‘Keyhole’ surgery has its flaws
Things began to go seriously wrong shortly after the Ontario woman’s routine gallbladder surgery started.
After she was put under general anesthetic, the surgeon made an incision into the woman’s navel, and then inserted a sharp bladed trocar, a device used during laparoscopic surgery to create a portal or hole into the abdominal cavity through which instruments and cameras can be passed.
The doctor had difficulty getting the trocar in, and so he gave it a little extra shove, according to his operative notes, accidentally puncturing the woman’s abdominal aorta in the process.
By the time the injury was detected, the pooling blood had caused such significant nerve damage the woman was left with chronic, debilitating pain. The case went to a court-decided settlement, and the woman was awarded just under $1 million in damages, according to her lawyer, John Makins.
The case is one example of the legal risks doctors are being warned by their malpractice insurer they can face when minimally invasive keyhole surgeries “do not go as planned.”
The Canadian Medical Protective Association’s (CMPA) review of 423 closed cases involving laparoscopic surgery found injuries involving lacerated or damaged bowels, blood vessels, reproductive organs or nerves, delays in recognizing and treating injuries and surgery on the wrong body part, or patient.
In all, 46 people died. The review covered cases closed between 2011 and 2015. Experts were critical of the care provided in 74 per cent of them. The laparoscopic procedures most frequently involved were hysterectomy and other gynecological procedures, cholecystectomy (gallbladder removal), appendectomy and nephrectomy (kidney removal).
Many of the injuries involved punctured or lacerated bile ducts during gallbladder surgery.
Bile can spill into the abdominal cavity, causing potentially life-threatening infections.
Laparoscopic surgery appeals to people because it can mean less pain, smaller scars and quicker recovery time than traditional “open” surgery.
However, while complication rates are low, the smaller “keyhole” incisions can make it more challenging for surgeons to visualize the anatomy, and see and protect internal organs. “It’s a two-dimensional look at what’s in three dimensions,” said Dr. Gordon Wallace, managing director of safe medical care at the CMPA.
Studies show half of the most serious complications are related to the insertion of the trocar. Insertion is often done “blindly,” meaning the doctor can’t see where it’s heading. The trocar can be inserted too far, too quickly, with too much pressure or off-angle.
In 2010, 24-year-old Andres Martinez died during emergency appendix surgery at a Calgary hospital, after a surgeon blindly inserted a sharp bladed trocar into Martinez’s abdomen and unexpectedly cut a major artery. Despite hours of attempted repairs and resuscitation, he died from massive blood loss.
The judge overseeing an inquiry into the death blamed improper use of a bladed, disposable trocar, instead of a blunt, reusable one. The surgeon overseeing the operation was highly skilled, the judge added, but had “experienced a momentary lapse in judgment that caused him to believe that he could use the bladed trocar safely.”
Wallace, of the CMPA, said laparoscopic surgery complication rates are falling as surgeons gain experience. “We’re training surgeons differently; there’s much more simulation,” he said.
“Young surgeons have much more real, laparoscopic experience.” (The Ontario case involved an older surgeon approaching retirement.)
“The important point is that although safe, things do sometimes not go well,” Wallace said. “And we’re trying to alert the profession as to what the issues are so they can further reduce any preventable harm.”
However, the review found cases of doctors failing to react to a “deteriorating” situation by, for example, promptly switching to an open surgery.
Some of the injuries that occurred during surgery weren’t detected until the person developed symptoms in the post-op period. “Even then, surgeons sometimes failed to consider the possibility of a surgical injury,” the review found.
Cases of surgery on the wrong body part — or wrong patient — often occur during crisis situations, Wallace said, like sudden multiple trauma cases or last-minute changes to the OR list.
Many hospitals have introduced surgical safety checklists that should be followed before a single incision is made; in some provinces, they’re mandatory.