 2 cm, what not patients experienced the

operation inside of 2 h of obtrusive situating. The assessment files included situating

achievement rate, situating related difficulties, and rate of transformation to thoracotomy. In

Class A, nine patients (23.68%) experienced transformation to thoracotomy; in Class B, three

patients (6.52%) did. This distinction was factually critical (P < 0.05). The normal operation

span was 118 ± 21 min in Gathering and 53 ± 18 min in Gathering B. The distinction

between both gatherings was factually huge (P < 0.05). The normal length of healing center

stay of patients who experienced transformation to thoracotomy was 8.7 ± 2.2 days, and of

patients who experienced thoracoscopic pneumonic wedge resection was 4.5 ± 1.6 days. This

distinction was measurably critical (P < 0.05). Authors finally conclude that results from

quantitative analysis emphasises that CT scan guided hook wire marking method effectively

NotesMonkey

localises the pulmonary nodules during preoperative thoracoscopic surgery. Besides helping

in the co-localisation of pulmonary nodules, it also effectively lessens the rate of conversion

to thoracotomy, and minimises the time taken for the thoracoscopic surgery.

Patient/Population Fifty one male and 33 female patients with medical history

of pulmonary lesions and who undertook thoracoscopic

surgeries were chosen in the present study. The

experimental set up has two groups with group A

consisting of 38 patients and Group B of 46 patients. Only

group A receives the CT guided hook wire positioning

system whereas group B undergoes thoracoscopic surgery

without CT guided hook wire positioning.

Intervention CT/PET guided hook wire surgical site marking method

was used as surgical intervention for guiding the surgical

removal of lesions and lumps during thoracoscopic surgery

Comparison In Class A, nine patients (23.68%) experienced

transformation to thoracotomy; in Class B, three patients

(6.52%) did. This distinction was factually critical (P <

0.05). The normal operation span was 118 ± 21 min in

Gathering and 53 ± 18 min in Gathering B. The distinction

between both gatherings was factually huge (P < 0.05). The

normal length of healing center stay of patients who

experienced transformation to thoracotomy was 8.7 ± 2.2

days, and of patients who experienced thoracoscopic

pneumonic wedge resection was 4.5 ± 1.6 days. This

distinction was measurably critical (P < 0.05).

Outcome Preoperative CT guided hook wire site marking was

observed to be quick, reliable, safe and effective method

for surgeries.

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Chapter 4: Discussion and Future Implications

Discussion

Surgical site marking has gained popularity in recent years due to reduced impact over wrong

site surgeries. There are various methods employed by surgeons to reduce wrong site surgery

such as timed out method, surgical safety check list, surgical site marking etc. Among these

practices, surgical site marking was employed conventionally in surgical practices. The

present study is designed as qualitative method utilising secondary data collection methods

for attempting to answer research question. Due to the convenience and less time needed for

accessing the literary archives, the current research is designed as secondary research. In this

method, data is gathered from summary of medical research sources like books, reviews,

consensus reports and raw or original findings from various research articles and journals

directed towards various methods for surgical site marking. Although, the need of clinicians

is different from the need of the researchers and other non clinical professionals, this model

will be very much beneficial in making preliminary researches so that based on the findings

of the present study further research investigations can be directed in primary research

designs. Thus, in this study, research articles and medical sources are retrieved from

MedLine, PubMed, PubMed Central are employed and critically reviewed. The study

attempts to answer research question entitled ““what is the best method for surgical site

marking?”. Out of 15 articles retrieved from above databases from the period of 2008 to

2014, only 10 articles met the inclusion criteria of this research.

Chlorhexidine vs Iodine based skin preparations for surgical site marking

Studies conducted by Thakar and Mearse (2012) and Mearse (2009) focuses on the use of

chlorhexidine based solution and iodine based solutions for surgical site marking. Both the

studies focus on the efficacy of iodine based solutions since chlorhexidine based solutions

erase the skin markings made in the skin surface. The withstanding time is very long for

chlorhexidine based solutions than iodine based solutions. So, authors clearly conclude that

iodine based solutions are safe and reliable way to mark sites due to the issues regarding

postoperative complications and wrong marking. This study also recommends that iodine

based solutions is very helpful for surgeons.

