Paracchini S, Bustos B, Aviles R, Bourdel N, Canis M, Rabischong B, Slim K, Botchorishvili R
Department of Gynecological Surgery, CHU Estaing, Clermont-Ferrand, France; Department of Surgical Sciences, AOU Città della Scienza e della Salute di Torino, Torino, Italy.
Department of Gynecological Surgery, CHU Estaing, Clermont-Ferrand, France; Hospital Parroquial de San Bernardo, Region Metropolitana, Chile.
J Visc Surg. 2021 Dec;158(6):476-480. doi: 10.1016/j.jviscsurg.2020.10.018. Epub 2020 Nov 19.
The aim of this study was to assess incidence, causes and consequences of equipment failures in a high volume, advanced endoscopic surgery department.
This is a prospectical observational single centre study between April and July of 2019 in the Gynecological surgery department of the Estaing University Hospital of Clermont-Ferrand, France. During the study period, 171 laparoscopies were observed. Data were collected real time by three supernumerary observers.
In total, 66 (38.6%) laparoscopies were complicated by equipment failures. The bipolar cable and forceps accounted for 31% of the total amount of malfunctions in laparoscopy. Causes of malfunctions were in 45% due to the instrument per se and in 43% due to the incorrect combination of elements. Less commonly, the equipment was not available or a mismatched was reported. The total length of the surgery increased by 1.35% due to the malfunctions. Human error was identified in 50% of cases. No morbility, neither mortality was reported in this series; however we observed 34 malfunctions that could have led to serious consequences for the patients and 3 incidents induced a real consequence on the operation workflow.
Equipment failure is a common event in endoscopy. On the opposite, time wasted for the malfunctions is low in laparoscopy, as it only accounts for 1.35% of the overall surgical time. Human decisions contributed to malfunctions in almost half of cases. This alarming finding may advise for intensification in training on instruments of the whole surgical team.
本研究旨在评估一家高流量、先进的内镜手术科室中设备故障的发生率、原因及后果。
这是一项于2019年4月至7月在法国克莱蒙费朗埃斯泰昂大学医院妇科手术科室进行的前瞻性单中心观察性研究。在研究期间，观察了171例腹腔镜手术。数据由三名额外的观察者实时收集。
总共66例（38.6%）腹腔镜手术因设备故障而出现并发症。双极电缆和钳占腹腔镜手术故障总量的31%。故障原因45%是由于器械本身，43%是由于元件组合不正确。较少见的情况是设备不可用或报告不匹配。由于故障，手术总时长增加了1.35%。50%的病例中发现人为失误。本系列中未报告有发病率或死亡率；然而，我们观察到34起可能对患者造成严重后果的故障，以及3起对手术流程产生实际影响的事件。
设备故障在内镜检查中是常见事件。相反，腹腔镜手术中因故障浪费的时间较少，仅占总手术时间的1.35%。几乎一半的故障是由人为决策导致的。这一惊人发现可能建议加强对整个手术团队器械操作的培训。
