A study of misadventure data relating to laparoscopic surgery shows that the injury most frequently associated with the procedure is damage to the common bile duct, followed by perforation of the small bowel and of the colon. Injuries occur most often during gall-bladder operations, with exploratory laparoscopy coming second.
The data are contained in a report from the Physicians Insurers Association of America, which draws on information from 19 medical insurance companies.
This latest study analyzed data from 535 cases, in which 163 claims were settled, with payments to the plaintiffs totaling $34 million. Payments ranged from $1,500 to $925,000, with the average being $212,350.
Failure to identify the injury once it occurred was a key factor in the severity of the outcome. In more than two thirds of the incidents examined, the injury was not identified until some time after the conclusion of the procedure. In some cases, that delay led to serious complications, such as peritonitis and sepsis. Resulting indemnity payments averaged 10% more when the patient's injury was not recognized before the conclusion of the procedure.
Cholecystectomy injuries were not recognized before the conclusion of the surgery in 83% of claims. Injuries that were recognized tended to be vascular in nature, whereas visceral injuries causing complications were more likely to remain unrecognized until after the end of surgery. Difficulty in visualizing the anatomic structures during laparoscopic surgery was a contributing factor to these types of adverse incidents.
Trocars were the most common type of device causing injury. More than a quarter of all claims cited either primary or secondary trocar insertion as the prime cause of injury. Surgical clips were the second most common reason for injury (9%), followed by Veress needles (8.2%), cautery equipment (5.4%), and sharp objects such as scissors or scalpels.
The average age of patients who died of alleged injuries was 51 years. Deaths commonly resulted from multiple injuries. Perforations of the small bowel and colon resulted in the severest injury, probably resulting from the long delay between the surgical procedure, the discovery of the injury, and the repair.
The report's recommendations included the following: before a new procedure is performed, proper training should be under-taken ; indications for using laparoscopic surgery should be documented, contraindications recorded, and the specific reasons why benefits outweigh risks specified; the patient should be evaluated for injuries before the procedure is concluded; and if the surgery is being done on an outpatient basis, the patient or caregiver (or both) should be educated to recognize complications.