Stomal site marking and its effectiveness

Studies from Colwell and Gray (2007) and Shah et al (2011) recommends the effectiveness of

stromal site marking among paediatric surgeons and author concludes that most of the articles

emphasised that stomal marking will reduce the postoperative complications and decreases

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the incidence of wrong site surgery among 20 surgeons working with 167 child patients.

Statistical analysis were conducted by chi squared tests depicts that elderly surgeons most

likely prefer site marking using markers for bilateral myingotomy placement whereas 84% of

surgeons prefer surgical site marking.

Bio absorbable Tissue marker

Harmen and Benjamin (2013) have stressed the safety and efficacy of BioZorb, a

trademarked product for tissue marking before surgical resections. The results suggest that

malignant tumours are clearly marginalised with tissue markers in every patient. Besides

surgery, it was also found to help radiation therapy among breast cancer patients.

Relationship between willingness and demographics for surgical site marking

A survey study from Berg et al (2010) has stressed that there was no significant relationship

between patients involvement in surgical site marking which is regarded as unreliable.

Authors finally concluded that patient’s demographic variables are entirely unrelated with the

demographical variables such as age, gender, income, smoking status etc. In this study 200

patients who had undergone orthopaedic surgery are recruited. The overall response rate is

68%. There was no statistical significant difference noted with the willingness with

respective to the demographics of patients undergoing preoperative surgical site marking

procedures. Another study by Person et al (2012) has conducted a survey study on 105

participants using quality of life survey questionnaires observed that stoma site marking

procedure has been observed to reduce the wrong site surgery, enhancing their autonomy and

also reduces the rate of clinical complications in patients during post-operative conditions.

This study employs quantitative research design to assess the survey responses. Data gathered

through survey responses are analysed statistically through chi squared test with significance

p<0.05. Statistical results suggests that patients who had permanent stomal marking during

preoperative conditions had enhanced quality of life with reduced post-operative clinical

complications such as leakage, skin irritations, lack of fitness, need for customised pouches

and pain

CT guided hook wire surgical site marking.

Studies conducted by Suzuki et al (2014), Hoang (2012) and Li et al (2014) has stressed the

safety, reliability, speed and efficacy of the surgical operations. Li et al (2014) reports that in

Class A, nine patients (23.68%) experienced transformation to thoracotomy; in Class B, three

patients (6.52%) did. This distinction was factually critical (P < 0.05). The normal operation

NotesMonkey

span was 118 ± 21 min in Gathering and 53 ± 18 min in Gathering B. The distinction

between both gatherings was factually huge (P < 0.05). The normal length of healing center

stay of patients who experienced transformation to thoracotomy was 8.7 ± 2.2 days, and of

patients who experienced thoracoscopic pneumonic wedge resection was 4.5 ± 1.6 days. This

distinction was measurably critical (P < 0.05).

Studies from Nouri et al (2013) has stressed that hook wire positioning method guided with

PET or CT scans are efficiently used in pneumothorax, pulmonary haemorrhage etc. Also

reports from (Masroor et al, 2012) argue that using hook wire to position lesions might cut

the steel wire used for the surgery. But convincing reports from (Miyoshi et al., 2009) has

recommended that hook wire positioning decreases the dislocation of lesion and tumours

during the surgery. Also, it is deep penetrable to the pulmonary nodules and accomplishes

current surgical sites during preoperative conditions. All in all, thoracoscopic preoperative

CT-guided snare wire situating is a speedy, exact, and compelling technique that adds to the

evacuation of pneumonic knobs that are little in width and delicate in surface. It can viably

diminish the rate of change to thoracotomy, diminish the operation time, and grow the

surgical signs. The procedure has some blemishes in situating shallow little aspiratory knobs

and profound pneumonic knobs. The quantity of cases utilized as a part of our study was

little, and the specimen size should be extended in future exploration with a specific end goal

to get more solid results. So, the study concludes that CT guided hook wire marking

effectively guides the surgeries.

