Laparoscopic bowel injuries: forty litigated gynaecological cases in Canada

To review the clinical circumstances and the clinical and legal outcomes of 40 laparoscopic bowel injuries that were litigated in Canada.

Retrospective review of 40 litigated cases of laparoscopic bowel injury, from 1990 to the end of 1998, provided by the Canadian Medical Protective Association (CMPA).

The laparoscopy was performed for diagnosis (n = 13), tubal occlusion (n = 15), and as an operative therapeutic procedure (n = 12). Injuries were related to the initial peritoneal entry in 22 (55%) women (19 during the closed technique and 3 with the open technique). Of these, the injury was due to the primary trocar (n = 17), scalpel (n = 1), Veress needle (n = 1), Veress needle or undetermined (n = 2), and fascial suture (n = 1). The small bowel was injured in 9 of 11 entries by the trocar during diagnostic laparoscopy and in 6 of 14 tubal occlusions. Five injuries in the tubal occlusion group were attributed to "cautery." The injury was recognized intra-operatively in 55% of cases. The clinical outcome was uncomplicated in 85% of patients. There was no difference in clinical outcome between small versus large bowel injuries and between intra-operative versus post-operative diagnosis of the injury. The litigation outcome was favourable to the physician in 75% of cases. Recognition was delayed in 45% of cases and this was associated with 67% of the litigation outcomes unfavourable to physicians.

(1) The initial laparoscopic entry into the peritoneal cavity remains the major contributor to bowel injury in laparoscopic surgery. (2) The open (Hasson) technique does not prevent bowel injuries. (3) Delayed recognition was a major factor in assessment of liability.