Original Article

Cancellation of Elective Surgical Cases in a Nigerian Teaching Hospital:

Frequency and Reasons
CJ Okeke1,2, AO Obi1,3, KH Tijani2,4, UE Eni1,3, CO Okorie1,3

1
Department of Surgery, Background: Dwindling economic resources and reduced manpower in the
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Abstract
Alex-Ekwueme Federal
University Teaching Hospital,
health sector require efficient use of the available resources. Day of surgery
Abakaliki, Ebonyi State, cancellation has far reaching consequences on the patients and the theatre staff
2
Department of Surgery, involved. Full use of the theatre space should be pursued by every theatre user.
Lagos University Teaching Objective: The study aimed to report on the rates and causes of day of surgery
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Hospital, Idi-Araba, Surulere, cancellation of elective surgical cases in our hospital as a means towards
Lagos, 3Department of proffering solutions. Materials and Methods: It was a retrospective study of all
Surgery, Ebonyi State
University, Abakaliki,
elective cases that were booked over a 15‑month period from January 2016 to
Ebonyi State, 4Department March 2017. Cancellation was said to have occurred when the planned surgery did
of Surgery, College of not take place on the proposed day of surgery. Cancellations were categorized into
Medicine, University of patient‑related, surgeon‑related, hospital‑related and anesthetist‑related. Reasons for
Lagos, Idi-Araba, Surulere, the cancellations were documented. Data were analyzed using Statistical Package
Lagos, Nigeria for the Social Sciences  (SPSS) software program, version  22. Variables were
compared using Chi‑square tests. A  value of P <  0.05 was considered statistically
significant. Results: During the 15‑month period, a total of 1296 elective surgeries
were booked. Of this, 118  (9.1%) cases were cancelled. Patient‑related factor
was the most common reason  (47.5%) followed by surgeon‑related factor  (28%).
Received:
Lack of funds was the most common patient related‑reason for cancellation.
02-Dec-2019; Majority of the cancelled cases were general surgical cases  (36.4%) followed by
Revision: orthopedics  (25.4%) and urology  (11%). Seventy percent of the cancelled cases
06-Jan-2020; were first and second on the elective list. Conclusion: The cancellation rate in
Accepted: this study is high. The reasons for these cancellations are preventable. To ensure
17-Apr-2020; effective use of the theatre, efforts should be made to tackle these reasons.
Published:
03-Jul-2020 Keywords: Cancellation, elective surgery, operating theatre

Introduction increasing cost.[11] It prolongs the waiting list, causes

C ancellation of elective surgical cases refers to
surgical procedures not being done on the intended
day of surgery.[1] It is a common problem worldwide.[2‑8]
In Nigeria, the rising cost of health care is unmatched
by the dwindling economy and brain drain in the
health sector; hence, the need for effective use of every
available resource.[9]
Day of surgery cancellation results in ineffective use of
scarce resources.[10] It has far‑reaching consequences.
To the patient, it results in prolonged hospital stay
and repetition of preoperative investigations, thereby
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upward stage migration of previously booked cancer
cases and results in poor patient turnover which is also
detrimental to residency training in teaching hospitals.
It is a waste of time for the surgeons and other staff
involved.[8] Cancellation rate is an indicator of quality of
patient care.[12]
Address for correspondence: Dr. CJ Okeke,
Department of Surgery, Lagos University Teaching Hospital,
Idi‑Araba, Lagos, Nigeria.
E‑mail: textchikeokeke@yahoo.com
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DOI: 10.4103/njcp.njcp_650_19

How to cite this article: Okeke CJ, Obi AO, Tijani KH, Eni UE, Okorie CO.
PMID: ******* Cancellation of elective surgical cases in a nigerian teaching hospital:
Frequency and reasons. Niger J Clin Pract 2020;23:965-9.

© 2020 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow 965

 Okeke, et al.: Cancellation of elective surgical cases in a nigerian teaching hospital: Frequency and reasons

The study aimed to report on the rates and causes of Table 1: Specialty distribution of booked cases
day of elective surgery cancellation in our hospital as a Specialty No. of booked cases (n) Percentage
means towards proffering solutions. General surgery 440 34
Orthopedic 314 24.2
Materials and Methods Urology 143 11
Approval for the study was obtained from the hospital Pediatric surgery 128 9.9
Plastic surgery 126 9.7
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ethical committee.
Ear nose and throat 87 6.7
It was a retrospective study of all consecutive Cardiothoracic 30 2.3
elective cases which were done from January 2016 Maxillofacial 24 1.9
through March 2017 in Alex-Ekwueme Federal Neurosurgery 4 0.3
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University Teaching Hospital, Abakaliki, Ebonyi 1296 100

