Royal Free Hospital, London Endoscopic Surgery: Risk Management and Medico-Legal issues.

Royal Free Hospital, London

Endoscopic Endoscopic Surgery:Surgery:

Risk Management Risk Management and Medico-Legal and Medico-Legal

issuesissues


Laparoscopic complicationsLaparoscopic complications

1. Complications are less common than with laparotomy, but when they do occur, they are potentially more serious.

2. Patients assume “key hole” surgery is “minor surgery” and so should not be associated with “major complications”.


Possible laparoscopic Possible laparoscopic complicationscomplications

Injury to:

Major blood vessels

Anterior abdominal wall vessels

Large bowel

Small bowel

Bladder

Ureter

Liver

Stomach

Spleen

Subcutaneous emphysema

Pneumothorax

Pneumomediastinum

Gas embolism

Hypercarbia

Post-operative shoulder pain

Persistence of pneumoperitoneum

Cardiac arrhythmia

Cardiac arrest

Nerve injury (e.g. brachial plexus injury)










Medico-legal cases involving Medico-legal cases involving operative laparoscopy I have operative laparoscopy I have

given an opinion on:given an opinion on:Injury to external iliac artery

Injury to common iliac

vessels

Injury to pelvic side-wall

vessels

Injury to aorta

Cardiac arrest

Post-operative bleeding

Injury to sigmoid colon

Injury to ascending colon

Injury to transverse colon

Injury to small bowel

Injury to bladder

Injury to ilio-inguinal nerve


Risk managementRisk management

1. Identify risk2. Analyse risk

- Publications- Incident reporting- Complaints- Medico-legal claims

3. Modify practice to prevent, control or minimize risk in future


What factors increase the risk What factors increase the risk of laparoscopic complications?of laparoscopic complications?

1. Complex surgery

2. Older patient

3. Extremes of weight

4. Previous abdominal surgery/adhesions

5. Poor surgical technique/inexperience

6. Faulty/incorrect equipment





1. Complex surgery

2. Older patient








1. Complex surgery

2. Older patient









1. Complex surgery

2. Older patient








1. Complex surgery

2. Older patient







Laparoscopic procedure

No. of procedures to

reach proficiency

CholecystectomyFundoplicationColectomyHerniorrhaphySplenectomy

20 (8 to 200)28 (20 to 60)40 (13 to 70)30 (20 to 50)20 (16 to 20)


Experienced surgeon Trainee surgeon




1. Complex surgery

2. Older patient






Endoscopy cart for Endoscopy cart for laparoscopylaparoscopy

Light source

Electrosurgicalgenerator

High flow insufflator Video monitors

Suction/irrigation unit

Electronic morcellatorCamera unit


How to reduce laparoscopic complicationsHow to reduce laparoscopic complications

1. Complications related to laparoscopic entry

2. Complications related to the operative procedure

3. Complications related to pneumoperitoneum

4. Complications related to patient position

5. Complications related to anaesthesia


How to reduce laparoscopic complicationsHow to reduce laparoscopic complications

1. Complications related to laparoscopic entry

2. Complications related to the operative procedure

3. Complications related to pneumoperitoneum

4. Complications related to patient position

5. Complications related to anaesthesia


How to reduce How to reduce complications complications

related to related to laparoscopic laparoscopic

entryentry


Summary data for major laparoscopic Summary data for major laparoscopic complicationscomplications

Overall complication rate Intestinal Vascular Urinary tract

7-12.6 per 10001.6 to 2.4 per 10000.3 per 10002 to 8.5 per 1000

Complication during setup phase 1:3

Conversion to laparotomy 2%

Complication not recognised 1:4

Mortality rate 4.4 per 100,000

Mortality after hysterectomy for benign indications

150 per 100,000



Remember, bowel injury during Remember, bowel injury during abdominal entry also occurs with abdominal entry also occurs with

conventional surgeryconventional surgery














Alternative entry techniquesAlternative entry techniques

Optical Veress needle

Microlaparoscopy

Optical trocar

Safety-shield

ENDOTIP cannula

Step Radial Expanding System

Palmer’s point





Subumbilical insufflation and insertion of primary Subumbilical insufflation and insertion of primary trocar and cannulatrocar and cannula

1. Palpate for aorta2. Elevate anterior abdominal wall (to increase distance

between needle and bowel/major vessels)3. Aim Veress needle and trocar and cannula towards the

hollow of the sacrum (away from major vessels)4. Create a high pressure pneumoperitoneum prior to inserting

umbilical trocar and cannula (to increase distance between needle and bowel/major vessels)

5. Insert trocar and cannula no more than a few centimetres into the peritoneal cavity (to reduce risk of bowel or vascular injury

6. Avoid Trendelenburg tilt (head down) until laparoscope has been inserted (to avoid bringing major vessels closer to umbilicus)

