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Intraoperative injuries from abdominopelvic surgery: an analysis of national medicolegal data

Guylaine Lefebvre, Kirsten A. Devenny, Diane L. Héroux, Cara L. Bowman, Heather K. Neilson, Richard Mimeault, Sukhbir S. Singh and Lisa A. Calder
CAN J SURG April 01, 2021 64 (2) E127-E134; DOI: https://doi.org/10.1503/cjs.010219
Guylaine Lefebvre
From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women’s Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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Kirsten A. Devenny
From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women’s Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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Diane L. Héroux
From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women’s Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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Cara L. Bowman
From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women’s Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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Heather K. Neilson
From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women’s Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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Richard Mimeault
From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women’s Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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Sukhbir S. Singh
From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women’s Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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Lisa A. Calder
From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women’s Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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    Table 1

    Characteristics of patients who experienced intraoperative injury from abdominopelvic surgery, Canadian Medical Protective Association civil legal cases, closed 2013–2017

    CharacteristicNo. (%) of patients*
    All cases
    n = 181
    Nongynecologic
    n =111
    Gynecologic
    n = 70
    Age, median (IQR), yr47 (39–61)54 (38–66)44 (40–50)
    Female sex127 (70.2)57 (51.4)70 (100.0)
    Body mass index ≥ 3033 (18.2)23 (20.7)10 (14.3)
    Previous abdominal or pelvic surgery59 (32.6)28 (25.2)31 (44.3)
    ASA classification
     1: normal healthy patient51 (28.2)28 (25.2)23 (32.9)
     2: mild systemic disease90 (49.7)50 (45.0)40 (57.1)
     3: severe systemic disease; non–life-threatening33 (18.2)27 (24.3)6 (8.6)
     4: severe systemic disease; constant threat to life1 (0.6)1 (0.9)0 (0.0)
     Unknown6 (2.2)5 (2.7)1 (1.4)
    Surgery acuity
     Elective155 (85.6)87 (78.4)68 (97.1)
     Urgent26 (14.4)24 (21.6)2 (2.9)
    Type of surgery
     Cholecystectomy51 (28.2)51 (45.9)—
     Hysterectomy alone24 (13.3)—24 (34.3)
     Gastrointestinal tract (stomach, bowel, rectum)23 (12.7)23 (20.7)—
     Hysterectomy with oophorectomy and/or salpingectomy20 (11.0)—20 (28.6)
     Oophorectomy and/or salpingectomy19 (10.5)—19 (27.1)
     Hernia repair9 (5.0)9 (8.1)—
     Abdominal or pelvic cavity (mesentery, lysis of adhesions, diaphragm)8 (4.4)5 (4.5)3 (4.3)
     Appendectomy7 (3.9)7 (6.3)—
     Nephrectomy7 (3.9)7 (6.3)—
     Pelvic floor repair4 (2.2)—4 (5.7)
     Prostatectomy3 (1.7)3 (2.7)—
     Pancreaticoduodenectomy3 (1.7)3 (2.7)—
     Other urinary2 (1.1)2 (1.8)—
     Liver lobectomy1 (0.6)1 (0.9)—
    • ASA = American Society of Anesthesiologists; IQR = interquartile range.

    • ↵* Except where noted otherwise.

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    Table 2

    Frequencies and types of injury from abdominopelvic surgery

    CharacteristicLocation or type of injury; no. of cases (% of all cases)*
    All cases
    n = 181
    Bowel†
    n = 53
    Bile duct
    n = 32
    Vascular
    n = 32
    Ureter
    n = 30
    Bladder
    n = 19
    Other‡
    n = 8
    Retained surgical item§
    n = 25
    Type of surgery
     Nongynecologic111 (61.3)27 (14.9)32 (17.7)28 (15.5)8 (4.4)3 (1.7)7 (3.9)16 (8.8)
     Gynecologic70 (38.7)26 (14.4)0 (0.0)4 (2.2)22 (12.2)16 (8.8)1 (0.6)9 (5.0)
    Surgical approach*
     Laparoscopic126 (69.6)41 (22.7)32 (17.7)23 (12.7)15 (8.3)12 (6.6)6 (3.3)12 (6.6)
     Laparotomy55 (30.4)12 (6.6)0 (0.0)9 (5.0)15 (8.3)7 (3.9)2 (1.1)13 (7.2)
    Mechanism of injury*
     During dissection79 (43.6)¶31 (17.1)6 (3.3)15 (8.3)23 (12.7)11 (6.1)3 (1.7)NA
     Ligation/clip placement38 (21.0)3 (1.7)25 (13.8)8 (4.4)4 (2.2)3 (1.7)2 (1.1)NA
     Entry-related (e.g., trocar)23 (12.7)10 (5.5)0 (0.0)7 (3.9)1 (0.6)3 (1.7)2 (1.1)NA
     Thermal/cautery9 (5.0)4 (2.2)1 (0.6)1 (0.6)2 (1.1)0 (0.0)1 (0.6)NA
     During closure32 (3.9)4 (2.2)0 (0.0)1 (0.6)1 (0.6)2 (1.1)0 (0.0)NA
     Unknown10 (5.5)5 (2.8)1 (0.6)1 (0.6)2 (1.1)1 (0.6)1 (0.6)NA
    • NA = not applicable.