State. The institution is the only referral center in X2=1154.778 [df=8] P<0.0001
the state. It receives referrals from neighboring
Table 2: Total day of surgery cancellation per specialty
states of Enugu, Benue, Cross River, and Imo.
Specialty Number of Number of Percentage
The patients for surgery were seen in the surgical booked cases(n) cancelled cases (n)
outpatient department and were clinically worked up. General surgery 440 43 36.4
The patients were admitted when considered fit for Orthopedics 314 30 25.4
surgery, usually about two  (2) days prior to surgery Urology 143 13 11
date. Day cases were admitted on the morning of Pediatric surgery 128 11 9.3
surgery. They were all reviewed by the anesthetists Plastic surgery 126 6 5.1
while on the ward. Emergency cases were excluded Ear nose and throat 87 5 4.2
from the study. Data collected included number on Cardiothoracic 30 4 3.4
the elective surgical list, specialty involved with Maxillofacial 24 5 4.2
Neurosurgery 4 1 0.8
reasons for the cancellation. A member of the surgical
Total 1296 118 100
team completed a questionnaire to fill in these data
X2=121.644 [df=8] P=0.000. Analysis of the table below shows that the
and what caused the cancellation. Causes were first and second on the list took a high percentage of case cancellations
grouped into: Patient‑related which included lack of
funds, failure to procure materials for surgery, refusal Table 3: Distribution of cases cancelled by number on the list
of consent, inability to provide blood for surgery Number on list Frequency (n) Percentage
and failure to show up for surgery; surgeon‑related 1 50 42.4
factor which included, late arrival of surgeon, failure 2 33 28
to identify/control co‑morbidities, cancellation by 3 15 12.7
4 8 6.8
surgeon when surgery was deemed not necessary;
5 7 5.9
hospital/system related factors which included lack of
6 3 2.5
drapes, gowns, boots, non‑functional equipment, lack 7 1 0.8
of theatre space, unavailability of light, oxygen and 8 1 0.8
water and anesthesia‑related factors which included Total 118 100
difficult intubation and unavailability of anesthetists. X2=148.983 [df]=7 P=0.000. Concerning the reasons for cancellation,
Data collected on a proforma were analyzed using patient and surgeon related factors were the most common reasons
contributing to cancellation. Table 4 shows the distribution
Statistical Package for the Social Sciences  (SPSS)
software program, version  22.0. Variables were stated Table 4: Reasons for cancellation
as frequencies. Chi‑square test was used to compare Reason Number (n) Percentage
categorical variables. Patient-related factor 56 47.5
Surgeon- related factor 33 28
Results Hospital-related factor 16 13.6
Anesthesia-related factor 4 3.4
A total of 1409 elective surgical cases were booked
Patient and surgeon 5 4.2
during the 15‑month study period (January 2016 to
Surgeon and hospital 3 2.5
March 2017). Of these, 113  cases were excluded Surgeon and anesthetist 1 0.8
because of incomplete data. A  total of 1296  cases were Total 118 100
subsequently analyzed. General surgery and orthopedic X2=226.441 P=0.000. Concerning the individual reasons for cancellation per
surgery accounted for 754 (58.2%) of cases done during specialty, patient-related factor was the most common reason in all specialties
the period as shown in Table 1. followed by surgeon and hospital related reasons as shown in Table 5

966 Nigerian Journal of Clinical Practice  ¦  Volume 23  ¦  Issue 7  ¦  July 2020
 Okeke, et al.: Cancellation of elective surgical cases in a nigerian teaching hospital: Frequency and reasons

Table 5: Reasons for cancellation by specialty

Specialty Patient factor Surgeon factor Hospital factor Anesthesia factor Multifactorial Total
General surgery 23 (53.5%) 10 (23.3%) 7 (16.3%) 1 (2.3%) Patient and surgeon 2 (4.7%) 43
Orthopedics 13 (43.3%) 9 (30%) 5 (16.7%) Surgeon and anesthesia 1 (3.3%) 30
Hospital and surgeon 2 (6.7%)
Urology 6 (46.2%) 5 (38.5%) 1 (7.7%) Patient and surgeon 1 (7.7%) 13
Pediatric surgery 6 (54.5%) 3 (27.3%) 1 (9.1%) Patient and surgeon 1 (9.1%) 11
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Plastic surgery 4 (66.7%) 1 (16.7%) 1 (16.7%) 6

