Blog 2: My fateful day, the 23rd March 2012

March 2012 in England was the third warmest March on record – and according to the Met Office, it was outshone only by 1938 and 1957.

My calm and relaxed drive to the private clinic, in the company of my wife and daughter, was enhanced by the beautiful English countryside scenery.

As we approached the clinic, I reminded them of the fact that hernia repair for us surgeons is a routine operation and there is nothing for them to worry about. I also reassured them that I am in good hands. I paused for a moment as I remembered something, and then added, but there is one thing and only one thing I feared most — nerve entrapment by a suture.

I vividly remember two victims of nerve entrapment from the time when I was training as a surgical registrar. God Oh God, did they suffer!

I pledged to myself that such an awful and negligent mistake would never happen to any of my patients.

At eleven o’clock in the morning I checked into the private clinic.  As soon as I paid for my treatment, I was ushered to my room by one of the nurses. I was then made to complete some paperwork.

In my private room before my hernia operation

My wife had to leave for a job interview in another hospital. As she waved goodbye, I gave her the thumbs up that everything will be fine. My daughter Alia stayed with me. My son Riyadh couldn’t be with us today as he was in college.

The surgeon paid me a quick visit. One odd thing I noticed is that he did not greet my daughter! That certainly did not impress her!

I was expecting him to ask permission from my daughter to leave the room so that he can examine me. But instead, he examined me in the private room’s toilet. He confirmed the presence of my hernia and then marked the operation site. Nothing else – I will come back to that in a future blog. 

Even though I am an experienced surgeon and having done well over a thousand of hernia repairs myself, I was expecting him to tell me the way he was going to do my operation along with any potential risks and complications – he didn’t. I had not seen him for well over 17 years.

Not only that he did not tell me about any potential risk, but crucially he did not mention to me that one of the dangers was nerve injury by suture entrapment. Had he done so I would have been extremely concerned because I knew that this is a complication which should not arise in competent hands. Had he said that he was at risk of damaging a nerve by suture entrapment, I would not have agreed to go ahead with him. I would have wanted to choose a surgeon who was confident that he would avoid what I would have regarded as a negligent complication of surgery.

When it comes to my patients, I make no exceptions whatsoever, and I give the same amount of information to all, doctors or otherwise.

Here is a copy of my consent form:

Please note that this copy was part of my medical record that was sent to me on the 11th July 2012 by the General Manager of the private hospital.

What is your opinion about this consent? I shall put this consent form under the microscope and analyse it carefully in one of my future blogs.

As there was a paucity of forthcoming information, I requested that the surgeon

  • Does my operation open and not laparoscopic (keyhole surgery)
  • Perform Lichtenstein (tension-free) hernia repair
  • Make the skin cut horizontal and not oblique
  • Use a lightweight partially absorbable Ultrapro mesh (associated with less pain and inflammation)

He said, “I will do whatever you like Adel.”

It was the anaesthetist (whom I also knew from my surgical training days) who alerted me to the fact that the surgeon uses skin staples to close the wound. When I asked some other questions, the anaesthetist said: “I shall ask your surgeon to see you again in the anaesthetic room before you go to sleep.”

The surgeon saw me again in the anaesthetic room. He stressed that he uses skin staples to close the wound and does not normally use dissolvable subcuticular (under the skin) stitches. Again, I reminded him to use ultra-pro mesh.

On my way to the operating theatre

Here is a copy of my operation note:

Please note that this copy was part of my medical record that was sent to me on the 11th July 2012 by the General Manager of the private hospital.

Here is the transcript for this operation note:

“Left Inguinal Hernia Repair

Groin incision

Large direct defect controlled with nylon (Bassini). Lichtenstein repair with prolene mesh and nylon sutures. Vicryl + Clips for closure

Home later. Clips out 7/7.”

It is worth mentioning here that the surgeon’s transcript of this operation note (in his witness statements) was different from the above!

Any views about this operation note? What type of mesh did the surgeon use? Will come back to that in a future post.

Can you spot the odd thing in following postoperative observation record? Please note that this copy was part of my medical record that was sent to me on the 11th July 2012 by the General Manager of the private hospital.

After one hour and forty minutes in the operating theatre complex, I was returned to my private room where my daughter was anxiously waiting.

My daughter Alia preparing toasted bread with butter and jam for me.

Thirty-seven minutes after I returned to my private room, I text messaged a work colleague who wished me well before I went to the operating theatre:

“just came out of operation.”  “It is bloody sore despite Local Anaesthetic. Can’t move.”

The nurse who looked after me after my operation recorded that my pain level was 0/10.

It was painful for me to walk and I needed the support of my wife and daughter. My wife drove us back home.

As soon as I got home, I went straight to bed and fell asleep.

The following morning at one thirty, I woke-up to pass water, but as soon as I moved to get out of bed, I was in excruciating pain (a lot more about this in later blogs). My wife helped me get out of bed. I went back to sleep and woke up again at five o’clock in the morning in extreme amounts of pain.

In my next blog, I shall tell you about what happened during the first week after my operation.

Detailed information for future reference:

Please note that I collected this information from the copy of my medical record that was sent to me on the 11th July 2012 by the General Manager of the private hospital.

I have collected the following information from my medical records (this is just for future reference):

12:15 – Nurse’s assessment for VTE (Venous Thrombo-Embolism) risk.

No recorded time – Consultant anaesthetist visited me in my room.

No recorded time – Surgeon visited me in my room (he did not write anything in my notes apart from what was in my consent form – I will return to this in my future blogs).

14:20 to 14:45 – Anaesthetic Practitioner’s record in the anaesthetic room.

14:40 – Knife to skin.

14:40 – Paracetamol 1 gram.

No recorded time – Tramadol 100 mg.

No recorded time – Diclofenac 75 mg.

No recorded time and no name – Wound infiltration with 20 ml of 0.5% Marcaine.

15:15 – Time out.

15:25 to 15:35 or 15:45 (two different recorded times!) – In the recovery room.

Instructions written in my notes for the recovery room staff – Morphine 2 mg at 5 minutes intervals until comfortable (not clear if any of this was given).

16:00 – Returned to the ward.

16:30 – Oral fluids and light diet commenced.

17:30 – Last postoperative observation recorded.

17:30 – Passed urine.

18:30 – Documented in the Communication page, “He is going home @ 18:30.”

I was sent home on Paracetamol 1000 mg four times per day + Diclofenac (Voltarol) 75 mg three times per day + Tramadol 100 mg four times per day for one week.

 

From the above, we can conclude that the total operating time was 35 minutes (14:40 to 15:15).  

Total time in the operating theatre was 1 hour and 40 minutes (14:20 to 16:00).

About the Author

Dr Adel H. Rateme
Retired Consultant General Surgeon and Oncoplastic Breast Surgeon

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