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


General Surgery Department, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, England, UK. [Email]


BACKGROUND : 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.
CONCLUSIONS : 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.