Atypical clinical presentation of internal herniation after laparoscopic Roux-en-Y gastric bypass.

A 60-years old women with history of Roux-en-Y gastric bypass presented with progressive abdominal pain, mainly at the left loin. Imaging was aspecific. Exploratory laparoscopy showed an internal herniation trough the Petersen space.

Medical liability in ancient times: a surgeon's view.

Even in ancient times, medical liability occupied man. Various civilizations had their own interpretation and solutions for this. Original writings are very rare and articles on the subject are equally hard to find. The only relatively trustworthy sources are of a legal nature with their origin in Roman law and Greek philosophy, which is still reflected in our modern western way of thinking and acting today. At a later stage, the influence of the Middle East gives a special view on what was important in other civilizations and their way of thinking. All this proves that medical liability originated in ancient times.

Some notes on medical liability in ancient times.

Already in ancient times did medical liability occupy mankind. Various civilizations did give their own interpretation on the subject and proposed solutions. Original writings are rare and articles concerning ancient medical liability equally are hard to find. The only relatively trustworthy sources are of legal nature and find their origin in Greek philosophy and Roman Law. At a later stage, Arabic philosophers gave a renewed view on the statements of these previous civilizations and added their own way of thinking. All these influences still reflect in our modern western way of medical acting. Some of these ancient customs concerning medical liability will be discussed in this article.

Analysis of surgical errors in malpractice claims in Belgium.

The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical errors and identify opportunities for prevention. We retrospectively reviewed 427 surgical malpractice claims from 3202 malpractice liability cases in which patients alleged error between 1996 and 2006. Surgeon-reviewer examined the litigation file and medical record to determine whether and injury attributable to surgical error had occurred and, if so, what factors contributed. Detailed descriptive information concerning etiology and outcome was recorded. The reviewer identified surgical errors that resulted in patient injury in the 427 studied claims. Sixty-three percent of these cases involved significant or major injury; 6% involved death. In most cases (48%), errors occurred in intra operative care; 15% in preoperative care; 37% in postoperative care. Nine percent of the cases had errors occurring during multiple phases of care; in 28%, more than one clinician played a contributory role. System factors contributed to error in 90% of cases. The leading system factors were inexperience/lack of technical competence (57%) and communication breakdown (42%). Cases with technical errors (57%) were more likely than those without technical errors (43%) to involve elective surgery (57% vs. 60%, Fisher's Exact Test < 0.001). There were no clear contributions to error from multiple personnel (26% vs. 31%, Fisher's Exact Test 0.28) and errors in multiple phases of care (73% vs. 68%, Fisher's Exact Test 0.28). In addition technical error cases were more likely than those without technical errors to have been caused by lack of clear lines (14% vs. 21%, Fisher's Exact Test 0.03), abnormal or different anatomy (6% vs. 2%, Fisher's Exact Test 0.04), interruption or distraction (14% vs. 4%, Fisher's Exact Test < 0.001). On the other hand, they were less likely to have been caused by judgment errors (47% vs. 59%, Fisher's Exact Test < 0.001). There were significant more problems caused by the numbers of personnel involved in university hospitals than in non-university hospitals. On the other hand, they were less likely to have been caused by failure of vigilance/memory (16% vs. 58% Fisher's Exact Test < 0.001), breakdown (19% vs. 50%, Fisher's Exact Test < 0.001), lack of supervision (2% vs. 34%, Fisher's Exact Test < 0.001) and lack of clear lines (1% vs. 22%, Fisher's Exact Test < 0.001) in university hospitals than in non-university hospitals. System factors play an important role in most surgical errors, including technical errors and some non technical errors. Malpractice claims analysis could encrypt the leading areas for intervening to reduce errors.

Ureteral injury from blunt abdominal trauma sustained in a bicycle accident.

Ureteral injuries from blunt abdominal trauma are rare. A 67-year-old man presented with left flank pain after blunt abdominal trauma sustained in a bicycle accident. Only two hours later he developed haematuria and pain in the left inguinal area. Contrast enhanced computed tomography scans revealed a partial disruption of the left uretero-pelvic junction.

The informed consent for surgery. Update for Belgium in 2008.

Until the no-fault law in Belgium (15/05/2007) comes in action on 01/01/2009 it will be a system of fault to prove. Therefore the informed consent stays a mean or not liability progress. At this moment it stays a problem for the surgeon when he has not given any information about informed consent to the patient. If an operative intervention is unlawful. Then the signature of the patient does not remove the unlawful character of this intervention. Also the decline in standard forms with no personal contact and loss of individual adaptation cannot give a good result of information. The consequences of informed consent and how to prove the informed consent in medico legal setting are important for the surgeon's behavior. For the surgeons it will be a duty to make good informed consent brochures and forms that are adapted to the needs of the individual patients. First an oral and personal explanation between the surgeon and the patient has to be done during the first consultation. Secondly a form has to be handed over to the patient. Thirdly the patient must have the possibility to read it. Fourth the patient has to give his oral and written informed consent to the surgeon before being operated on by that same surgeon or any member of his staff. There is always a risk for sanctions in several procedures like criminal law and civil law until the no-fault system comes into action on 01/01/2009.

Plexus injury after reduction of anterior caudal dislocation of the shoulder.

The case is reported of a 45-year-old male patient who fell when his ladder slipped away from underneath him. He sustained a bilateral dislocation of the shoulders (bilateral luxatio erecta humeri). The injury on one hand was a glenohumeral dislocation of the humerus head right to ventral and caudal, accompanied by a suspected fracture of the tuberculum major and on the other hand a glenohumeral dislocation of the left humerus head to ventral and caudal, accompanied by a suspected total collum fracture. Based on this case and the pertinent literature, the patho-physiology, diagnosis and treatment of this rare injury are discussed. After immediate closed reduction, soft tissue damage, fractures or neurovascular lesions should be operated on as soon as possible.

Plexus injury after reduction of anterior caudal dislocation of the shoulder.

The case is reported of a 45-year-old male patient who fell when his ladder slipped away underneath him. He sustained a bilateral dislocation of the shoulders (bilateral luxatio erecta humeri). The injury on the one hand a glenohumeral dislocation of the humerus head right to ventral and caudal, accompanied by a suspected fracture of the tuberculum major and on the other hand a glenohumeral dislocation of the left humerus head to ventral and caudal, accompanied by a suspected total collum fracture. Based on this case and the pertinent literature, the patho-physiology, diagnosis and treatment of this rare injury are discussed. After immediate closed reduction, soft tissue damage, fractures or neurovascular lesions should be operated on as soon as possible.