Doctor Game: The $1,000,000 surgical error

By Medicine Hat News on July 31, 2017.

Many years ago I wrote, “The problem with laparoscopic (keyhole) surgery is it leaves the impression that tiny incisions mean a simple, uncomplicated way to perform an operation. Unfortunately, this is not always the case as catastrophic complications can happen.” Recently, a Canadian Medical Protective Association (CMPA) survey confirmed the potential dangers of keyhole surgery. So what went wrong to cause a $1,000,000 settlement?

The CMPA reviewed 423 surgical cases involving keyhole surgery. It revealed that patients suffered a number of injuries to the bowel, blood vessels, nerves, and reproductive organs. There were 46 deaths.

Operations that resulted in the most trouble were hysterectomy, other gynecological procedures, removal of the gallbladder, appendix and kidney.

In one study of 613,706 gallbladder operations, 2,380 suffered an injury to the common bile duct that drains bile from the gallbladder, an incidence of 0.39 per cent.

So how does this happen? To see inside the abdomen, surgeons first insert a small needle through the abdominal wall which fills the abdomen with gas. This lifts the abdominal muscles from the underlying bowel. Then a large sharp tube called a trocar is blindly pushed through the abdomen. This step resulted in half of the serious injuries. One of these cases that resulted in extensive injury cost the CMPA $1 million! Lastly, the lighted laparoscope is inserted through the hollow trocar.

A previous infection, or an earlier operation, may cause a loop of bowel to become adherent to the abdominal wall. If the trocar is inserted at this location it can cause severe laceration of the bowel. Some complications can therefore be an unavoidable “act of God.” In other cases, the trocar may be inadvertently inserted too far, injuring an organ.

There’s an old saying that, “Practice makes perfect.” It applies to a plumber or a surgeon. It applies especially to laparoscopic procedures where the surgical learning curve must be extensive. Looking through a small lighted tube, while at the same time manipulating other instruments, requires well trained dexterity.

It’s been said that wise generals know when to retreat. So do wise surgeons. When their first look into the abdomen shows more trouble than expected, it’s wiser to stop the procedure and make a traditional incision. Problems occur when surgeons fail to follow this rule and continue keyhole surgery when a conventional operation would be prudent.

The CMPA survey also revealed that post-operative complications, such as undetected bleeding or a torn bowel sometimes go undiagnosed, causing additional problems and at times death. These problems should decrease as surgeons become more experienced with keyhole surgery

The good news is that today a huge number of operations are done without problems resulting in less pain for the patient and a speedier recovery. We will see an increasing number of keyhole surgeries in the future.

But never forget that possible complications will continue to be a part of keyhole surgery. No surgeon can ever guarantee a 100 per cent safe outcome whether by minor or major surgery. As Harvard’s Professor of Neurosurgery once remarked, “There is no such thing as minor surgery, but there are a lot of minor surgeons!”

Keep this slogan in mind as well, that “you cannot make a person feel any better who has no symptoms.” This means that, if an ultrasound discovers stones in the gallbladder, and they’re not causing symptoms, think twice before having surgery. The best treatment for these stones is the crematorium.

So what is the bottom line in deciding if keyhole surgery is the way to go. If the sun is shining, the birds are singing and God is in Heaven and no complications occur, this is the ideal treatment. The best way to ensure this happens is to have a skilled laparoscopic surgeon perform the procedure.

If you are lucky to know a scrub nurse, ask her who she would choose if she needed keyhole surgery. Scrub nurses watch different surgeons operating day after day and they know who has the skilled hands. If you later find out, he or she, has the personality of Dracula, forget it. Remember, it’s the hands, not personality, that are doing the surgery.