7. Avoid excessive force during insertion (to limit the distance the instruments advance into the peritoneal cavity.


Palpation for aortic bifurcationPalpation for aortic bifurcation


Body mass index Body mass index


Body mass index Body mass index





Midclavicular linebelow costal margin

Palmer’s point: laparoscopic entry site in “high Palmer’s point: laparoscopic entry site in “high risk” casesrisk” cases

Use in cases ofPrevious laparotomyPrevious peritonitisLarge pelvic mass

Inflammatory bowel disease



Vessels of the lower anterior Vessels of the lower anterior abdominal wallabdominal wall


Insert ancillary ports under Insert ancillary ports under direct visiondirect vision


The inferior epigastric vessels are always outside to The inferior epigastric vessels are always outside to the safe trianglethe safe triangle


The inferior epigastric vessels are always outside to The inferior epigastric vessels are always outside to the safe trianglethe safe triangle

X



How to reduce How to reduce complications complications related to the related to the laparoscopic laparoscopic procedureprocedure


Causes of laparoscopic Causes of laparoscopic operative injuriesoperative injuries

Cutting (eg. scissors, laser, monopolar

electrosurgery)

Burning (eg. electrosurgery, laser)

Tearing (eg. blunt dissection)

Ligating (eg. sutures, clips, staples)


Safe laparoscopic surgerySafe laparoscopic surgery

Ensure structures are well visualisedDo not tear tissue by applying too

much force when probing or retractingBe careful during during sharp

dissection (eg. division of adhesions)Be very careful using thermal energy

(eg. electrosurgery, laser) near bowel, ureter and other vital structures.



Some complications are not Some complications are not recognisedrecognised

Overall complication rate Intestinal Vascular Urinary tract

7-12.6 per 10001.6 to 2.4 per 10000.3 per 10002 to 8.5 per 1000

Complication during setup phase 1:3

Conversion to laparotomy 2%

Complication not recognised 1:4

Mortality rate 4.4 per 100,000

Mortality after hysterectomy for benign indications

150 per 100,000






GMC guidance: GMC guidance: Making and Making and Using Visual and Audio Using Visual and Audio Recordings of Patients Recordings of Patients


Informed Informed consentconsent


Laparoscopic complicationsLaparoscopic complications

1. Complications are less common than with laparotomy, but when they do occur, they are potentially more serious.

2. Patients assume “key hole” surgery is “minor surgery” and so should not be associated with “major complications”.







Electrosurgical generatorElectrosurgical generator

Monopolar circuit

Blend

Bipolar circuit

Cutting Coagulation


Electrosurgical generatorElectrosurgical generator

Monopolar circuit

Blend

Bipolar circuit

Cutting Coagulation

Increasingvoltage


Management of laparoscopic Management of laparoscopic vascular injuryvascular injury

Minor oozing Inspect under low pressure

Moderate intraperitoneal bleeding

Control with electrosurgery, suturing or clips

Major intraperitoneal bleeding

Immediate laparotomy, pressure and call surgeons

Retroperitoneal bleeding Observe haematoma and laparotomy if enlarging


Management of laparoscopic Management of laparoscopic vascular injuryvascular injury

Minor oozing Inspect under low pressure

Moderate intraperitoneal bleeding

Control with electrosurgery, suturing or clips

Major intraperitoneal bleeding

Immediate laparotomy, pressure and call surgeons

Retroperitoneal bleeding Observe haematoma and laparotomy if enlarging


Management of laparoscopic Management of laparoscopic bowel injurybowel injury

Sharp, partial thickness Laparoscopic suture

Full thickness, small volume contamination

Laparoscopic suture, check for leakage

Full thickness, large volume contamination

LAPAROTOMY

Small bipolar injury Laparoscopic suture

Large bipolar injury LAPAROTOMY

Monopolar injury LAPAROTOMY


Management of laparoscopic Management of laparoscopic bowel injurybowel injury

Sharp, partial thickness Laparoscopic suture

Full thickness, small volume contamination

Laparoscopic suture, check for leakage

Full thickness, large volume contamination

LAPAROTOMY

Small bipolar injury Laparoscopic suture

Large bipolar injury LAPAROTOMY

Monopolar injury LAPAROTOMY


Management of laparoscopic urinary Management of laparoscopic urinary tract injurytract injury

Bladder perforation < 2 cm

Prolonged bladder drainage

Bladder perforation > 2 cm

Surgical repair (by laparoscopy or laparotomy)

Ureteric transection Surgical repair (by laparoscopy or laparotomy)

Ureteric ligation Remove suture


Management of laparoscopic urinary Management of laparoscopic urinary tract injurytract injury

Bladder perforation < 2 cm

Prolonged bladder drainage

Bladder perforation > 2 cm

Surgical repair (by laparoscopy or laparotomy)

Ureteric transection Surgical repair (by laparoscopy or laparotomy)

Ureteric ligation Remove suture

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Royal Free Hospital, London Endoscopic Surgery: Risk Management and Medico-Legal issues.

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