Prediction and Perception of Technical Difficulties in Adult Cardiac Surgery

  • Yasser Y Hegazy Department of Cardiac Surgery, Mediclin Herrzzentrum Lahr/ Baden, Germany.
  • Mohamed Samy Nassar Department of Cardio-thoracic Surgery, Faculty of Medicine, Alexandria University, Egypt
  • Wael Hassanein Department of Cardio-thoracic Surgery, Faculty of Medicine, Alexandria University, Egypt
  • Moustafa Elhamami Department of Cardio-thoracic Surgery, Faculty of Medicine, Alexandria University, Egypt
  • Juergen Ennker School of Medicine, Faculty of Health, University of Witten Herdecke, Witten, Germany


Background: Unexpected intra-operative technical difficulties are not uncommon in cardiac surgery. Our objective is to study the incidence, predictors, and consequences of unexpected difficulties in adult cardiac operations. 

Methods: A total of 500 consecutive elective operations were included in the study. Before every operation, the surgeon and the assistant were asked to study the case and give a score (one to ten) for the expected technical difficulty of the operation. After every operation, the surgeon and the assistant were asked to give a score for the observed technical difficulty. The scores and perioperative data were collected and statistically analyzed.

Results: In relation to different interventions and consultant/trainee predictions, unexpected technical difficulties were encountered in 7% to 16% of cases. There was a significant difference between surgeons and trainees in the perception of level of increased difficulty, represented by the mean of differences between expected and observed score (0.084 ± 0.54 versus 0.016 ± 0.5, P = .0002). In multivariable analysis, only female gender (P < .0001) was identified as a factor associated with unexpected technical difficulties. There was no correlation between the incidence of complications and unexpected surgical difficulty. However, there was a weak positive correlation between operative times and observed
difficulty score. 

Conclusion: Unexpected technical difficulties are not uncommon in adult cardiac operations. Trainees tend to underestimate the difficulties perceived by the surgeon. This study can be a first step towards developing a technical difficulty score, which could be a helpful tool for medical quality management, as well as in training programs.


Ad N, Holmes SD, Patel J, et al. 2016. Comparison of EuroSCORE II, original EuroSCORE, and the society of thoracic surgeons risk score in cardiac surgery patients. Ann Thorac Surg 102:573-9.

Ban D, Tanabe M, Ito H, et al. 2014. A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci 21:745-53.

Buellesfeld L, Stortecky S, Kalesan B, et al. 2013. Aortic root dimensions among patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv 6:72-83.

Connors RC, Doty JR, Bull DA, et al. 2009. Effect of work-hour restriction on operative experience in cardiothoracic surgical residency training. J Thorac Cardiovasc Surg 137:710-13.

Diwadkar GB, Jelovsek JF. 2010. Measuring surgical trainee perceptions to assess the operating room educational environment. J Surg Educ 67:210-16.

Hiteshi AK, Li D, Gao Y, et al. 2014. Gender differences in coronary artery diameter are not related to body habitus or left ventricular mass. Clin Cardiol 37:605-9.

Jones EE. 1976. How do people perceive the causes of behavior? Experiments based on attribution theory offer some insights into how actors and observers differ in viewing the causal structure of their social world. American Scientist 64:300-5.

Mokadam NA, Fann JI, Hicks GL, et al. 2017. Experience with the cardiac surgery simulation curriculum: Results of the resident and faculty survey. Ann Thorac Surg 103:322-8.

Nikitin NP, Witte KK, Thackray SD, et al. 2003. Effect of age and sex on left atrial morphology and function. Eur J Echocardiogr 4:36-42.

Odell DD, Macke RA, Tchantchaleishvili V, el al. 2015. Resident perception of technical skills education and preparation for independent practice. Ann Thorac Surg 100:2305-13.

Osborne SA, Severn P, Bunce CV, et al. 2006. The use of a pre-operative scoring system for the prediction of phacoemulsification case difficulty and the selection of appropriate cases to be performed by trainees. BMC Ophthalmol 6:38.

Pauley K, Flin R, Yule S, et al. 2011. Surgeons’ intraoperative decision making and risk management. Am J Surg 202:375-81.