Medicolegal and Ethical Considerations
These further research questions also bring up some ethical and legal
areas of interest. The above mentioned pathologies are rare and
frequently self-limited. Quality care is transparent care and therefore
these possibly fatal complications should be presented to our patients
during the consent process. We should also be clear to our patients that
there are limited ways to mitigate these risks and that entry techniques
vary greatly between
surgeons13. If these
events occur, they should be communicated to the patient in the
post-operative area. These events, and their management, should also be
documented in the operative report. This communication will be
invaluable for the next laparoscopist and anesthesiologist.
Sandberg et al found that more than a third of Dutch laparoscopic
malpractice claims were entry related. The number of claims has stayed
relatively constant over the last twenty
years14. However, the
United Kingdom case of Palmer v Cardiff and Vale NHS has established
precedent, at least in England, that injury during laparoscopic entry is
considered negligent13.
If litigation were to be pursued, then a clear and thorough
documentation of events and the thought process behind management will
assist in making intent very clear to other parties.
Intraoperative decisions frequently need to be made without the
assistance of our patients. If a vagal response or carbon dioxide emboli
is managed successfully, the decision to reattempt insufflation is made
solely by the patient’s surgeon and anesthesiologist. Shared decision
making becomes near impossible when one half of the parties involved are
under general anesthesia. There appears to be no way around this but it
is a humbling thought none-the-less and again speaks to a thorough
consent process.
Finally, should laparoscopy be performed in a setting where an
anesthesiologist and/or surgeon trained in large vessel repair are not
readily available? Safety is paramount but limiting access to the
benefits of minimally invasive procedures seems to be an undue burden
for such rare events. The benefits of minimally invasive laparoscopic
procedures are great and with further research and this review article
hopefully the risks can be further mitigated.