「失敗学」から見た脳動脈瘤手術におけるトラブルシューティング

抄録

In this study, we analyzed the causes of problems encountered during aneurysm surgery based on “the study of failure, ” which was originally devised for system engineering. We describe four problematic cases, which were all successfully managed by troubleshooting techniques. The majority of the problems (failures) were caused by the surgeon’s “carelessness and/or decision error”. Large vessel injury during aneurysm dissection is formidable but can be managed by troubleshooting techniques such as micro-suturing or a bypass procedure in the deep operative field. Prompt and secure micro-anastomotic suturing is one of the vital troubleshooting techniques during aneurysm surgery. Personal preparation of micro-suturing instruments and daily off-the-job training are essential to master such troubleshooting procedures.