Laparoscopic Related Trocar Injury Experience and Literature Review
Christina Richards, MD
General Surgeon, Salt Lake City, Utah
Member, UMIA General Surgery Patient Safety and Claims Review Committee
A.T. Williams, MD
Assistant Medical Director
Chairman, Underwriting, UMIA
A review of malpractice claims filed against UMIA insured laparoscopic surgeons reveals a significant dollar loss associated with vascular or other organ injury from use of trocars for port placement. These types of claims did not exist before 1992 and have recently increased in frequency and severity. This article reviews these losses, the relevant medical literature, and offers some suggestions on how to minimize these injuries. Hopefully this brief review will heighten surgeon’s awareness of this known, but difficult complication of laparoscopic surgery.
Trocar and needle injuries are rare complications of laparoscopy and can be sustained with open, closed, or visualized entry techniques.1 Unfortunately, it is not rare to see or hear of a major accident or death related to first trocar insertion. These events are always catastrophic for the patient, of course, but also for the surgeon.2
UMIA Loss Experience
Over the last ten years, UMIA identified eleven trocar related injury claims. Six of these claims were closed with indemnity payments of $1.94 million dollars and defense costs of $464,000 and rising. Five of the eleven claims remain open. The single largest loss involved injury to the aorta and adjacent organs, including the pancreas, with a trocar in a thin, muscular male undergoing a laparoscopic fundoplication. Two closed claims involved injury to the iliac arteries with a trocar, one leading to death in a 34 year old. All closed claims resulted in an indemnity payment with the average payment amounting to $324,000.
Review of Laparoscopic Literature
There are very few controlled, randomized studies looking at closed versus open trocar placement. These come down slightly in favor of an open technique.2,4 Unfortunately, this technique is not without trouble, and the medical literature primarily contains studies done prior to the advent of optical trocars. Initial teaching, when laparoscopy was in its infancy, suggested trocar placement at a forty-five degree angle downward into the pelvis. Later studies showed that this may have a higher risk of vascular injury. Subsequent experience demonstrated that placing trocars at an angle may make their manipulation difficult, particularly in advanced laparoscopic procedures where a larger field of vision and multiple working vistas are required. In these instances, a perpendicular approach is favored.
Certain populations of patients are at greater risk for trocar injuries, particularly during the initial entry. These include the very obese, the elderly, post-partum women, re-operative surgery candidates, and the very thin or muscular patient.
The very obese have a varied amount of subcutaneous fat making the depth of abdominal fascia widely variable. Most bariatric surgeons now opt for an optical trocar entry. Visualizing each level of tissue makes loss of orientation less of a risk.
The elderly and post-partum women tend to have a lax abdominal wall making intra-abdominal injury more of a risk. Grasping the fascia and tenting it up may prevent injury. In the pregnant woman, attention to fundal height and staying away from the uterus both in location and trajectory is important.
During re-operative surgery, the basic tenet is to stay away from the previous operative scar and site of operation. Re-operative laparoscopic surgery holds less of a risk because of less scarring and fewer adhesions compared to open surgery. Many favor a left upper quadrant location for initial placement.3 Subsequent exploration of this area for occult injury is also important. Additionally, it is critical to stay away from the epigastric vessels with the initial trocar placement as well as subsequent trocars. Some individuals advocate transillumination of the abdominal wall to assist in visualizing these vessels.
The thin and muscular patient presents a challenge because of tough fascia. An approach similar to that advised for the elderly or post-partum patient of tenting up the fascia can reduce the chance of a trocar injury.
Even more troublesome is the injury sustained after initial entry. Visualization of the placement of subsequent trocars can ameliorate any unrecognized injury. In other words, if the placement of subsequent trocars is visualized, any injury sustained will be immediately evident.
Suggestions for Minimizing Injuries from Trocar Placement
The following is a checklist for laparoscopic surgeons to consider before proceeding with trocar placement:
- Is this a higher risk patient for a trocar injury? (Obese, elderly, post-partum, re-operation, pregnant, or thin and muscular)
- Do I have the optimal equipment and is it functional? Has it been checked?
- Do I have the optimal location for my ports?
- Do I know where my needle went?
- Have I checked carefully for any collateral organ damage?
- Is there any sign that I have a trocar injury?
These are questions a good surgeon will ask himself/herself as he/she prepares for and proceeds with the procedure, be it a general surgeon, obstetrician, or family physician.
What if an injury occurs?
Surgeons are not expected to be perfect, and it is well recognized that errors can occur even in the best of hands. First, the best outcomes occur when the surgeon provides the patient with reasonable, pertinent information during the pre-operative discussions and decision-making, and these conversations are well documented. A procedure-specific consent form is best for elective procedures, but a pen and good notes also work well.
Second, it is important to recognize the injury at the earliest possible time. This is obvious for a direct arterial injury, but may not be so obvious for venous, bowel, or other organ injuries. Always be suspicious and alert for injuries during the procedure and specifically look for them at the end of the procedure. When detected, repair the injury appropriately or get help to get it repaired. Third, with the patient taken care of, explain in a very open, honest, and transparent way what you know about the injury and how it happened, the prognosis, and your commitment to do everything to help the patient recover as fast as possible.
Finally, continue to monitor the patient post-operatively. If there are unexplained vital signs and findings, suspicion of an occult injury and return to the operating room is best for everyone involved. Maintain close and open communication with the patient and family, irrespective of how personally painful or embarrassing it may be to you. Keep monitoring the patient and document clearly the events in a factual way. Contact UMIA to discuss the event with a claims investigator and to get help with early intervention if it appears appropriate.
Following these guidelines will put the operating surgeon in the best possible position to weather whatever may evolve in terms of the patient’s course or a potential future claim.
If you have questions or comments about this information, please contact A. T. Williams, M.D. at UMIA at 801.531.0375.
References:
1. Surg Endosc (2001) 15: 275-280
2. Surg Endosc (2005) 19: 1667
3. Cont Surgery (2006) 62 (10): 470-473
4. World J Surg (1997) 21: 529-530
5. Cont Surgery (2006) 62 (11):527
