Risks and prophylaxis in laparoscopy: a survey of 100,000 cases.

Abstract

France's experience with laparoscopy differs from that in the US. There have been few sterilization complications, but this indication remains unusual in France. It represents only 3% of cases in the author's series of laparoscopies. Thus far, almost all accidents, even the fatal ones, have escaped legal action. This may be 1 reason why diagnostic laparoscopy has been practiced freely throughout France for the last 25 years. The objective was to study the advantages of laparoscopy versus laparotomy and to consider, despite difficult anesthesia, the blind introduction of instruments and their single-handed use under monocular vision. The author had no fatal cases but 7 serious accidents. Only 2 accidents seemed unavoidable. In 1974 personal interviews with 28 trained laparoscopists and 34 heads of departments were conducted. A major area of concern was cardiorespiratory accidents. The study of the 54 cardiorespiratory accidents revealed that this risk is often underestimated. The combined analysis of questionnaires, interviews, and insurance records gave the impression that there had been 38 errors of indication, faulty technique, or lack of surveillance of the patient. The brief period of gaseous insufflation appears to be the most dangerous stage. The data were sufficient to allow an etiologic analysis in 33 cases only. 3 points need to be stressed: a high probability exists of gas embolism in the 3 cases of death that occurred during insufflation; 24 cases are reminders of the dangers of overpressure and hypercapnea, and a different mechanism is suggested -- the possibility of slight but continous embolism due to the insufflation needle; and regarding the last 6 cases, vasovagal syncope must not be discarded lightly even though it is no longer fashionable. Until there is complete explanation for these accidents, it is always possible to avoid them by taking prophylactic and purely empiric measures that take into account the 3 points outlined. The survey revealed a total of 58 injuries due to the insufflation needle. The accidents due to trocars or ancillary instruments were striking but all could have been avoided. Half of the 33 bowel injuries or burns were unrecognized at the time of laparoscopy. The 27 hemorrhages from ovarian biopsies or sterilizations were immediate except for 3 cases. In sum, the risk of gynecologic laparoscopy can be reduced to 2 events: the inevitable hemorrhage due to the insufflation needle; and the unforeseeable embolism.