50 y.o. man that was to undergo elective robot assisted lap sleeve gastrectomy. It appears that the patient suffered 2 perforations to the small intestine, jejunum and aorta before the actual surgery even started. It was recognized, surgery was converted to open laparotomy. and vascular surgeon was called in to repair the significant vascular injury to the mesenteric vein (2 areas of injury at the area of the IMA were sutured) The patient lost 3 liters of blood, went into hemorrhagic shock, acute hypercapneic respiratory failure, ARF, likely ischemic AFN. Total of 9 units of PRBC, 4 units of FFP, 2 plt packs, 9 liters of IVFs. He initially appeared to stabilize but his pHs failed to correct, and patient began to develop abdominal distension and hemodynamic instability (hemorrhagic shock) and he was returned to surgery wherein a small 2 mm defect in the wall of the aorta was noted and repaired.
At the end of the operative report, the surgeon reported: “the injury occurred during initial entry into the abdomen with the Visiport. When looking with the scope, he continued to see adipose tissue thinking he was in subcutaneous tissue. However, he had already passed through the abdominal wall and was in the peritoneal cavity and the port was passed through the omentum and mesentery and into the vessels causing the injuries”
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Do you believe there might have been medical error?
Any injury to an organ or blood vessel during Visiport placement is an error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The error is not identifying that the port has reached the peritoneal cavity and continuing To apply pressure to the port through the small bowel as well as the aorta.
What makes you a good expert for this case?
I have placed thousands of peritoneal cavity ports for laparoscopic surgery. Approximately 25% of these are visiports.
How often do you encounter cases similar to this one in your practice?
I have not personally injured the aorta with a port however, I know of a colleague who has done that once. This is over 10 year period of practice. Personally I have had one small bowel injury, placing the port over 10 years of practice. I have assisted in about a handful of other cases over 10 years with small entry placement.
Do you believe there might have been medical error?
When using a visiport, it is imperative that you proceed cautiously, having a high index of suspicion. It became apparent that there was in injury, and the case was correctly converting to an open case. It would seem that the port was attempted to be placed in or near the midline given the location of the injuries. It is safer to pace then initial port in Palmer's Point (left upper quadrant just below the costal margin) which off the midline and typically avoid injuring the midline structures including the aorta. Once there was noted to be a penetrating injury, then a trauma laparotomy approach should be considered. This would involve, among other things, an evaluation of the entire tract of the penetrating instrument. This would include the retroperitoneum and evaluation of the aorta at the initial operation. The case presented does not say that that was or was not done, but, if it had been done, the aortic injury could have been recognized and avoided the some of the complications of bleeding and re-operation
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As described above, placing the initial port in the midline has an increased injury risk. Additionally, one should be able to see the layers of the abdominal wall with the visiport given the contrast in color when traversing the muscular portion of the abdominal wall
What makes you a good expert for this case?
I am a robotic surgeon and work as a trauma and acute care surgeon I have 18 years of experience post fellowship and work at a busy level one verified trauma center
How often do you encounter cases similar to this one in your practice?
I manage trocar injuries as part of my practice. They are quite rare, but are managed similarly to other penetrating injuries.
Do you believe there might have been medical error?
Aorta can't be injured during initial port placement without some sort of error.. Hard to say definitively without review of medical records.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Patient had an aortic injury during port placement; by definition an error that resulted in injury.
What makes you a good expert for this case?
Rescue of patients from surgical misadventures is a substantial part of my practice as an academic vascular surgeon at a quaternary referral center.
How often do you encounter cases similar to this one in your practice?
Trocar/port placement misadventures resulting in vascular injuries occur 1-3 times/year in our facility, and we have patients transferred to us from other hospitals at least 2=3 times a year for similar injuries.
Do you believe there might have been medical error?
Unfortunately, this is a known complication of lap surgery. The question is. 1. properly trained 2. had the volume to support this technique
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Res Ipsa Loquitur. There is not doubt, the injury was the direct and proximate cause.
What makes you a good expert for this case?
Decades of med mal work, clinically active, academic appointment at a major University, and the ability to explain complex medical issues in a simple manner
How often do you encounter cases similar to this one in your practice?
Yes. I have been involved and opined on many of these types of cases.
Do you believe there might have been medical error?
Injury to bowel and blood vessels in the abdomen are a know possible complication of laparoscopic surgery. Typically, the patient is informed and consented that those injuries could potentially occur. Having said that, the error that occurred in this case is a technical error. Improper visualization of tissue planes and/or excessive force is what caused these injuries to occur. While there may not necessarily be a deviation from the standard of care, there certainly was an error in technique that caused the injuries.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The error (which was a technical intraoperative error) did cause harm to the patient by virtue of the injury that was sustained and the fact that the patient was then subjected to additional surgery and prolonged hospitalization and postoperative complications.
What makes you a good expert for this case?
I perform laparoscopic surgery on a daily basis. I have been in practice for nearly a decade. I am the Chair of the Department of Surgery. I have been a medical expert witness in multiple cases.
How often do you encounter cases similar to this one in your practice?
I perform laparoscopic surgery daily. I perform acute care surgery, oftentimes managing patients with complications. I work in an academic center, where I teach surgical trainees on operative complications such as the one described.
Do you believe there might have been medical error?
This is a purely technical error and a known, albeit rare, complication of establishing laparoscopic access by using a Visiport technique. The injuries sustained in this cases were to the intraperitoneal (intestine) and retroperitoneal (vessels) organs and were caused by surgeon's inability to recognize when a proper plane has been reached and the trocar was advanced much deeper than it should have been.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The inability to recognize when the appropriate plane was reached and then surpassed (e.g. the medical error) led to the injury to the aforementioned structures when the port traversed the abdominal cavity.
What makes you a good expert for this case?
Expert bariatric surgeon with numerous publications, presentations, lectures, and seminars in my past. Current vice-president of the California/Nevada chapter of the American Society of Metabolic Bariatric Surgeons. Former academic surgeon (assistant professor) with multiple educational responsibilities dealing with residents and medical students. Provided expert medical opinion in multiple surgical cases, both for defense and prosecution.
How often do you encounter cases similar to this one in your practice?
Never in my personal practice, but have encountered similar cases in the facilities where I have practiced.
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