A 62-year-old female patient presented to the ER with intermittent dull back pain for 2-3 weeks. She was previously seen at her primary care doctor, diagnosed with a UTI and sent home. The imaging results obtained in the emergency room suggested a possible aortic dissection and the patient was rushed to emergency surgery. Upon opening the abdominal cavity the doctor reported in his surgical note that there was a minimal tear and he performed a conservative repair. Shortly after the patient was discharged she received an anonymous note from a nurse stating that during the surgery, after opening the chest, the patient was found to have essentially a normal aorta without any dissection or aneurysm and despite the opinion of the OR team, the surgeon performed an extensive surgery and completely disregarded the patient’s safety in what presumably seemed as a way to overbill for his services.

Wrong Diagnosis Leads to Unnecessary Surgery

This case involves a 61-year-old male patient who presented to the emergency room with chest pain that had persisted for the past 45 minutes before his arrival. The ER staff performs an EKG that is read as abnormal and his blood was taken that revealed a troponin level of 0.017. His next two troponin levels were 14.58, and 26.4 which were collected 6 hours after the first sample. The patient was taken to the cardiac cath lab 4 hours after his first abnormal troponin level and the patient’s echo done during the cath showed an ejection fraction of 25%.

Delay in Cardiac Catheterization After Heart Attack Leads to Heart Failure

This case involves the removal of a malignant kidney tumor on a fifty-eight-year-old male patient using the da Vinci robotic surgery system. The procedure was met with significant complications that resulted in the untimely death of the patient. The patient’s aorta was nicked during the introduction of the mechanical arms into the patient’s thoracic cavity. Upon further investigation, it was determined that there was inadequate training amongst the surgeons involved in the procedure. Several hospital employees gave statements that the hospital was more concerned with having an opportunity to utilize the new device rather than ensuring proper 

Da Vinci Robot Surgery Results in Untimely Death

This case involves a forty-three-year-old obese male with a one-month history of one-sided neck pain, headache, and elevated blood pressure. He presented to his family physician due to elevated blood pressure, discomfort in his neck when lying on his left side, headache, and elevated blood pressure. The patient followed up with his physician four times with the same symptoms and no improvement, despite treatment. One day later, the patient experienced dizziness, left sided paresthesias, and neck pain. EMS was called and paramedics transported him to the Emergency Department. An MRI was ordered; results showed left vertebral artery dissection and secondary acute to early subacute infarction of left dorsolateral spinal cord at the level of C1. Subsequently, the patient suffered from a severe physical disability and chronic pain.

ER Expert Witness Comments on Delayed Diagnosis of Infarction

This case involves a seventy-four-year-old male, with a history significant for BPH, that presented to the emergency room after a syncopal episode. The patient also complained of upper back pain that was thought to be associated with rigorous physical activity the past few days. The patient reported becoming dizzy and sweating while lying in bed. He thought he was having a heart attack, but when he got up to take an aspirin, he passed out for a few minutes. The patient denied chest pain or shortness of breath on arrival, but did feel nauseous and vomited two times before coming to the hospital. While in the ER, the patient started to complain of right shoulder blade pain traveling to the front of his chest towards the neck. The patient was not worked up with the standard diagnostic tests for an aortic dissection or abnormal heart rhythms. Only a chest X-ray, EKG, and cardiac enzymes were ordered as part of a brief cardiac workup. The EKG showed a prolonged QT wave and also inverted T waves. The patient was admitted to the internal medicine floor for observation and within four hours of his admission, the patient sustained another syncopal episode while trying to ambulate. The patient was found by nursing staff and a code blue was called. CPR protocol was initiated but the patient was unable to be revived.

