Access for Laparoscopic Surgery - Negligence

Introduction:

Complications of Laparoscopic Surgery include those related to the operation itself (see Surgical Negligence section), as well as those related to intra-peritoneal access (getting into the abdomen) in order to perform the surgery. Though “access” applies to all laparoscopic surgeries, it is given its own section because it is a common cause of litigation. The discussion that follows describes the various access techniques, their complications, and potential deviations from the medical standard of care.

Laparoscopic Access Techniques:

There are three main methods of entry into the peritoneal cavity. These include:

• Open /Hasson Technique
• Veress Needle Technique
• Optical Trocar Technique

The Open / Hasson Technique involves a small skin incision, usually at the belly button. Two stay sutures are then placed on either side of the deeper tissue, in order to elevate it away from the underlying bowels. The deeper tissue is then grasped and cut, thus directly entering the peritoneal cavity (abdomen). A Hasson trocar, which is a hollow plastic tube with a blunt tip, is then inserted into the abdomen. The previously placed “stay” sutures are wrapped around small blunt hooks on the trocar to help keep the pneumoperitoneum (carbon dioxide) within the abdomen.

The Veress Needle Technique involves a long needle with a “quick release” cover on the tip. This cover theoretically guards the underlying sharp tip. A small skin incision is made. The Veress Needle is inserted and carefully advanced. When the needle pushes against the underlying tissue, the “quick release” cover slides out of the way so that the needle penetrates the deeper tissue. Once the needle tip is through the tissue, the cover is designed to slide back into place and cover the needle tip. To ensure that the needle tip is within the abdomen, “the saline drop test” is performed. This involves attaching a saline filled syringe to the Veress Needle and attempting to aspirate material. If material (bowel contents) is aspirated, an injury has occurred and needs to be addressed. If blood is aspirated, a blood vessel has been injured and needs to be addressed. If no material is aspirated, a small amount of saline is injected. If this saline is easily aspirated back into the syringe, the tip is likely not yet in the abdomen and needs to be adjusted. If the saline cannot be aspirated into the syringe, the tip is likely in the abdominal cavity. Ideally, this protects the abdominal organs from injury, and the abdomen is then insufflated through the needle. The needle is removed, and a regular trocar is then inserted blindly.

A new access method, known as the Optical Trocar has been recently developed.  This new technology allows for more controlled entry into the abdomen through continuous visualization.  The optical trocar is a clear plastic tube with a blunt tip. A laparoscope (telescope) is placed into the hollow optical trocar.   A small skin incision is made and the trocar is then inserted carefully into the peritoneal cavity by watching the tip penetrate each individual layer of the abdominal wall. More recently, an optical trocar that allows for insufflation was developed; thus insufflating the peritoneal cavity with carbon dioxide as soon as the trocar first enters the abdomen.

Risks:

Many studies have been carried out to determine what is the “best”, or “safest” technique to enter the abdomen. A consensus, however, has not been reached. The risk involved in the above described techniques is that the tip of the trocar or the Veress Needle may cause an injury to an organ within the abdomen, regardless of the technique used. Just about any organ in the abdomen has been reported to be injured; most commonly includes the small intestine, colon, or major blood vessels. The presence of adhesions from previous abdominal surgery may complicate entry, and caution should be exercised under such conditions.

Medical Negligence:

The symptoms of a missed injury vary depending on the organ injured. If the injured organ is part of the gastrointestinal tract (stomach, intestine, and colon), then intestinal contents would be leaking into the abdomen, causing diffuse pain, fever, high heart rate, and low blood pressure.

• If this complication is not diagnosed and dealt with in a timely fashion, diffuse intra-abdominal infection (peritonitis) will develop which could soon lead to the patient’s demise. If the injured organ is a major blood vessel, more likely will be noted immediately as there is profuse bleeding in the abdomen. On rare occasions, however, such injuries to major blood vessels can be contained and may become clinically apparent later. An injury to major abdominal blood vessels should be addressed in a timely fashion. Injury of the gastrointestinal tract and major blood vessels by itself is not necessarily a deviation from the standard of care. The delay in diagnosis and treatment, however, of such complications may constitute a deviation from the standard of care. The severity of the injury may also come into play under a specific clinical scenario. For example, a major injury of a major blood vessel (aorta or inferior vena cava) by a trocar that results in death would be considered a deviation from the standard of care. 

• Access complications may be due to either surgeon’s inexperience, or lack of attention and poor judgment. These factors may be difficult to prove.

• Another example of substandard care may be in the case of a previously operated abdomen with suspected adhesions (scar tissue), or a history of severe abdominal infection (peritonitis). Under such circumstances, the surgeon is expected to exercise appropriate caution with access to the abdomen. Use of the Veress Needle and the subsequent blind insertion of a bladed trocar would not be prudent under these circumstances due to the high probability of injury to an intra-abdominal organ attached to the abdominal wall by the scar tissue.