Effect of the neurosurgeon's surgical experience on outcomes from intraoperative aneurysmal rupture.

OBJECTIVE: The neurosurgeon's surgical experience is one of the most important and least studied factors affecting a patient's outcome after an intraoperative rupture of an aneurysm. Therefore, this analysis was undertaken to evaluate the effect of the neurosurgeon's experience on the management of this catastrophe in a consecutive series of patients treated microsurgically.
METHODS: The neurosurgeon's surgical experience was analyzed in terms of annual aneurysm case volume and duration. Management of intraoperative aneurysmal rupture was analyzed in terms of timing of rupture, duration of temporary clipping, and neurological outcomes using the Glasgow Outcome Scale. During a 7-year period in which 1038 aneurysms were treated microsurgically in 838 patients, 68 (6.6%) ruptured intraoperatively.
RESULTS: The neurosurgeon's annual aneurysm case volume increased by 35% over this period, and mean case duration decreased by 31%. The annual frequency of intraoperative ruptures fluctuated, with most (88%) occurring with previously ruptured aneurysms in patients with subarachnoid hemorrhage. With increasing surgical experience, the number of ruptures during predissection and clip application, the mean duration of temporary clipping, and the surgical mortality rate all declined, whereas the number of patients experiencing a good outcome (Glasgow Outcome Scale score of 5 or 4) increased.
CONCLUSION: Intraoperative rupture is an unavoidable danger in aneurysm surgery that does not diminish with increasing surgical experience of the neurosurgeon performing the operation. However, experience did improve the neurosurgeon's response to aneurysm rupture and the patients' outcomes. Mental anticipation and technical repetition over time transform into efficiency, confidence, and insight in the management of this distressing intraoperative event.