The impact of accurate documentation of parotid tumor operative reports on secondary surgical procedure

OBJECTIVE To develop a comprehensive operative report schema based on the accuracy of primary operative reports (OpR) assessed on a department's experience with parotid gland tumor re-operations. DESIGN Retrospective cross-sectional study. SETTING A tertiary referral center, the Department of Otolaryngology and Laryngological Surgery, Poznan University of Medical Sciences, Poland from 2008 to 2017. SUBJECTS Out of 1154 surgeries, 71 patients underwent reoperation. Their OpR were categorized into accurate and non-accurate, and re-operation field and re-operation course were categorized as anticipated or unanticipated, according to defined criteria. INTERVENTION None Main outcome measures: The impact of accuracy of the first OpR on re-operation course. RESULTS In this series, OpR were 39% (14/36) accurate, 61% (22/36) non-accurate. Re-operation fields were 16% (11/71) anticipated, 37% (26/71) unanticipated. Re-operation courses were 37% (26/71) anticipated, 63% (45/71) unanticipated. An anticipated re-operation course followed 20% (5/26) of accurate and 20% (5/26) of non-accurate primary OpR. An unanticipated re-operation course followed 20% (9/45) of accurate and 40% (18/45) of non-accurate OpR. There is no significant relationship between the re-operation course and accuracy of the first OpR (Chi2(1)=0.69; p=0.40466). The most common variable that affected non-accuracy of the OpR was facial nerve function after surgery (6/12). CONCLUSIONS The operative report should be based on clear criteria, robust classification and comprehensive protocol. This will improve follow-up and facilitate the planning of re-operation.