    • ↵* Some patients had more than 1 injury and mechanism (and approach).

    • ↵† Includes esophagus (2), stomach (2), small bowel (29), colon (15) and rectum (10).

    • ↵‡ Includes liver (4), uterus (1), spleen (1), kidney (1) and nerve (1).

    • ↵§ These most often included failures in surgical count procedures (e.g., surgical sponge, instruments) and also equipment breakdown (e.g., trocar ring, metallic edge of an endopouch, surgical bag, tip of uterine manipulator, bulb syringe, strip of insulation from a monopolar laparoscopic instrument).

    • ↵¶ Included in cases in which cautery was used with dissection.

    • View popup
    Table 3

    Clinical management and patient outcomes following injury from abdominopelvic surgery

    CharacteristicNo. (%) of cases
    All cases
    n = 181
    Nongynecologic
    n = 111
    Gynecologic
    n = 70
    Surgical phase of injury discovery
     Intraoperative43 (23.8)30 (27.0)13 (18.6)
     Postoperative same admission43 (23.8)27 (24.3)16 (22.9)
     Postdischarge95 (52.5)54 (48.6)41 (58.6)
    Management of injury*
     Intraoperative repair19 (10.5)10 (9.0)9 (12.9)
     Return to operating room139 (76.8)86 (77.5)53 (75.7)
     Transfer to tertiary care centre40 (22.1)37 (33.3)3 (4.3)
     Transfer to intensive care unit35 (19.3)27 (24.3)8 (11.4)
     Conservative treatment19 (10.5)11 (9.9)8 (11.4)
    Patient harm
     Death25 (13.8)21 (18.9)4 (5.7)
     Severe55 (30.4)38 (34.2)17 (24.3)
     Moderate/mild101 (55.8)52 (46.8)49 (70.0)
    • ↵* Some patients had more than 1 means of injury management.

    • View popup
    Table 4

    Medicolegal outcomes from injury during abdominopelvic surgery based on peer expert opinion

    OutcomeNo. (%) of casesp value
    All cases
    n = 181
    Nongynecologic
    n = 111
    Gynecologic
    n = 70
    Inherent risk with no expert criticism47 (26.0)16 (14.4)31 (44.3)< 0.01
    Inherent risk with expert criticism20 (11.0)12 (10.8)8 (11.4)0.9
    Harmful incident with expert criticism of provider’s care*109 (60.2)79 (71.2)30 (42.9)< 0.01
    Harmful incident with expert criticism of team and system issues only5 (2.8)4 (3.6)1 (1.4)0.8
    • ↵* May also include criticism of health care team and system.

    • View popup
    Table 5

    Factors contributing to intraoperative injuries based on peer expert opinion in legal cases with criticism of care

    Contributing factorNo. (%) of cases*
    All cases
    n = 134
    Nongynecologic
    n = 95
    Gynecologic
    n = 39
    Provider clinical care110 (82.1)80 (84.2)30 (76.9)
     Clinical evaluation and decision-making58 (43.3)44 (46.3)14 (35.9)
     Deficient knowledge, skill or technique53 (39.6)41 (43.2)12 (30.8)
     Misidentification of anatomy37 (27.6)34 (35.8)3 (7.7)
     Delayed recognition of injury28 (20.9)21 (22.1)7 (17.9)
     Procedural violation27 (20.1)16 (16.8)11 (28.2)
    Team communication factors62 (46.3)45 (47.4)17 (43.6)
     Informed consent40 (29.9)28 (29.5)12 (30.8)
     Documentation33 (24.6)26 (27.4)7 (17.9)
    System factors15 (11.2)11 (11.6)4 (10.3)
     Equipment or resource issues9 (6.7)7 (7.4)2 (5.1)
     Administrative protocols8 (6.0)6 (6.3)2 (5.1)
    • ↵* Some cases had more than 1 contributing factor.

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Canadian Journal of Surgery: 64 (2)
CAN J SURG
Vol. 64, Issue 2
1 Apr 2021
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Intraoperative injuries from abdominopelvic surgery: an analysis of national medicolegal data
Guylaine Lefebvre, Kirsten A. Devenny, Diane L. Héroux, Cara L. Bowman, Heather K. Neilson, Richard Mimeault, Sukhbir S. Singh, Lisa A. Calder
CAN J SURG Apr 2021, 64 (2) E127-E134; DOI: 10.1503/cjs.010219

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Intraoperative injuries from abdominopelvic surgery: an analysis of national medicolegal data
Guylaine Lefebvre, Kirsten A. Devenny, Diane L. Héroux, Cara L. Bowman, Heather K. Neilson, Richard Mimeault, Sukhbir S. Singh, Lisa A. Calder
CAN J SURG Apr 2021, 64 (2) E127-E134; DOI: 10.1503/cjs.010219
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