Gianlorenzo Dionigi1, Marco Raffaelli2, Rocco Bellantone2, Carmela De Crea2, Carlo Enrico Ambrosini3, Paolo Miccoli3, Gabriele Materazzi3, Antonio Ieni4, Ettore Caruso5, Daqi Zhang1,6, Henning Dralle7. 1. Division of Endocrine and Minimally Invasive Surgery, University of Messina, Messina, Italy. 2. U.O.C. Chirurgia Endocrina E Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy. 3. Department of Surgery, University of Pisa, Pisa, Italy. 4. Division of Pathology, University of Messina, Messina, Italy. 5. Division of Endocrine and Minimally Invasive Surgery, University of Messina, Messina, Italy. ettore_caruso@hotmail.it. 6. Division of Thyroid Surgery, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine On Differentiated Thyroid Carcinoma, China-Japan Union Hospital of Jilin University, Changchun, 130000, China. 7. Sektion Endokrine Chirurgie, Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
Abstract
BACKGROUND: In thyroid surgery, wrong-site surgery (WSS) is considered a rare event and seldom reported in the literature. CASE PRESENTATION: This report presents 5 WSS cases following thyroid surgery in a 20-year period. We stratified the subtypes of WSS in wrong target, wrong side, wrong procedure and wrong patient. Only planned and elective thyroid surgeries present WSS cases. The interventions were performed in low-volume hospitals, and subsequently, the patients were referred to our centres. Four cases of wrong-target procedures (thymectomies [n = 3] and lymph node excision [n = 1] performed instead of thyroidectomies) and one case of wrong-side procedure were observed in this study. Two wrong target cases resulting additionally in wrong procedure were noted. Wrong patient cases were not detected in the review. Patients experienced benign, malignant, or suspicious pathology and underwent traditional surgery (no endoscopic or robotic surgery). 40% of WSS led to legal action against the surgeon or a monetary settlement. CONCLUSION: WSS is also observed in thyroid surgery. Considering that reports regarding the serious complications of WSS are not yet available, these complications should be discussed with the surgical community. Etiologic causes, outcomes, preventive strategies of WSS and expert opinion are presented.
BACKGROUND: In thyroid surgery, wrong-site surgery (WSS) is considered a rare event and seldom reported in the literature. CASE PRESENTATION: This report presents 5 WSS cases following thyroid surgery in a 20-year period. We stratified the subtypes of WSS in wrong target, wrong side, wrong procedure and wrong patient. Only planned and elective thyroid surgeries present WSS cases. The interventions were performed in low-volume hospitals, and subsequently, the patients were referred to our centres. Four cases of wrong-target procedures (thymectomies [n = 3] and lymph node excision [n = 1] performed instead of thyroidectomies) and one case of wrong-side procedure were observed in this study. Two wrong target cases resulting additionally in wrong procedure were noted. Wrong patient cases were not detected in the review. Patients experienced benign, malignant, or suspicious pathology and underwent traditional surgery (no endoscopic or robotic surgery). 40% of WSS led to legal action against the surgeon or a monetary settlement. CONCLUSION: WSS is also observed in thyroid surgery. Considering that reports regarding the serious complications of WSS are not yet available, these complications should be discussed with the surgical community. Etiologic causes, outcomes, preventive strategies of WSS and expert opinion are presented.
Entities:
Keywords:
Malpractice; Medical errors; Patient safety; Thymectomy; Thymectomy instead of thyroidectomy; WSS; Wrong patient; Wrong procedure; Wrong side; Wrong-site surgery
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