British Journal of Plastic Surgery (1999), 52, 33–36

© 1999 The British Association of Plastic Surgeons

Complications of long operations: a prospective study of morbidity associated

with prolonged operative time (> 6 h)

B. J. Fogarty, K. Khan, G. Ashall* and A. G. Leonard

The Northern Ireland Plastic and Maxillofacial Service, Ulster Hospital Dundonald, Belfast, Northern Ireland

SUMMARY. Reconstructive surgical procedures often take a long time to perform and duration of surgery is frequently
cited as a major risk factor for postoperative complications. Whether operative time is an independent risk factor is
unknown, as patients undergoing long operations may have numerous other risk factors. From September 1996 to
September 1997, we prospectively assessed those patients undergoing reconstructive surgery lasting 6 h or more. A
total of 62 patients were studied and they were grouped into three categories: head and neck surgery (n = 23), breast
reconstruction (n = 18) and upper and lower limb surgery (n = 21). Postoperative complications were recorded and the
results of each group compared. Each of the three patient categories had a similar mean duration of surgery but there
were large differences in postoperative morbidity between the three groups, e.g. within the head and neck group
postoperative respiratory and wound complications occurred in 43% and 26% of patients, respectively. In the limb
surgery group, however, only 5% of patients had respiratory complications and 5% had wound complications. Despite
having similar duration of surgery the differences in postoperative complications between the three groups suggest
that duration of surgery alone is not a major determinant of postoperative morbidity and that the type of surgery
performed and the patient’s general health are more important predictors of outcome.

Keywords: complications of surgery, microsurgery, thrombosis, sepsis.

Traditional surgical and anaesthetic teaching has
expounded the complications associated with prolonged
duration of surgery despite the paucity of evidence to
support this tenet.1 Indeed, the association between long
operations and morbidity is hard to disentangle as the
duration of surgery is often proportional to the
complexity of the procedure. The exact impact of
duration of surgery on patient morbidity has been
questioned by others, but unfortunately little has been
published about complications that arise purely as a
result of prolonged operative time as opposed to the
complications specific to a given procedure.2
In other surgical disciplines, e.g. cardiac surgery, the
surgery often disturbs a major physiological system
making assessment of the effect of operative duration
difficult. Within the speciality of plastic surgery
however, we have many varied types of opera-tions that
often take a long time to perform. With this in mind we
wanted to describe the risks directly associ-ated with
long operative time by examining a number of patient
groups undergoing different types of recon-structive
procedures; common to each was their long duration of
surgery.
Patients and methods
Between September 1996 and September 1997, patients
undergoing reconstructive surgery which lasted 6 h or
more were studied prospectively. Breast reconstructive
surgery was performed in the Royal Victoria Hospital,
Belfast (RVH), while the rest of the operations were
carried out in the Ulster Hospital Dundonald (UHD).
The information collected included preoperative details
(past medical history, relevant risk factors, preoperative
prophylactic measures), operative details (duration and
type of surgery, intraoperative anaes-thetic or surgical
problems, nursing care provided) and postoperative
complications.
Patients operated upon in the UHD lay on a syn-thetic
soft overlay table pad (Pre-vent, Tecnol, Fort Worth,
TX, USA) which lay on a warming blanket (Hawksley
ripple mattress, Lancing, Sussex, UK) on top of a 7.5 cm
foam mattress. Jelly pads were used for heel support and
a jelly head ring for head support in head and neck cases.
A warming blanket (Bair Hugger, Augustine Medical,
USA) was then laid over the patient before sterile towels
were draped. Any bony prominences were further
protected with gamgee dressing gauze.
In the RVH there were slight differences in intra-
operative nursing care, with patients lying on a sheep-
skin instead of a synthetic soft underblanket. An overlay
foil blanket or ‘space blanket’ was used instead of a Bair
Hugger blanket. Patients in the RVH also received
pressure relief by means of elevating the legs in the
middle of a procedure. All patients had a urinary catheter
placed preoperatively and urine output was monitored.
Additional invasive monitoring was used selectively
depending on the clinical circumstances.
*This work was initiated by the late Mr Geoff Ashall to whom
this paper is dedicated.

