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.