Fatal Arrhythmia Causes Sudden Cardiac Death

The patient presented to her primary care physician complaining of atypical chest pain. The treating physician ordered investigation and it was determined that the dissection was growing and most likely responsible for the new onset pain. After an extended workup it was decided that the patient required an open repair of the descending aortic aneurysm. The patient was taken to surgery and the procedure was conducted under hypothermic circulatory arrest with cardiopulmonary bypass through right leg and spinal cord drainage. The surgery was successful and was not met with any complication. In the post-operative period the patient complained of right leg pain at which point a vascular consult was requested. The vascular surgeon diagnosed the patient with compartment syndrome of the right lower limb. The patient required a fasciotomy to relieve the rapidly increasing pressure which was causing her causing excruciating pain. There were also concordant lab value arrangements including increasing creatinine levels and a severely elevated CK. The patient suffered from rhabdomyolysis that went undiagnosed and untreated for some time. When the condition was finally recognized it had progressed rapidly and there was no longer anything that could be done salvage the limb. The patient underwent a below-the-knew amputation of the right limb to prevent further advancement of the condition.

This case involves a fifty-eight-year-old female with a past medical history of a descending aortic dissection which was stented two years before the ensuing event

Vascular Surgery Expert Witness Opines on Delayed Diagnosis of Compartment Syndrome

Although laparoscopic and robotic surgeries are guided by the same surgical principles as open surgery, they are inherently different from conventional surgery. The major difference is that laparoscopic surgery uses a video camera to visualize a three dimensional surgical field on a two dimensional monitor. It uses long rigid instruments to manipulate, coagulate and cut


Although laparoscopic and robotic surgeries are guided by the same surgical principles as open surgery, they are inherently different from conventional surgery. The major difference is that laparoscopic surgery uses a video camera to visualize a three dimensional surgical field on a two dimensional monitor. It uses long rigid instruments to manipulate, coagulate and cut the tissue. Therefore, it requires extensive training.

The robotic surgery has overcome these two obstacles by providing a three dimensional surgical view. Also by providing flexible, wristed instruments that can mimic a surgeon’s hand motions. Therefore, robotic surgery is more comparable to conventional surgery than laparoscopic surgery. It also requires a shorter learning curve.

However, unlike open surgery, both laparoscopic and robotic surgeries require a specific abdominal entry. Blindly placing a 10mm trocar into the abdominal cavity, together with a camera and ancillary instruments.

Robotic surgery uses the same surgical principles as laparoscopic surgery; prior knowledge of laparoscopic surgery helps minimize complications encountered with robotic surgery. Such complications primarily have to do with inadequate surgical expertise related to abdominal entry, use of electro surgery, knowledge of anatomy, use of proper instrumentation and adherence to the principles of minimally invasive surgery.

While some complications are unavoidable and stem from circumstances beyond a surgeon’s control, the majority of surgical complications are preventable. In order to minimize complications, the surgeons must pay attention to proper pre-operative planning, intraoperative management and finally postoperative follow-up.

Many times patients and surgeons pursue laparoscopic surgery with a misguided view that it carries a lower risk of adverse events than “open” surgery. Before obtaining the patient’s consent, a surgeon must properly counsel and inform and educate the patient about all the inherent risks of the procedure. The patient’s initial understanding and expectations of the procedure, surgical outcomes, and postoperative recovery are governed by such pre-operative discussions.

Abdominal Entry Techniques and Trocar Insertion

More than half of all complications related to laparoscopy are associated with the entry technique. Preventing complications associated with initial abdominal entry is a prime concern for laparoscopic surgeons. Complications of the abdominal entry are associated with grave patient consequences. Prompt recognition and adequate treatment are essential for patient survival. Most of these complications are defendable in litigation, if the surgeon has strictly adhered to the principles of minimally invasive surgery.

The most important factor with regard to safe entry is a surgeon’s familiarity and proficiency. Thus, a combination of patient surgical history, body habitus, gynecologic pathology, and surgeon experience affect the technique used.

There are many techniques for entering the abdomen – none of which are uniformly safe. As Table 1 indicates, there areno significant differences among complication rates based on technique used.

Table 1: Complication rates based on technique of abdominal entry (from Jacobson et al.)

Technique Complication Rate per 1000 Veress needle 0.3-2.7 Open laparoscopy 0.6-12.0 Direct trocar 0.6-1.1 First trocar 1.9-2.7 Accessory trocar 0.8-6.0

Both the anatomy of the patient and the expertise of the surgeon must be considered when determining the appropriate method of access for any procedure. For example, thin, nulliparous patients may require a different technique than the morbidly obese. Patients with previous abdominal surgeries present additional challenges.

