Over 250,000 endoscopic sinus surgeries are performed yearly in the United States alone.1 Although overall complication rates are low, surgical errors can lead to significant morbidity due to the close proximity of the sinuses to the orbit and skull base and the resultant potential for blindness, cerebrospinal fluid leak, and catastrophic bleeding. This reality is reflected in U.S. malpractice litigation, wherein rhinology claims represent 70% of the total indemnity compensation for otolaryngology lawsuits, with sinusitis being the most common diagnosis.2
Surgical checklists are endorsed by the World Health Organization (WHO) and have been incorporated into most U.S. operating rooms as a measure to minimize avoidable errors. Substantial data exist acknowledging that a simple, basic checklist can improve outcomes such as infection rates and overall mortality.3 However, standardized surgical checklists were developed with general and/or orthopedic procedures in mind and in many instances fail to incorporate concerns specific to endoscopic sinus surgery (ESS). In response to this clinical problem, we sought to develop and institute an ESS surgical checklist. This ESS-specific checklist would seek to preemptively address those errors that are unique to endoscopic sinonasal procedures.
This ESS checklist is designed as a supplement to existing generic surgical checklists, which are likely to already be in place in most operating rooms. These additional steps are surgeon led and can easily be incorporated regardless of surgical setting or nature of the existing checklists. The ESS checklist is broken down into sections centered around definable time points common to all procedures: 1) prior to intubation, 2) prior to instrumentation, and 3) prior to extubation (Figure 1). Prior to intubation, the surgeon confirms that the necessary imaging study (usually computed tomography scan or magnetic resonance image) is available, displayed in the operating room (OR), and matches the correct patient and date. As prior studies have shown, radiographic errors contribute to the majority of wrong-site sinus procedures. Proper left-right orientation of the films should be confirmed.4 If image guidance is required for the case, the machine should be present in the OR suite, with necessary images properly loaded into the system. Last, the surgeon(s) reviews and articulates specific anatomic variations that may predispose to complications and must be accounted for in the operative plan (e.g., skull base erosion, dehiscent lamina papyracea, sphenoethmoid [Onodi] cell). Although many surgeons review scans in detail prior to the operative case, this last step is best repeated at the outset of each individual case, as it can be difficult to remember the specific anatomy in the midst of a busy surgical caseload.
The traditional surgical time-out or pause occurs just prior to instrumentation of the patient. Most operating rooms have adopted a single generic checklist to which all surgical teams must adhere (e.g., medication allergies, important comorbidities, antibiotics). After completion of the generic checklist, we have added several additional statements that cover unique and critical elements of ESS. First, the surgeon informs the team that a topical vasoconstricting agent will be used (often high-dose epinephrine, cocaine, or oxymetazoline), and that this agent has been stained (usually fluorescein or marking ink), is labeled appropriately, and is not to be used for injection. This step is critical, as injection of these potent agents is a genuine risk and can precipitate hypertension, arrhythmia, and even stroke, myocardial infarction, or death.5 The step also serves to inform the anesthesiologist that this medication is being used and reiterates the potential danger to the nursing and tech teams. In a similar fashion, the surgeon informs the team of the medication to be used for injection and confirms it has been properly labeled. The surgeon also confirms that necessary specialized equipment to control bleeding is sterilized and available (endoscopic cautery and hemostatic materials). Last, the surgeon should inform the team whether specimens will be taken and the methodology of collection. This is especially important during bilateral cases and when instrumentation requires special setup to collect specimen, such as with a microdebrider.
The last aspect of the checklist occurs at the completion of the surgical case. The surgeon confirms with the nursing and tech teams that the pledget count is correct and specimens, if collected, have been properly labeled. If nonabsorbable synthetic materials have been placed in situ (spacers, stents, packing), these items are properly documented in the medical record along with their projected date of removal.