Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements

Abstract

Background: To define what type of injuries are more frequently related to medicolegal claims and civil action judgments.

Methods: We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries.

Results: The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a "poor" visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries.

Conclusions: During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.

Keywords: biliary injury; laparoscopic cholecystectomy; legal practice; litigation; postoperative complications.

Figure 1

PRISMA flow diagram of study search.

Figure 2

ROBINS-I risk of bias assessment summary: authors’ judgements about each methodological quality item for each included study.

Figure 3

ROBINS-I risk of bias assessment graph.

Figure 4

Flowchart of causes of litigation during laparoscopic cholecystectomy.

Figure 5

Radar chart: causes of litigations. The Radar chart shows two polygons, demonstrating the most common reasons of litigations (blue polygon: improper intraoperative surgical performance; pink: improper post-operative management injury). The blue polygon has the largest area, showing that, in effect, the improper intraoperative surgical performance is the most common cause of litigations. The smaller pink polygon is very asymmetrical for the heterogeneity of the rate, as reported in Table 3. The other two causes (incorrect presurgical assessment or unnecessary surgery) are very uncommonly reported, and the rate of occurrence is particularly low in the studies that analyzed this data; for these reasons, these two polygons (green and yellow) are not presented here.

Figure 6

Radar chart: Causes of improper intraoperative surgical performance. The Radar chart shows the biggest polygon (green area) which is the most common indicator of intraoperative surgical performance: poor decision making or misinterpretation (“problematic visualization”). The areas of the smaller polygons (yellow: improper response to damage; blue: surgical injuries) are particularly small to demonstrate the few cases reported.

Figure 7

Radar chart: Defensive verdicts in litigations. The largest polygon (pink area) is the most common cause of defensive verdicts in litigations, that is, the improper post-operative management of the injury. The other two areas demonstrate incorrect presurgical assessment (grey area) and improper intraoperative surgical performance (blue area).

Figure 8

Flowchart of defense verdicts in litigations concerning laparoscopic cholecystectomy.

Figure 9

Radar chart: Defensive verdicts in litigations for problematic visualization. The largest polygon (green area: improper intraoperative surgical performances consequent to poor decision making or misinterpretation—“problematic visualization”) is the most common cause of a lower rate of defensive verdicts in litigations (blue area).

Figure 10

Radar chart: defensive verdicts in litigations for visceral damage. The largest polygon (blue area: visceral surgical injuries) is associated with a high rate of defensive verdicts in litigations (pink area).

Figure 11

Flowchart of causes of location of injuries in litigations performed for laparoscopic cholecystectomy.

Figure 12

Injuries distribution consequent to laparoscopic cholecystectomy.

Figure 13

Radar chart of injuries during laparoscopic cholecystectomy. The yellow line shows that the most frequent injury is the laceration of the common bile duct; the other most frequent lesion is the injuries of hepatic duct.

Figure 14

Flowchart of causes of defense verdicts in location of injuries for laparoscopic cholecystectomy.