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Tables
- Table 1
Characteristics of patients who experienced intraoperative injury from abdominopelvic surgery, Canadian Medical Protective Association civil legal cases, closed 2013–2017
Characteristic No. (%) of patients* All cases
n = 181Nongynecologic
n =111Gynecologic
n = 70Age, median (IQR), yr 47 (39–61) 54 (38–66) 44 (40–50) Female sex 127 (70.2) 57 (51.4) 70 (100.0) Body mass index ≥ 30 33 (18.2) 23 (20.7) 10 (14.3) Previous abdominal or pelvic surgery 59 (32.6) 28 (25.2) 31 (44.3) ASA classification 1: normal healthy patient 51 (28.2) 28 (25.2) 23 (32.9) 2: mild systemic disease 90 (49.7) 50 (45.0) 40 (57.1) 3: severe systemic disease; non–life-threatening 33 (18.2) 27 (24.3) 6 (8.6) 4: severe systemic disease; constant threat to life 1 (0.6) 1 (0.9) 0 (0.0) Unknown 6 (2.2) 5 (2.7) 1 (1.4) Surgery acuity Elective 155 (85.6) 87 (78.4) 68 (97.1) Urgent 26 (14.4) 24 (21.6) 2 (2.9) Type of surgery Cholecystectomy 51 (28.2) 51 (45.9) — Hysterectomy alone 24 (13.3) — 24 (34.3) Gastrointestinal tract (stomach, bowel, rectum) 23 (12.7) 23 (20.7) — Hysterectomy with oophorectomy and/or salpingectomy 20 (11.0) — 20 (28.6) Oophorectomy and/or salpingectomy 19 (10.5) — 19 (27.1) Hernia repair 9 (5.0) 9 (8.1) — Abdominal or pelvic cavity (mesentery, lysis of adhesions, diaphragm) 8 (4.4) 5 (4.5) 3 (4.3) Appendectomy 7 (3.9) 7 (6.3) — Nephrectomy 7 (3.9) 7 (6.3) — Pelvic floor repair 4 (2.2) — 4 (5.7) Prostatectomy 3 (1.7) 3 (2.7) — Pancreaticoduodenectomy 3 (1.7) 3 (2.7) — Other urinary 2 (1.1) 2 (1.8) — Liver lobectomy 1 (0.6) 1 (0.9) — ASA = American Society of Anesthesiologists; IQR = interquartile range.
↵* Except where noted otherwise.
Characteristic Location or type of injury; no. of cases (% of all cases)* All cases
n = 181Bowel†
n = 53Bile duct
n = 32Vascular
n = 32Ureter
n = 30Bladder
n = 19Other‡
n = 8Retained surgical item§
n = 25Type of surgery Nongynecologic 111 (61.3) 27 (14.9) 32 (17.7) 28 (15.5) 8 (4.4) 3 (1.7) 7 (3.9) 16 (8.8) Gynecologic 70 (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* Laparoscopic 126 (69.6) 41 (22.7) 32 (17.7) 23 (12.7) 15 (8.3) 12 (6.6) 6 (3.3) 12 (6.6) Laparotomy 55 (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 dissection 79 (43.6)¶ 31 (17.1) 6 (3.3) 15 (8.3) 23 (12.7) 11 (6.1) 3 (1.7) NA Ligation/clip placement 38 (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/cautery 9 (5.0) 4 (2.2) 1 (0.6) 1 (0.6) 2 (1.1) 0 (0.0) 1 (0.6) NA During closure 32 (3.9) 4 (2.2) 0 (0.0) 1 (0.6) 1 (0.6) 2 (1.1) 0 (0.0) NA Unknown 10 (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.
- Table 3
Clinical management and patient outcomes following injury from abdominopelvic surgery
Characteristic No. (%) of cases All cases
n = 181Nongynecologic
n = 111Gynecologic
n = 70Surgical phase of injury discovery Intraoperative 43 (23.8) 30 (27.0) 13 (18.6) Postoperative same admission 43 (23.8) 27 (24.3) 16 (22.9) Postdischarge 95 (52.5) 54 (48.6) 41 (58.6) Management of injury* Intraoperative repair 19 (10.5) 10 (9.0) 9 (12.9) Return to operating room 139 (76.8) 86 (77.5) 53 (75.7) Transfer to tertiary care centre 40 (22.1) 37 (33.3) 3 (4.3) Transfer to intensive care unit 35 (19.3) 27 (24.3) 8 (11.4) Conservative treatment 19 (10.5) 11 (9.9) 8 (11.4) Patient harm Death 25 (13.8) 21 (18.9) 4 (5.7) Severe 55 (30.4) 38 (34.2) 17 (24.3) Moderate/mild 101 (55.8) 52 (46.8) 49 (70.0) ↵* Some patients had more than 1 means of injury management.
- Table 4
Medicolegal outcomes from injury during abdominopelvic surgery based on peer expert opinion
Outcome No. (%) of cases p value All cases
n = 181Nongynecologic
n = 111Gynecologic
n = 70Inherent risk with no expert criticism 47 (26.0) 16 (14.4) 31 (44.3) < 0.01 Inherent risk with expert criticism 20 (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 only 5 (2.8) 4 (3.6) 1 (1.4) 0.8 ↵* May also include criticism of health care team and system.
- Table 5
Factors contributing to intraoperative injuries based on peer expert opinion in legal cases with criticism of care
Contributing factor No. (%) of cases* All cases
n = 134Nongynecologic
n = 95Gynecologic
n = 39Provider clinical care 110 (82.1) 80 (84.2) 30 (76.9) Clinical evaluation and decision-making 58 (43.3) 44 (46.3) 14 (35.9) Deficient knowledge, skill or technique 53 (39.6) 41 (43.2) 12 (30.8) Misidentification of anatomy 37 (27.6) 34 (35.8) 3 (7.7) Delayed recognition of injury 28 (20.9) 21 (22.1) 7 (17.9) Procedural violation 27 (20.1) 16 (16.8) 11 (28.2) Team communication factors 62 (46.3) 45 (47.4) 17 (43.6) Informed consent 40 (29.9) 28 (29.5) 12 (30.8) Documentation 33 (24.6) 26 (27.4) 7 (17.9) System factors 15 (11.2) 11 (11.6) 4 (10.3) Equipment or resource issues 9 (6.7) 7 (7.4) 2 (5.1) Administrative protocols 8 (6.0) 6 (6.3) 2 (5.1) ↵* Some cases had more than 1 contributing factor.
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