Accident analysis: Factors contributing to a ureteric injury during deep endometriosis surgery

R. Schonman*, C. De Cicco, R. Corona, D. Soriano, P. R. Koninckx

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

Objective: To analyse factors associated with a ureteric injury. Design: Retrospective accident analysis. Setting: Deep endometriosis surgery in a tertiary referral centre. Sample: Video recording of a surgical accident was analysed by six gynaecologists. Methods: A 26-year-old woman underwent laparoscopy for deep endometriosis that involves the rectosigmoid and left ureter. Post operatively left ureter transection was identified and corrected by laparoscopy. Interventions were recorded and reviewed independently. Main outcome measures: Changes in surgical behaviour that could be measured were identified using the video recording. Results: During the intervention, the periods of uncontrolled bleeding (P < 0.0001) and the duration of laser activation (P = 0.013) increased progressively. Simultaneous laser activation and bipolar coagulation only occurred at the end of surgery (seven episodes). Fatigue could not be measured. Conclusion: Unconscious acceleration of surgery, possibly as a consequence of fatigue, is suggested as a contributing factor for an error of judgement.

Original languageEnglish
Pages (from-to)1611-1615
Number of pages5
JournalBJOG: An International Journal of Obstetrics and Gynaecology
Volume115
Issue number13
DOIs
StatePublished - Dec 2008
Externally publishedYes

Keywords

  • Deep endometriosis
  • Surgical mistakes
  • Video recording

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