33
34 British Journal of Plastic Surgery

Table 1 Patient demographics

Head and neck Breast Limb Total

No. of patients 23 18 21 62
Duration of surgery (mean) 9 h 52 min 7 h 59 min 8 h 36 min 9 h 03 min
(Range) 6 h 5 min → 13 h 35 min 6 h → 10 h 45 min 6 h → 12 h 15 min
Mean age (years) 58 44 29 43

The patient’s postoperative progress was assessed (by Table 2 Surgical procedures studied
the authors) and any complications noted. Special Category of surgery Number of patients
attention was paid to those complications felt likely to be
related to duration of surgery, i.e. septic compli-cations, Head and neck tumours 23
venous thrombosis, pressure sores and com-pression Intraoral 19
neuropathies. External ear 2
Scalp 1
Recurrent neck disease 1
Breast 18
Results Pedicled TRAM (unilateral) 11
Pedicled TRAM (bilateral) 2
Free TRAM 5
Sixty-two patients were studied over the 12-month Lower limb 13*
period (Table 1). These fell into three main groups: head Latissimus dorsi 7
and neck (n = 23), breast reconstruction (n = 18) and Rectus abdominis 6
upper and lower limb cases (n = 21). Upper limb 9
Replantation/revascularisation 4
All of the head and neck group of patients had Reversed radial forearm 3
surgery for malignancy. The sites of disease included Free latissimus dorsi 1
intraoral disease, the external ear, the scalp and one Tendon repair 1
patient undergoing redo neck dissection for recurrent
*One patient had two procedures; 13 procedures were carried out on
disease (Table 2). Nineteen of the patients had free tissue 12 patients.
transfer as part of their reconstruction, using the radial
forearm flap (n = 15), latissimus dorsi (n = 3) or a free
fibula in one case. All the head and neck patients had form of DVT prophylaxis while 100% had antibiotic
thromboembolism prophylaxis and antibiotic cover and, prophylaxis.
in the course of the procedure, the patient had skin Postoperative complications are given in Table 3.
preparation with chlorhexidene/ cetrimide solution Those patients having upper or lower limb surgery were
grouped together to aid comparison of data. There were
(Travasept®, Baxter Healthcare Norfolk, UK) and then
two deaths in the study, both occurring in head and neck
alcohol spirit. Postoperatively most patients (91%) were patients. One was a 61-year-old man who developed
electively ventilated in the intensive care unit overnight multi-system organ failure, possibly secondary to sepsis.
or until their clinical condition allowed extubation. The other patient was a 76-year-old man with a history
Details of those patients having breast reconstruc-tion of ischaemic heart disease who died of a perioperative
are shown in Table 2. All patients had throm- myocardial infarction. The commonest complications
boembolism prophylaxis and 83% of patients had were either respiratory or wound infections and these
antibiotic prophylaxis. Only one of the patients was were most common in the head and neck group of
ventilated overnight in the intensive care unit as she had patients. There were 10 patients in the head and neck
a past history of asthma, otherwise patients were not group who had respira-tory complications (infection = 9,
routinely admitted to the intensive care unit. tracheitis = 1). All of the patients with respiratory
Of the patients having lower limb surgery, one patient complications in the other two groups developed chest
had a second free flap performed after the ini-tial rectus infections.
abdominis flap failed. Thus there were 13 procedures There were three patients who suffered cardiac
carried out on 12 patients, the indications for surgery complications (cardiac failure = 1, atrial fibrillation = 1,
being either for cover of a compound fracture (n = 9) or myocardial infarction = 1) with one of these patients
as part of a two-stage procedure for chronic dying. No patients suffered a pressure sore. Only one
osteomyelitis (n = 3). All patients received deep venous patient had symptoms of an ulnar nerve neuropraxia.
thrombosis (DVT) prophylaxis post-operatively, having This was transient, lasting only a number of days, and
a 5-day course of intravenous dextran and then daily manifest only by paraesthesia in the ulnar nerve
sub-cutaneous enoxaparin (20 mg). All lower limb distribution.
patients had antibiotic pro-phylaxis during and after One patient developed a small pulmonary embolus,
surgery. There were a total of nine patients who had which was treated with anticoagulation. This 56-year-
upper limb surgery lasting old obese lady had two operations; a free TRAM flap
> 6 h. Most patients were operated on for replantation/ breast reconstruction lasted 8 h 30 min and then re-
revascularisation (n = 4), while those patients who had exploration of the flap was required on the second
reverse radial forearm flaps had traumatic soft tissue postoperative day when a ‘no-reflow’ problem was
defects, as did the patient requiring free latissimus dorsi diagnosed. This second procedure lasted 5 h. The patient
cover. Eighty-nine per cent of patients had some received DVT prophylaxis as preoperative low
Complications of long operations
Table 3 Postoperative complications
