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

Endoscopic Surgery:
Risk Management and MedicoLegal issues
Royal Free Hospital, London
Laparoscopic 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”.
Royal Free Hospital, London
Possible laparoscopic complications
Injury to:
Subcutaneous emphysema
Major blood vessels
Pneumothorax
Anterior abdominal wall vessels
Pneumomediastinum
Large bowel
Gas embolism
Small bowel
Hypercarbia
Bladder
Post-operative shoulder pain
Ureter
Persistence of pneumoperitoneum
Liver
Cardiac arrhythmia
Stomach
Cardiac arrest
Spleen
Nerve injury (e.g. brachial plexus injury)
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Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Medico-legal cases involving operative
laparoscopy I have given an opinion on:
Injury to external iliac artery
Injury to sigmoid colon
Injury to common iliac vessels
Injury to ascending colon
Injury to pelvic side-wall vessels
Injury to transverse colon
Injury to aorta
Injury to small bowel
Cardiac arrest
Injury to bladder
Post-operative bleeding
Injury to ilio-inguinal nerve
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Risk management
1. Identify risk
2. Analyse risk
- Publications
- Incident reporting
- Complaints
- Medico-legal claims
3. Modify practice to prevent, control or
minimize risk in future
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What factors increase the risk 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
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
What factors increase the risk 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
Royal Free Hospital, London
Royal Free Hospital, London
What factors increase the risk 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
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
What factors increase the risk 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
Royal Free Hospital, London
Royal Free Hospital, London
What factors increase the risk 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
Royal Free Hospital, London
Royal Free Hospital, London
Laparoscopic
procedure
Cholecystectomy
Fundoplication
Colectomy
Herniorrhaphy
Splenectomy
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No. of procedures to
reach proficiency
20 (8 to 200)
28 (20 to 60)
40 (13 to 70)
30 (20 to 50)
20 (16 to 20)
Experienced surgeon
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Trainee surgeon
Royal Free Hospital, London
What factors increase the risk 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
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Endoscopy cart for laparoscopy
High flow insufflator
Video monitors
Electronic morcellator
Camera unit
Light source
Suction/irrigation unit
Electrosurgical
generator
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How 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
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How 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
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How to reduce complications
related to laparoscopic entry
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Summary data for major laparoscopic complications
Overall complication rate
Intestinal
Vascular
Urinary tract
7-12.6 per 1000
1.6 to 2.4 per 1000
0.3 per 1000
2 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
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Royal Free Hospital, London
Remember, bowel injury during abdominal
entry also occurs with conventional surgery
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Alternative entry techniques
Optical Veress needle
Microlaparoscopy
Optical trocar
Safety-shield
ENDOTIP cannula
Step Radial Expanding System
Palmer’s point
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Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Subumbilical insufflation and insertion of primary trocar and cannula
1. Palpate for aorta
2. 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.
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Palpation for aortic bifurcation
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Body mass index
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Body mass index
Body mass index
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Body mass index
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Royal Free Hospital, London
Royal Free Hospital, London
Palmer’s point: laparoscopic entry site in “high risk” cases
Midclavicular line
below costal margin
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Use in cases of
Previous laparotomy
Previous peritonitis
Large pelvic mass
Inflammatory bowel disease
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Vessels of the lower anterior abdominal wall
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Insert ancillary ports under direct vision
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The inferior epigastric vessels are always outside to the safe triangle
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The inferior epigastric vessels are always outside to the safe triangle
X
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Royal Free Hospital, London
How to reduce complications
related to the laparoscopic
procedure
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Causes of laparoscopic operative injuries
Cutting (eg. scissors, laser, monopolar electrosurgery)
Burning (eg. electrosurgery, laser)
Tearing (eg. blunt dissection)
Ligating (eg. sutures, clips, staples)
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Safe laparoscopic surgery
Ensure structures are well visualised
Do not tear tissue by applying too much
force when probing or retracting
Be 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.
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Royal Free Hospital, London
Some complications are not recognised
Overall complication rate
Intestinal
Vascular
Urinary tract
7-12.6 per 1000
1.6 to 2.4 per 1000
0.3 per 1000
2 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
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
GMC guidance: Making and Using Visual
and Audio Recordings of Patients
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Informed consent
Royal Free Hospital, London
Laparoscopic 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”.
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Royal Free Hospital, London
Electrosurgical generator
Cutting
Bipolar circuit
Monopolar circuit
Blend
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Coagulation
Electrosurgical generator
Increasing
voltage
Cutting
Bipolar circuit
Monopolar circuit
Blend
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Coagulation
Management of laparoscopic vascular 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
Royal Free Hospital, London
Management of laparoscopic vascular 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
Royal Free Hospital, London
Management of laparoscopic bowel injury
Sharp, partial thickness
Laparoscopic suture
Full thickness, small volume
contamination
Full thickness, large volume
contamination
Small bipolar injury
Laparoscopic suture, check
for leakage
LAPAROTOMY
Large bipolar injury
LAPAROTOMY
Monopolar injury
LAPAROTOMY
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Laparoscopic suture
Management of laparoscopic bowel injury
Sharp, partial thickness
Laparoscopic suture
Full thickness, small volume
contamination
Full thickness, large volume
contamination
Small bipolar injury
Laparoscopic suture, check
for leakage
LAPAROTOMY
Large bipolar injury
LAPAROTOMY
Monopolar injury
LAPAROTOMY
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Laparoscopic suture
Management of laparoscopic urinary tract 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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Management of laparoscopic urinary tract 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
Royal Free Hospital, London