Direct Laparoscopic Trocar Insertion; Lessons Learned From Nine Litigated Cases

Abstract Study Objective To report circumstances and clinical and medico-legal outcomes of nine litigated cases associated with direct trocar insertion (DTI) injuries to bowel (7 cases) and major vessel (2 cases) during primary laparoscopic access. Design Case series from 1990 through 2015. Patients Nine litigated cases. Intervention Retrospective review of medical and legal records of litigated cases in Canada reviewed by the primary author (GAV). Measurements and Main Results The average and (range) of age and BMI of the women were 31 years (14-65) and 25 Kg/m2 (20-35), respectively. Indications for laparoscopy included diagnostic (4), laparoscopically assisted vaginal hysterectomy (3), pelvic mass (1) and laparoscopic cholecystectomy (1). DTI was performed with 10 mm trocars (5 shielded, 1 reusable, 3 unknown). Two complications were experienced by patients of the same male surgeon (case 2 and 9). Injuries included small bowel (4 cases), colon (3 cases), and major vessel (2 cases). Vascular injuries resulted in permanent brain damage in one and near loss of limb in the other; litigation was favorable to the plaintiff in both cases. All bowel injuries presented with sign and symptoms of peritonitis within three post-operative days (5 patients on POD #1, 1 patient on POD #2, 1 patient on POD #3); however, only 2 cases were acted upon and remedied with favorable clinical and medico-legal outcomes. Delayed exploratory laparotomy resulted in significant adverse clinical outcomes (ileostomy/colostomy in 4 patients, multiple surgeries in seven patients, one death) and in all delayed actions medico-legal outcomes where favorable to the Plaintiff. Conclusions During laparoscopic primary peritoneal access using the DTI technique, inadvertent intra-abdominal injury may be significant when major vessels are involved and when intervention is delayed in bowel injuries. These result in significant adverse clinical complications and may provoke higher litigation with more favorable outcomes for the Plaintiff.