From Medscape Medical News
Robert Lowes
February 9, 2010 — Laparoscopic cholecystectomy (LC) is one of the most common surgeries in the nation, but yesterday's death of Rep. John Murtha (D-PA) points out the rare, but unique, risks of this high-tech procedure, which include lack of depth perception and limitations in inspecting for operative damage.
Murtha died of major complications from LC at Virginia Hospital Center in Arlington. He had undergone an LC at the National Naval Medical Center in Bethesda, Maryland, on January 28, and was admitted to Virginia Hospital Center 3 days later. Several news organizations have independently reported that Rep. Murtha suffered an infection after his intestine was inadvertently cut during the cholecystectomy. Neither hospital, when contacted by Medscape Medical News, would confirm the nature of the complication.
Medical authorities typically put the complication rate for LC at roughly 2%. A study published in the April 1995 issue of the Annals of Surgery, for example, reported a morbidity rate of 1.9% for LC compared with 7.7% for open-field cholecystectomy.
Among LC complications, a nicked intestine is one of the least common, according to a study by Thomas McLean, MD, JD, published in July 2006 in the Archives of Surgery. Dr. McLean, a staff thoracic surgeon at the Dwight D. Eisenhower Veterans Affairs Medical Center in Leavenworth, Kansas, found that bowel injuries accounted for 2% of adverse events in LCs that triggered a malpractice suit. The leading cause of litigation — 78% — was injury to the bile duct. Such bile duct injuries are more common in LC than open-field cholecystectomy, Dr. McLean told Medscape Medical News.
Intestinal injuries, he said, are usually caused by trocar insertion. "There may be as many as 5 [trocars] inserted. This tends to be feel-only."
The intestine also can be injured when a surgeon is trying to separate it from an inflamed gallbladder that has adhered to it, said Nathaniel Soper, MD, chairman of the Department of Surgery at Northwestern University Feinberg School of Medicine, Chicago, Illinois. The pressure of the carbon dioxide gas used to inflate the abdomen during LC can seal up intestinal punctures that leak only after the gas is gone, Dr. Soper told Medscape Medical News. He noted that either the small or large intestine can be accidentally cut during LC, although the duodenum of the small intestine is the more likely candidate because of its proximity to the gallbladder. It is not clear from published accounts which intestine of Murtha's was accidentally cut.
Limitations of Laparoscopic Vision
Dr. Soper said the risk for accidental cuts increases with the distorted, depthless vision of the laparoscope.
"You're dependent on a 2-dimensional image," said Dr. Soper. "Because the image is very magnified, you're looking only at a very small part of the (surgical) field, and you don't have a normal sense of feel using 2-foot long instruments."
In contrast, surgeons performing an open-field cholecystectomy enjoy a direct, 3-dimensional, panoramic view, added Dr. McLean. That improved view helps them not only avoid a scalpel accident but also spot any accidents that occur during surgery. In addition, if surgeons are worried about inadvertently cutting an intestine, they can pick it up and gently squeeze it to check for a leak.
Another risk factor for accidental intestinal cuts is obesity. In noting that the intestines can be injured during LC, the American College of Surgeons states on its Web site that "patients who are obese...make it more difficult to move and manipulate instruments." However, an open-field cholecystectomy for a morbidly obese person carries its own special risk — an incision that can be double the normal length, noted Dr. Soper.
Rep. Murtha, who was 77 years old, had represented the 12th Congressional District in southwestern Pennsylvania since 1974. An ex-Marine and Vietnam War combat veteran, he was chairman of the House Appropriations Subcommittee on Defense.
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