Future Implications

The present study is conducted as the preliminary research to identify the best practises in the

surgical site marking to reduce the wrong site surgeries. In future, this research is planned to

conduct on 1000 participants suffering from various kinds of malignancies are selected with

the medical history of chemotherapy or radiotherapy and aimed to evaluate the effectiveness

of CT guided hook wire site marking for surgical removal of lumps or malignant tumours

from the sample participants. The main aim of the study is to identify the differences on the

safety and efficient localisations with respective to the specific carcinoma involved in the

study.

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Chapter 5: Conclusion and Limitations

Conclusion

1. The present study is aimed to analyse the ideal practices followed by surgeons for

surgical site marking as literature remarks that surgical site marking reduces the

wrong site surgery by concentrating on both post and preoperative surgeries. The aim

of the study has identified best methods to prevent wrong site surgery thereby

analysing the effective method for surgical site marking that assists the surgeons. The

following research objectives are designed to answer the research question of “what

is the best method for surgical site marking?”

They are as follows

1. To analyse the impact of wrong site surgery and its adverse effects

2. To identify the importance of surgical site marking in preventing wrong site surgery

and its associated fatalities.

3. To observe the best and effective method for surgical site marking

4. To discuss the effectiveness of the method from various medical research databases,

journals, research articles and other online sources

5. To conclude and discuss based on the methods addressed in the literature.

First objective was achieved by gathering the statistical incidence of wrong site surgeries

around the world. It was observed from literature evidences that incidences are continuously

increasing per annum. Second and third objectives are acquired by conducting a qualitative

research study on the practise based extended critical review of literature was chosen as the

research design. The ultimate reason for selection of this model is to identify the best

methods for surgical site marking from the available medical literature and to critically

review which method is widely used in current medical practise. Growing source of

information available in the form of electronic records and medical research databases have

reduced the pain of researchers and healthcare practitioners for identification and selection of

ideal method which is retrieved effectively at reduced cost of time and money. This study is

conducted as a preliminary research to observe the best method for surgical site marking

practise to prevent the wrong site surgery. Due to the convenience and less time needed for

accessing the literary archives, the current research is designed as secondary research. In this

method, data is gathered from summary of medical research sources like books, reviews,

consensus reports and raw or original findings from various research articles and journals

NotesMonkey

directed towards various methods for surgical site marking Thus, in this study, research

articles and medical sources are retrieved from MedLine, PubMed, PubMed Central are

employed and critically reviewed.

It was observed that totally 10 articles met inclusion criteria and only two studies confirmed

the efficacy of iodine based site marking preparations for surgeries and only one study

confirmed the efficacy and safety of tissue biomarkers for surgical resection and radiotherapy

which is cost effective in nature. But three studies have confirmed the efficiency of CT scan

guided hook wire marking or positioning system during preoperative conditions. The

literature suggests that it is widely used for cancer related surgical resections such as

ovarectomy, lumpectomy and removal of lesions. Studies from Nouri et al (2013) has

stressed that hook wire positioning method guided with PET or CT scans are efficiently used

in pneumothorax, pulmonary haemorrhage etc. Also reports from (Masroor et al, 2012) argue

that using hook wire to position lesions might cut the steel wire used for the surgery. But

convincing reports from (Miyoshi et al., 2009) has recommended that hook wire positioning

decreases the dislocation of lesion and tumours during the surgery.

Limitations

The present study exhibits following study limitations

• Less time was available to gather data

• The duration of the study includes from 2007 to 2014, but only 15 articles were

available suggesting the lack of research in this area.

• To reduce the wrong site surgeries, most of the surgeons still employ traditional joint

commission based check lists and most of the research studies were targeting the

efficacy of checklists and efficient education and training program for nurses, doctors

and surgeons

• The sample size of 10 articles is very low and further research should be executed to

strongly conclude the safety, reliability and efficacy of the CT guided hook wire

positioning site marking system.