The closed entry technique with a Veress needle consists of blindly inserting the Veress needle to insufflate the abdominal-pelvic cavity. Open laparoscopy, as described by the developer of the technique, Dr. Harrith Hasson, has been shown to minimize vascular injuries but does not reduce bowel injuries. Direct trocar entry is performed by elevating the anterior abdominal wall away from the viscera, then using a see-through trocar with endoscope attached to enter the abdomen. This technique is becoming more popular. A clear advantage of the direct trocar entry technique is in visualizing the layers of the abdominal. The trocar passes through and immediately detects vascular or bowel injuries. Alternative entry sites, such as the left upper quadrant (Palmer’s point), may be considered in cases involving a large uterus, pregnancy, challenging umbilical entry, or prior abdominal or pelvic surgeries that may have caused adhesions around the umbilical area.

Veress needle injury to retroperitoneal vessels can result in minimal hemoperitoneum with a large retroperitoneal hematoma that is difficult to visualize in laparoscopy. Catastrophic bleeding occurs when the primary trocar injures a major artery or vein deep to the umbilicus. It should be noted that the location of the aortic bifurcation varies depending on the patient’s body habitus.

However, certain principles may reduce the percentage of injuries, and a few tricks may provide some measure of safety in gaining access to the abdomen:

Keep the patient flat and centered on the operating table when entering the abdomen. Avoid the Trendelenburg (when the patient’s head is lowered) position initially because the Trendelenburg position rotates the sacral promontory closer to the umbilicus.

Use standard length instruments. If the anatomy is considered and the appropriate access site and angle are chosen, there should be no need to use longer needles or trocars.

In patients with difficult access, either very thin or obese patients, or those who have had prior abdominal surgery, consider alternate sites for needle and trocar insertion.

Insufflate the abdomen to a relatively high pressure (e.g. 25 mmHg) for a short period of time to permit maximal counter pressure while inserting the trocar.

Avoid multiple passes with the Veress needle or the trocar.

Inspect the region underneath the insertion site immediately upon placement of the laparoscope. Look for blood, debris, or bowel contents.

Place all secondary ports under direct vision.

Finally, at the conclusion of the procedure, remove the laparoscope under direct vision, looking at each layer of the abdominal wall as the trocar sleeve is removed and ensure that a through-and-through injury has not occurred.

After reassurance of a non-traumatic abdominal entry, the abdomen and pelvis are surveyed for pathology. Endometriosis, pelvic inflammatory disease, and prior surgeries all contribute to distortion of the normal anatomy of the pelvic organs, blood vessels, ureters, and bowel. Adhesiolysis and ureterolysis with meticulous restoration of anatomy should first be undertaken before beginning the procedure. Once normal anatomy has been restored, key anatomic landmarks should be identified and recognized. These include anterior and posterior cul-de-sac, ureters, and major blood vessels. This process, though tedious, will aid in the correct identification of pelvic structures and decrease the risk of unintended injuries.

Knowledge of electrosurgery and tissue effects is essential to properly apply monopolar, bipolar, ultrasonic, and laser energy. Unintended electrosurgical injuries can occur due to defects in insulation that cause sparking. This could be from direct coupling with another instrument, indirect (capacitive) coupling, and the use of coagulation-type current to achieve the same effect as cutting current. The knowledge of electrosurgical principles is imperative in reducing the complications of electrical energy.

Vascular or vessel injuries are the most urgent and life-threatening injuries. They present immediately and are recognized either in the recovery room or within the first 24 hours postoperatively with abnormal or unstable vital signs in the recovery room or a significant drop in blood count.

Major vascular injuries occur most commonly during laparoscopic entry while placing the Veress needle or primary trocar. In addition, major vessel injuries have been reported with a variety of instruments including scissors, electrosurgery, stapling devices, and lasers.

