Bowel injury litigation after laparoscopy

Abstract

Since the first survey of the American Association of Gynecologic Laparoscopists (AAGL) , bowel injury has been recognized as one of the most serious complications of laparoscopy. Al though it occurs infrequently, the result of an unrecognized bowel injury is usually serious, often leading to long-term complications. The case histories of such incidents are frequently open to medical scrutiny for the first time during legal review by expert witnesses. In forming an opinion on the standard of care, it is common to rely on published treatises such as peer review articles, textbooks, and proceedings of medical organizations. Assumptions made in years past may prevail without scrutiny for decades if the fear of legal action prompts silence by those who have experienced a bad outcome. Such is the case with laparoscopic bowel perforation. Since the AAGL' s first survey over 20 years ago, the cause of the injury generally has been attributed to trauma or electrical injury. Because monopolar electrical energy lends itself to the remote-control surgery requirements of operative laparoscopy, it was a logical choice of the early laparoscopists who, for the most par t , c o n f i n e d the i r l apa ro scop i c e x p e r i e n c e s to female sterilization and lysis of adhesions. B e c a u s e s e v e r a l r e p o r t s in the ea r l y 1970s described abdominal skin burns and presumed bowel burns during m o n o p o l a r procedures , nonelect r ica l methods of sterilization were introduced at the same time as bipolar instruments. The latter were designed to el iminate aberrant electrical pathways and stray sparking. Concern about the risks of monopolar energy was h e i g h t e n e d when the Cen te r s fo r Disease Control (CDC) reported monopolar electrosurgery as a direct cause of three deaths p re sumed to be the result of delayed bowel perforation. 1 Of note however, is that because of a promise by the CDC not to disclose the names of the victims or the records, no subsequent histologic examinat ions of the injury sites were done to confirm or refute the cause of the perforations. In fact, in one of the three patients a perforation was never found; nevertheless, because monopolar energy was used, the injury was assumed to have an electrical cause. In retrospect, trauma was an equal possibility. In 1985, bowel perforations were inflicted on rabbits using a Veress needle, trocar, monopolar energy, or bipolar energy. 2 Four days after the injuries, the p e r fo r a t ed bowel was resec ted and analyzed. The gross appearance was inconclusive as to cause, but the microscopic findings were striking and diagnostic. Features of puncture injuries were limited, noncoagulative-type necrosis, more severe in the muscle coat t h an the m u co sa ; r ap id and a b u n d a n t c ap i l l a ry ingrowth with rapid white cell infiltration; and rapid fibrin deposition at the injury site followed by fibroblastic prol i fera t ion. Fea tures of electr ical injuries were absence of capillary in-growth or f ibroblast ic muscle coat reconstruction; absence of white cell infiltration except in focal areas at the viable borders of