Number (%) of patients
Head and neck
Deaths 2 (9)*
Respiratory 10 (43)
Wound infections 6 (26)
Cardiac 3 (13)
Thromboembolism 0 1 (6)
Delirium 2 (9)
Pressure sores 0 0
Compression 0 0
neuropathy
*Percentages refer to proportion of each category of surgery.
molecular weight heparin and then daily postoperative
dextran following her free flap.
Discussion
It is a long-held belief that prolonged surgery carries a
higher than expected complication rate. The evidence to
support this, however, is scarce, as often long opera-
tions are complex, with many other variables affecting
patient outcome.2 For instance, in a number of studies in
patients undergoing vascular surgery, increased
mortality was associated with the duration of surgery.
These patients, however, often had additional proce-
dures performed, such as renal or mesenteric revascu-
larisation, which would correlate with increased
mortality.3 Halpern on the other hand observed no
relation between operative time and complications in a
group of patients who had abdomino-perineal resec-tion
of the rectum.4 Any morbidity attached to long
operations is especially relevant to plastic surgery, as
complex reconstructive procedures of long duration are
often performed.
There is no identifiable time beyond which the com-
plication rate dramatically increases, but in a previous
study by Howland the authors analysed procedures
lasting over 6 h.5 They concluded that cardiovascular,
pulmonary and renal complications all increase with
each hour beyond the 6-h point. We therefore adopted
the same cut off point of 6 h for this study.
In a review of surgical complications and duration of
surgery, Scott concludes that wound infection and sepsis
are undoubtedly related to the duration of surgery. 2
Other complications, however, including atelectasis,
deep venous thrombosis and pulmonary embolus,
myocardial infarction, renal failure and delirium, may be
related to the duration of surgery but the evidence for
these is less conclusive.
There is ample evidence that the duration of surgery
increases the rate of wound infection. In one of the
largest surveys of wound infections, Cruse and Foord
observed a stepwise increase in wound infec-tions with
every hour of surgery; this was seen in all categories of
wound.6 More recently, in a study of plastic surgery
patients, a three-fold increase in the wound infection rate
was observed if the duration of surgery lasted over 2 h
compared to surgery lasting less than 60 min.7 This is
probably explained by an
35
Breast Limb Total
0 0 2 (3)
3 (17) 1 (5) 14 (23)
4 (22) 1 (5) 11 (18)
0 0 3 (5)
0 1 (2)
0 0 2 (3)
0 0
0 0
increase in the inoculating dose of bacteria that occurs
with time and by the decreased tissue resistance that
arises as a result of trauma and desiccation. In addi-tion
a more generalised immune depression occurs as a result
of continued blood loss and shock.
The rate of wound infection is notoriously difficult to
compare between centres, owing to clinicians’ defin-
ition of infection, but the frequency of wound infec-tions
observed in this series compares similarly to that seen in
other papers.8 With only one patient in our limb surgery
group having a wound infection (5%), this appears to be
a much smaller rate when compared to the other two
groups of patients. The mean age of patients in the head
and neck group was older than the limb group and, with
most head and neck patients having intraoral
reconstruction, they were at greater risk of
contamination than the limb group. While duration of
surgery is one of many risk factors for postoperative
wound infection, the low rate of infec-tion in the limb
surgery group would suggest that it is a minor factor.
Prolonged anaesthesia is frequently implicated in
postoperative pulmonary complications. Most studies,
however, have included patients undergoing thoracic or
abdominal surgery and thus the role of operative
duration on pulmonary complications is uncertain.9,10
Despite having long procedures the limb surgery group
had only one patient who developed a chest infection.
This 13-year-old boy had a past history of asthma and,
having a compound tibial fracture, had three operations
shortly before his free flap procedure. The head and neck
group of patients often had multi-ple risk factors for
chest infection including ventila-tion in the intensive
care unit, impaired gag reflex, smoking and increased
age. These factors, more so than the duration of surgery,
may be responsible for the higher rate of pulmonary
complications in this group when compared to the limb
surgery group. Patients in the breast reconstruction
group had a higher risk of postoperative chest
complications com-pared to the limb surgery group. As
all of these patients had TRAM flap reconstructions, the
abdomi-nal wounds may be more important in the
genesis of postoperative pulmonary complications than
the time taken to perform surgery.
Surgery lasting longer than 30 min is a recognised
risk factor for DVT but whether this risk is increased as
the length of surgery increases is unknown.11 In a
36
previous series of head and neck patients the incidence