The risk of bowel injury during minor laparoscopic procedures is 0.08%. The risk for major operative laparoscopic procedures is 0.3%. Bowel perforations by scissors or tearing, if not recognized at the time of surgery, typically result in early and severe postoperative abdominal pain and patients do not make a normal recovery. They may not develop severe illness immediately. Fever, absent bowel sounds, and acute abdomen should provoke suspicion in the early postoperative period. Delayed perforation may occur in patients where adhesiolysis or attempts at hemostasis were accompanied by the use of electrosurgery. Devascularization and coagulative necrosis may result in perforation days after the procedure. The average time from small bowel injury to diagnosis is 2-3 days for needle and cannula injuries and 10-12 days for electrosurgery injuries. Delayed diagnosis of a bowel injury can result in major sepsis and mortality rates up to 20%.

Small or large bowel injuries, if recognized during the laparoscopic surgery, can be fixed laparoscopically. Or the injured bowel may be pulled out through an expanded 10 mm incision and fixed.

Worsening and/or persistent pain after laparoscopic surgery necessitates immediate and thorough examination and adequate imaging tests to exclude bowel trauma. The majority of litigation occurs when the physicians do not recognize those injuries on time and not act promptly by taking the patient back to the operating room.

Bladder injury most commonly occurs in the setting of suprapubic trocar placement or dissection of the bladder from the lower uterine segment in women with prior pelvic surgery or cesarean sections, which can cause the bladder to scar or be pulled superiorly. The bladder is a forgiving organ; if the injury is detected intraoperatively it can be repaired laparoscopically in two layers using absorbable sutures. Bladder injury also presents in the immediate postoperative period with decreased urine output, abdominal distension, and constant leakage through the vaginal cuff after hysterectomy.

Ureteral injury occurs in 0.5-1.5% of open gynecological surgeries, and is slightly higher for laparoscopic surgeries. The best way to prevent ureteral injury is to identify the ureters at the beginning of the procedure and be certain of their location at all times during the procedure. Aside from knowing the location of the ureters, there are several techniques to prevent ureteral injury. In difficult cases where there is fibrosis and scarring, routine dissection of the pelvic ureters can be performed so that their location is clear throughout the entire surgical procedure.

Where there is doubt about a ureteral injury, an intraoperative cystoscopy is recommended. Indigo carmine is administered intravenously. After 5-10 minutes blue colored urine should be visualized jetting out of the ureteral orifices. Thermal injury to the ureter may be difficult to diagnose intraoperatively. Signs and symptoms of thermal injury usually do not appear until 10-14 days after surgery. Injuries recognized and repaired intraoperatively have the best prognosis. Still, a delay in diagnosis can lead to progressive deterioration of renal function. As many as 25% of unrecognized ureteral injuries result in eventual loss of the affected kidney. Depending on the location and the extent of the injury, the ureter can be laparoscopically repaired after passing a stent.

Ureteral injury usually occurs within the first 48-72 hours postoperatively, but may present later. Fever, flank pain, peritonitis, and abdominal distention should be recognized as concerning signs. These injuries may also present with leukocytosis and hematuria. If these injuries were not recognized intraoperatively, intravenous pyelogram (IVP) can assist with diagnosis.

While an unintended injury is an unfortunate occurrence, an unrecognized injury carries more serious, as well as long-term, problems. If extensive dissection of the pelvic sidewall was performed or electosurgery was used close to the ureter, cystoscopy with direct visualization of ureteral patency can assist in diagnosing ureteral injury. Directly visualizing ancillary trocar removal would reduce the possibility of unrecognized abdominal wall vessel injury. Dissection of endometriosis or adhesions from the posterior cul-de-sac may expose the bowel to injury. Sigmoidoscopy is a helpful test to detect defects in the rectum and sigmoid colon through visually inspecting the interior at the site of dissection. Another check is performed by filling the pelvis with saline irrigation while simultaneously occluding the distal portion of the sigmoid and placing air in the rectum through the sigmoidoscope. If there is a hole in the bowel air bubbles will escape from the hole.

While laparoscopic surgery has been a tremendous advance in the field of gynecology, it is not without its risks and complications. With careful attention to detail, a systematic approach to each procedure starting with the preoperative patient evaluation and counseling, complications may be anticipated and steps taken to minimize them.

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