Table 7 Eight clinical scenarios of emergency surgical procedures and classification of complications

1

A patient with generalized peritonitis was admitted to the hospital. The patient was in septic shock and large volume fluid resuscitation and vasopressor medication were administered in the emergency department. Laparotomy was performed and a perforated diverticulitis was managed with the Hartmann’s procedure. Postoperatively the patient was in the ICU for 6 days, recovered from septic shock and was discharged from hospital 2 weeks later.

Classification: (preoperative organ dysfunction), no complication

2

The same patient as in scenario 1, but resection and primary anastomosis was performed. Postoperatively the patient was admitted into the ICU. After 7 days patient had not recovered, and increasing doses of norepinephrine were needed. Computed tomography on seventh postoperative day showed a large (10 cm) pelvic abscess. The patient was re-operated and anastomotic leakage was managed by resection of the anastomosis and end-colostomy. After the second operation the patient recovers and is transferred to regular ward after 13 days and discharged from hospital 4 weeks later.

Classification: (preoperative organ dysfunction), grade IVb complication

3

An elective laparoscopic sigmoid resection due to diverticular disease was performed in another hospital in a 62-year old man. The patient was discharged in good condition on the second postoperative day according to enhanced recovery after surgery program. On the sixth postoperative day the patient develops severe abdominal pain and presents to our hospital with signs of peritonitis. While waiting for a CT scan his blood pressure drops and despite fluid resuscitation vasopressors are needed to maintain adequate blood pressure. Free air was found in the CT, and anastomotic dehiscence was found in emergency laparotomy requiring a Hartmann’s procedure. Postoperatively the patient recovered from shock and stayed in the ICU for two days, and was discharged from hospital 10 days later.

Classification: (preoperative organ dysfunction), no complication Note: Surgical unit, that had done elective surgery, should classify this patient as grade IV complication.

4

A 73-year old woman was admitted to the hospital with a sudden onset of severe abdominal pain. She had signs of peritonitis and free air on CT-scan, but no organ dysfunctions. Patient aspirated during intubation in the operating room. Emergency laparotomy was performed and a perforated duodenal ulcer was sutured with an omental patch. Postoperatively the patient developed signs of MODS, required mechanical ventilation, vasopressor support and was oliguric. She was transferred to the ICU where bilateral pneumonia was diagnosed later. After ten days of intensive care the patient was transferred to the regular ward, and she was discharged from hospital three weeks later.

Classification: (no preoperative organ dysfunction), grade IVb complication

5

A 23-year old hockey player was admitted to hospital due to blunt grade IV splenic trauma. He was haemodynamically stable, but the haemoglobin level was 70g/l and in the CT-scan there was a lot of intra-abdominal blood. Emergency laparotomy and splenectomy were performed. However, during the surgery there were technical difficulties to achieve haemostasis and the operation lasted for three hours. Due to bleeding the patient received 12 units of packed red blood cells and 8 litres of crystalloids during the first 24 hours. Postoperatively the patient was admitted to the ICU, required vasopressors during the first day and was mechanically ventilated for 2 days. The patient recovered and was discharged from hospital 6 days later.

Classification: (no preoperative organ dysfunction), grade IVb complication

6

The same patient in scenario 5, but the operation was performed without problems in 40 minutes. The patient was extubated after surgery and transferred to the regular ward postoperatively. The patient got only 4 units of packed red blood cells and 4 litres of crystalloids. The postoperative course was uneventful.

Classification:(no preoperative organ dysfunction), no complication

7

A 31-year old man with abdominal gunshot wound was admitted to the hospital. He was in haemorrhagic shock and required endotracheal intubation. The patient was transferred directly to the operating room, and emergency laparotomy was performed. Multiple bowel injuries and bleeding from mesenteric and left iliac vessels were found. Damage control laparotomy with good haemostasis was performed and the abdomen was left open at the end of the operation. The patient received 20 units of packed red blood cells and 12 litres of crystalloids. Postoperatively the patient was transferred to the ICU, mechanically ventilated and recovered from shock during the first postoperative day. Thirty-five hours later a planned re-operation was performed with restoration of bowel continuity and closure of the abdomen. The patient was extubated on the fifth day and transferred to the regular ward. The patient recovered and was discharged 12 days later.

Classification: (preoperative organ dysfunction), no complication

8

A 42-year old man with drug addiction was admitted to the hospital because of multiple abdominal stab wounds. He was haemodynamically stable but had signs of peritonitis. Emergency laparotomy was performed and two traumatic perforations in the transverse colon and one perforation in the ileum were identified and sutured. Postoperatively the patient was treated in the regular ward. He had constant pain requiring repeated doses of opioids. On the third postoperative day the patient developed shock, was transferred to the ICU by the medical emergency team and a CT-scan was performed. There was a considerable amount of peritoneal fluid, but no free air. An explorative laparotomy was performed and a missed perforation in the jejunum was found and sutured. Postoperatively the patient recovered uneventfully.

Classification: (no preoperative organ dysfunction), grade IVa complication