of DVT was 3% and thus lower than that seen in general
surgery patients.8 In our series only one patient suffered
a thromboembolic complication (6%). This 56-year-old
obese lady underwent a free TRAM breast
reconstruction lasting over 8 h. Postoperatively the flap
was compromised requiring a second procedure lasting 5
h. This patient had DVT prophylaxis, as did the vast
majority of our long operation patients. The low
incidence of thromboembolic complications in our long
operation group would suggest that prolonged surgery in
the plastic surgery patient is not a significant problem if
prophylactic measures are taken.
Whether cardiac complications are a risk of long
operations is again uncertain, with conflicting evidence
on this subject.12,13 Of the three patients having a cardiac
complication in our study, one patient had a past history
of myocardial infarction, another patient developed atrial
fibrillation after developing delirium tremens and the
remaining patient went into cardiac failure possibly as a
result of postoperative fluid overload. In this series of
patients, in the absence of a past history of cardiac
disease, operative duration does not appear to be a
significant risk factor for cardiac complications.
Duration of surgery has been cited as a risk factor for
postoperative delirium but the only two patients who
were agitated postoperatively in our study both had a
history of alcohol abuse.14 We feel that the latter is a
more significant risk factor for postoperative delirium
than operative time.
Our unit has a protocol for the care of patient pres-
sure areas should they be undergoing a long operation.
Although there were no pressure sores in the series of
patients studied, there was one patient who had a tran-
sient ulnar nerve paraesthesia. This 20-year-old man had
two long operations for lower leg reconstruction, the
first lasting 12 h and the second lasting 11 h. It is
uncertain whether there were any breaks in theatre
policy but strict adherence to pressure prevention
protocol should reduce the risks of such problems.
In conclusion, the complications ascribed to surgi-cal
duration often have multiple other risk factors which
make scientific study difficult. Those complica-tions
which arose most frequently in our study were either
chest or wound infections. Given effective pro-phylactic
measures, the possible complications of long surgery can
be minimised and we feel that the type of surgery
performed, rather than the duration of the procedure,
appears to be more relevant to morbidity.
British Journal of Plastic Surgery
References
1. Schwartz SI (ed). Principles of Surgery, 5th Edn. New York:
McGraw-Hill, 1989.
2. Scott CF Jr. Length of operation and morbidity: is there a rela-
tionship? Plast Reconstr Surg 1982; 69: 1017–21.
3. Huber TS, Harward TRS, Flynn TC, Albright JL, Seeger JM.
Operative mortality rates after elective infrarenal aortic
reconstructions. J Vasc Surg 1995; 22: 287–93; discussion
293–4.
4. Halpern NB, Cox CB, Aldrete JS. Abdominoperineal resection for
rectal carcinoma: perioperative risk factors. South Med J 1989;
82: 1492–6.
5. Howland WS, Schweizer O. Complications associated with pro-
longed operation and anesthesia. Clin Anesth 1972; 9: 1–7.
6. Cruse PJE, Foord R. A five-year prospective study of 23 649
surgical wounds. Arch Surg 1973; 107: 206–10.
7. Andenaes K, Amland PF, Lingaas E, Åbyholm F, Samdal F,
Giercksky KE. A prospective, randomized surveillance study
of postoperative wound infections after plastic surgery: a study
of incidence and surveillance methods. Plast Reconstr Surg
1995; 96: 948–56.
8. Simpson KH, Murphy PG, Hopkins PM, Batchelor AG. Prediction
of outcomes in 150 patients having microvascular free tissue
transfers to the head and neck. Br J Plast Surg 1996; 49: 267–
73.
9. Pedersen T, Eliasen K, Henriksen E. A prospective study of risk
factors and cardiopulmonary complications associated with
anaesthesia and surgery: risk indicators of cardiopulmonary
morbidity. Acta Anaesthesiol Scand 1990; 34: 144–55.
10. Davies JM. Pre-operative respiratory evaluation and manage-ment
of patients for upper abdominal surgery. Yale J Biol Med 1991;
64: 329–49.
11. Thromboembolic Risk Factors (THRIFT) Consensus Group. Risk
of and prophylaxis for venous thromboembolism in hospital
patients [see comments]. Br Med J 1992; 305: 567–74.
12. Steen PA, Tinker JH, Tarhan S. Myocardial reinfarction after
anesthesia and surgery. JAMA 1978; 239: 2566–70.
13. Tarhan S, Moffitt EA, Taylor WF, Giuliani ER. Myocardial
infarction after general anesthesia. JAMA 1972; 220: 1451–4.
14. Parikh SS, Chung F. Postoperative delirium in the elderly. Anesth
Analg 1995; 80: 1223–32.
The Authors
B. J. Fogarty BSc, FRCS, FRCSI, Senior House Officer, Plastic
Surgery,
K. Khan FRCSI (Plast), Specialist Registrar, Plastic Surgery,
G. Ashall FRCS (Plast), Formerly Consultant Plastic Surgeon
(deceased),
A. G. Leonard FRCS, Consultant Plastic Surgeon,
The Northern Ireland Plastic and Maxillofacial Service, Ulster
Hospital Dundonald, Belfast BT16 ORH, Northern Ireland.
Correspondence to Brendan Fogarty.
Paper received 29 April 1998.
Accepted 17 August 1998.