Operating room personnel morbidity from carbon dioxide laser use during preceptored surgery

To determine the extent of laser-induced morbidity away from the operative site during the preceptor phase of laser credentialing in our institution.

All laser surgeries performed from June 1, 1990 through May 31, 1991 and preceptored by one of the authors (MB) were included in the study. All of the surgeries were performed by a resident or attending physician seeking laser privileges in our institution. During that time, 141 such cases were performed.

In 13 of 141 cases (9%), there were injuries unrelated to the surgical procedure itself to either the patient or operating personnel. There were nine accidents associated with laser use during 42 laparotomy procedures (21%) and four accidents at the time of 44 vulvar surgeries (9%). There were no accidents during laparoscopic or colposcopic surgery of the vagina or cervix.

Despite extensive training requirements before use of the CO2 laser, accidents did occur. Operating room safety requirements should be a high priority to minimize morbidity. We report our experience with intraoperative morbidity caused by surgeons' errors and present recommendations to limit further complications.