General Surgeon Fails to Convert Laparoscopic Surgery to Open Procedure, Perforates Bowel

This case involves a female patient who underwent laparoscopic colorectal surgery for the treatment of diverticulitis. The surgeon encountered difficulty during the surgery, and the procedure took a total of four hours to complete overall. Despite the fact that he encountered significant difficulty using a laparoscopic approach, the surgeon did not convert to an open procedure. Following the surgery, the patient became septic and it was discovered that she had suffered a laceration to her bowels. She required a number of subsequent surgeries as well as treatment for the severe sepsis, and has nevertheless suffered permanent and debilitating injuries as a result.

Question(s) For Expert Witness

1. Do you routinely treat patients similar to the one described in the case? How often do you perform this procedure?

2. How long is a typical procedure?

3. Is it abnormal to proceed for over 4 hours?

4. When does it become appropriate to convert from laparoscopic to open?

Expert Witness Response E-008057

I am a board-certified gastrointestinal and general surgeon at an academic medical center, and I am Fellowship trained in minimally-invasive, bariatric, and robotic surgery. In my day to day practice I see a fair number of inpatient consults for complications (abscess, perforation, fistula, obstruction) of diverticular disease throughout any given year. Most of these require an operation that the majority of time is done via an open approach (usually a Hartmann's procedure). Also, I am fellowship trained in minimally-invasive surgery, so I do have experience with both laparoscopic as well as robotic colon resections. A straightforward laparoscopic sigmoid resection should take about 2 hours or less in experienced hands. Operating in an acute setting would general take longer as the inflammation makes it a more difficult dissection. Conversion to an open procedure should be considered when normal anatomy cannot be identified (ie, significant adhesions or inflammation is encountered) or when an operative complication (ie, bowel injury, major vascular injury with brisk bleeding, etc) as occurred. Conversion should occur anytime patient safety is jeopardized. When the surgeon encountered difficulty, the decision to convert to open should have crossed his mind.