Cardiothoracic 1 (25%) 1 (25%) 1 (25%) Hospital and surgeon 1 (25%) 4
Neurosurgery 1 (100%) 1
Ear nose and throat 3 (60%) 1 (20%) 1 (20%) 5
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Maxillofacial 2 (40%) 2 (40%) Patient and surgery 1 (20%) 5

Total 56 33 16 4 9 118
Patient-related factor was the most common reason for cancellation irrespective of the number on the list as shown in Table 6

Table 6: Reasons for cancellation by number on the list

Number on list Patient factor Surgeon factor Hospital factor Anesthesia factor Multifactorial Total
1 20 (40%) 17 (34%) 4 (8%) 3 (6%) Patient and surgeon 2 (4%) Surgeon and 50
hospital 3 (6%) surgeon and anesthetist 1
(2%)
2 17 (51.5%) 8 (24.2%) 5 (15.2%) Patient and surgeon 3 (9.1%) 33
3 8 (53.3%) 5 (33.3%) 1 (6.7%) 1 (6.7%) 15
4 5 (62.5%) 2 (25. %) 1 (12.5%) 8
5 3 (42.9%) 1 (14.3%) 3 (42.9%) 7
6 2 (66.7%) 1 (33.3%) 3
7 1 (100%) 1
8 1 (100%) 1
Total 56 33 16 4 9 118

Table 7: Causes of cancellation One hundred and eighteen cases 118  (9.1%) were
Reason Number (n) Percentage cancelled. Table  2 shows the distribution of cancelled
Patient related (n=56) 47.5 cases per specialty. Eighty‑three  (70.4%) of cancelled
Financial constraints 26 cases were first and second on the list as shown in
Failure to turn up for surgery 15 Table 3.
Inability to secure blood 4
Not following instructions 11
Patient‑related cancellation was the most common
Surgeon factor (n=33) 28 cause of cancellation  (47.5%), followed in decreasing
Patient unfit for surgery 28 frequency by surgeon‑related factor  (28%),
Change in plan 5 hospital‑related factor  (13.6%), and anesthesia‑related
Hospital factor (n=16) 13.6 factor (3.4%) as shown in Table 4.
Unavailability of instruments 16
Across all specialties, patient‑related factor was the
Anesthesia factor (n=4) 3.4
most common cause of cancellation followed by
Difficult intubation 4
Patient and surgeon factor (n=5) 4.2
surgeon, hospital and anesthetic factors as shown in
Patient unfit for surgery Table 5.
Inability to provide blood Irrespective of the number on the list for elective
Surgeon and hospital factor (n=3) 2.5 surgery, patient‑related factor accounted for most of
Patient unfit for surgery
the reasons for cancellation followed by surgeon factor.
Tiredness of surgeon
Table 6 shows the distribution of reasons for cancellation
Unavailability of instrument
by numbering on the elective surgical list.
Anesthesia and surgeon factor (n=1) 0.8
Presumed difficult intubation and For patient‑related reasons, 26 (46.4%) of surgeries were
also unfit for surgery cancelled due to financial constraints, another 15 (26.8%)
Total 118 100 were cancelled due to failure of patients to turn up for

