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Characterising ‘near miss’ events in complex laparoscopic surgery through video analysis
  1. Esther M Bonrath,
  2. Lauren E Gordon,
  3. Teodor P Grantcharov
  1. Division of General Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
  1. Correspondence to Esther M Bonrath, M.D., Division of General Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON, Canada M5B 1W8; Esther.bonrath{at}


Background Root cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical errors is essential for developing rescue mechanisms to prevent adverse outcomes.

Objective Descriptive study to characterise intraoperative technical error-event patterns in successful laparoscopic procedures.

Methods Events (injuries) identified during prior blinded analyses of 54 unedited recordings of bariatric laparoscopic procedures were subjected to a secondary review to determine the presumed underlying error mechanism. The recordings were obtained from one university-based bariatric collaborative programme, and represented consultant, fellow and shared trainee cases.

Results Sixty-six events were identified in 38 recordings, while 16 videos showed no events. In 25 (66%) of the videos that showed events, additional measures such as haemostasis or suture repair were required. Common identified events were minor bleeding (n=39, 59%), thermal injury to non-target tissue (n=7, 11%), serosal tears (n=6, 9%). Common error mechanisms were ‘inadequate use of force/distance (too much)’ (n=20, 30%) and ‘inadequate visualisation’ during grasping/dissecting (n=6, 9%), ‘inadequate use of force/distance (too much)’ using an energy device (n=6, 9%), or during suturing (n=6, 9%). All events were recognised intraoperatively.

Conclusions Analysis of successful operations allowed the identification of numerous error-event sequences. Reviewing injury mechanisms can enhance surgeons’ understanding of relevant errors. This error awareness may aid surgeons in preparing for cases, help avoid errors and mitigate their consequences. Thus, this approach may impact future surgical education and quality initiatives aimed at reducing surgical risks.

  • Surgery
  • Continuing education, continuing professional development
  • Graduate medical education
  • Human error
  • Patient safety

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