Inadequate or inaccurate surgical site marking – including the erroneous marking of the wrong side/site, imprecise marking of the correct site, and inadequate modality of site marking – represent a major risk factor for wrong site surgery (Figure ).
Figure 1 Clinical example of correct versus incorrect modalities of surgical site marking. A: This patient was scheduled for a surgical procedure on his right forearm. The intern marked and initialed the site on the dressing, which came off prior to surgery (1). (more ...)
Examples of such adverse circumstances include:
- The relegation of site marking and time out to a junior member of the surgical team, e.g. to an intern, or to a physician who will not be personally present during the operative procedure.
- Wrong modality of marking the correct side, e.g. using an "X" which may be misunderstood as "not this side".
- Marking of the wrong side/site based on misleading pre-procedure documentation, e.g. erroneous clinic note dictation, faulty documentation in chart and consent form, and mislabelling of diagnostic studies, e.g. X-rays.
- Imprecise site marking. Case examples include: (1) Marking the correct joint without specifying the operative site, leading to wrong-site collateral ligament release (medial vs lateral); (2) Marking the correct hand, without specifying the correct finger and joint, leading to wrong-level joint fusion (DIP vs PIP); (3) Marking the correct spinal level on skin, but fusing the wrong level after surgical dissection down to the spine.
- The use of non-permanent markers will increase the risk of wrong site surgery, since surgeons may operate on non-marked sites under the faulty assumption that the site marking had been wash off during the surgical preparation.
- Additional marking of the contralateral side (e.g. "no" or "not this side") is considered obsolete, since this will create confusion and increase the risk of wrong-sided surgery.
- Residual marks from a previous surgery in the same patient may be misleading and distract from the correct surgical site for an additional intervention (e.g. polytrauma patient with multiple fractures stabilized at different time-points).
- Inability (or contraindication) to mark the surgical site.
Moreover, specific instances may not allow surgical site marking, for technical or anatomic reasons. For example, site marking is impracticable on mucosal surfaces and on the teeth. Site marking is furthermore considered contraindicated in premature infants, due to the risk of inducing a permanent tattoo on the skin. Some surgical sites are inaccessible to accurate external marking. Exemplary circumstances include visceral surgery (internal organs), neurosurgery (brain, spine), interventional radiology (vascular procedures), and orthopaedic surgery on the torso (pelvis, spine). Rarely, patients may refuse surgical site marking for cosmetic or other personal reasons.
A defined, alternative process must be in place for all above-mentioned circumstances. Radiological diagnostics may need to be consulted pre- and intraoperatively to determine the surgical site with accuracy. For example, spine surgeons must ensure the correct intervertebral level with a needle using intraoperative fluoroscopy in order to avoid a wrong-level spine fusion. Similarly, general surgeons may have to rely on a preoperative or on-table cholangiogram to ensure clipping the correct bile duct, i.e., the cystic duct instead of common bile duct. Furthermore, interventional radiology procedures pose a similar risk for wrong site surgery, e.g. by the erroneous coiling of a wrong artery. Finally, neurosurgical interventions on the wrong part of the brain keep being reported in regular intervals [9
]. Unlike symmetric external body parts, such as extremities, eyes and ears, these "hidden" surgical sites may not be easily identified, confirmed and marked prior to surgery. Thus, these particular circumstances may mandate an accurate intraoperative localization under fluoroscopy, in conjunction with a careful evaluation of the surgical site by additional preoperative diagnostics, such as CT, MR, angiography, or cholangiography.
While it is currently not mandatory to mark the surgical site in 100% of patients, efforts should be made to mark all surgical sites whenever possible. This includes marking the abdominal wall or the chest for intended procedures on internal organs, which is aimed at increasing the surgeon's awareness and focus on performing correct site surgery.