Nigerian Journal of Clinical Practice  ¦  Volume 23  ¦  Issue 7  ¦  July 2020 967
 Okeke, et al.: Cancellation of elective surgical cases in a nigerian teaching hospital: Frequency and reasons
surgery. Twenty eight  (84.8%) of the surgeon‑  related
reasons for cancellation were due to improper work
up of patients. Table  7 shows the distribution of these
reasons.
Discussion
Use of theatre to full capacity should be sought after
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by all concerned. Cancellation of surgeries leads to
underutilization of the theatre space, increased waiting
list and reduced internally‑generated revenue for the
hospital.[13] Cancellation has far reaching effects on the
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patients and their relatives.[13]
The prevalence of cancellation in our study was 9.1%.
This is similar to a study in Jordan  (9.31%) but much
higher than the 5% cancellation rate reported in a
study in the United  Kingdom.[3,4] Our cancellation rate
is however lower than previous studies carried out in
Nigeria with cancellation rates ranging from 15.6% to
48.5%.[6,7,14]
Close to half  (47.5%) of all cancellations were
patient‑  related in this study. This is slightly lower than
what was reported by Kolawole and Bolaji in Ilorin,
Nigeria where they noted that 52.2% of cancellations were
patient‑related.[11] However, studies done in Jos, Kano
and Lagos reported patient–factors to have accounted for
as high as 62.7%, 60.8%, and 62%, respectively.[6,15,16]
Majority of the patient‑related cancellations were due
to financial challenges faced by the patient.This has
also been the experience of other authors.[6,7,15] This is
particularly important in our environment where poverty
is endemic and majority of the populace fund their health
care out‑of‑pocket.[17] Therefore, the implementation
of universal health coverage with adequate funding of
health care will certainly help reduce the cancellation
rate in our setting. The National Health Insurance
Scheme of Nigeria currently covers only federal civil
servants that constitute a small percentage of the
populace. The scheme needs to be expanded to include
state and local government workers. Special funds can
be set up for the treatment of indigent patients.
Another factor related to this is failure of patients to turn
up on the day of surgery for no apparent reason. One
can only speculate on the reasons. Financial challenges,
inadequate communication, decision by patients to seek
alternative care (including unorthodox medicare due to
fear of surgery) could be contributory. This incidence
can be reduced by seeing patients at the outpatient clinics
close to the day of planned surgery to ascertain their
readiness for surgery and replacing them with financially
and psychologically‑ready patients.[8] Communication
with the patients should be unambiguous as some of
the defaulting patients had later claimed not to have
968 Nigerian Journal of Clinical Practice  ¦  Volume 23  ¦  Issue 7  ¦  July 2020
understood the instructions. Communication channel
with booked patients should also be maintained via
GSM and their readiness for surgery ascertained before
the day of surgery.
Surgeon‑related factor was the second most common
reason for cancellation  (28%). Majority of the reasons
in this group were due to poor patient preparation with
patients having abnormal laboratory results that were
detected after admission. This factor can be mitigated by
reviewing the laboratory results closely before booking
patients. This would enable other patients to have their
surgeries done pending when the abnormal laboratory
results are corrected. Another solution is having a
pre‑anesthetic clinic for evaluation by the anesthetist.
Pre‑operative ward round specifically done a day before
surgery to check for fitness of the patients and their
readiness with funds, adequate investigation results, as
well as other necessary resources remain a good practice.
Hospital related factors ranked third accounting for 13.6%
of cancellations. This is less than the rate that was found
in Jos, Lagos, and Burkina Faso.[2,8,16] Most cases were
associated with non‑availability of functional equipment
to perform the surgery. Very high rates were reported
in Ido Ekiti by Olajide et al. where hospital‑related
cancellations accounted for 76.3%. In their study, top of
the reasons in the hospital factors include, lack of gowns,
linen, water and oxygen supply.[14] These reasons were
corroborated by other studies highlighting the extent
of this menace nationwide.[6‑8,11,15] This can be tackled
by confirming that there are materials for surgery in
the theatre before booking. Having a dedicated theatre
manager who oversees the stores and cooperates with
various units to monitor the supplies and equipment will
go a long way in curbing this menace. Power outage is
a chronic recurrent decimal in interrupting surgery in
our setting. Setting up a dedicated electricity supply to
tertiary health institution like ours will go a long way
to reduce logistic problems of unsterilized drapes or
instruments, shortage of water supply and lighting for
operations. That will in turn reduce surgery cancellation
rate in our setting. Government on its part needs to tackle
infrastructural decay, which hinders efficient services and
productivity with appropriate budgeting.
Anesthetic factor due to failed intubation accounted for
3.4% of all cancellations. Such patients often wake up
from induction anesthesia thinking their surgery had been
done; only to be disappointed. This can be overcome by
thorough improved pre‑anesthetic assessment of patients.
Where failed intubation is anticipated, arrangement with
otolaryngologist for an accessory tracheotomy should
be made in advance, to avert cancellation of planned
surgery.
 Okeke, et al.: Cancellation of elective surgical cases in a nigerian teaching hospital: Frequency and reasons
Nine  (7.6%) cancellations were due to interplay between
some of the factors. In one of the cancellations with
mixed etiology, operating table could not be adjusted and
the prosthesis to be used was not the appropriate size.
Cases booked as first or second on the list ranked
significantly high among those cancelled. This is
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apparently because most surgeons book the major cases
early on the list. It is of course the major cases that indeed
need more meticulous workup and preparations, including
arrangement for blood and intubation for general
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anesthesia. The operation cost for major cases are usually
also higher and constitutes a risk factor for cancellation of
the case on the desired day of surgery.
Conclusion
Cancellation rate in this study is far lower than studies
in other places in our environment. However this rate
can be further reduced if the preventable causes of
cancellation are tackled. Use of theatre to full capacity
should be the objective. Cancellation of surgeries leads
to underutilization of the theatre space, increased waiting
list and waste of scarce resources. 
Acknowledgement
Special thanks to my teachers for their unwavering
support towards seeing this article published and to Dr.
Chidimma Ogechukwu Ezeilo for her technical input.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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