Medico-legal problems: the new frontier of pediatric minimally invasive surgery.

In the last 12 months, as an expert in pediatric laparoscopy and/or court-appointed technical consultant, I have been asked to give advice in five court actions: in 2 cases some pediatric surgeons had received a notification and in 3 cases a request for compensation for the complications that occurred during a pediatric laparoscopic operation. Starting from the investigation of those cases, we will make some useful observations as for medico-legal aspects of MIS in pediatric age, considering that there are few reports in literature on this topic. In all the 5 cases the surgeons were expert in pediatric laparoscopy. As concerns the prosecuted operations, in 2 cases the patients had been splenectomized in laparoscopy for splenomegaly of hematologic origin, in 1 case a patient had undergone orchidopexy due to intrabdominal testis, in 1 case a herniorraphy for groin hernia, and in another case a cholecystectomy due to idiopathic cholelithiasis. In all cases the surgeon was accused of performing the operation in laparoscopy instead of the required laparotomy. In particular, in all the cases there was the report made by the party’s surgeon—which had not been made by an expert in laparoscopic surgery—which underlined that the surgeon had run the further risk of operating the patient in laparoscopy and that anyway the operation would have been safer if performed in open surgery. Besides, the party’s medico-legal reports criticized the new laparoscopic devices used in some operations to produce hemostasis, such as the ultrasonic scalpel or the clips applicator, by assessing that those devices were not as reliable as the suture ligatures carried out in open surgery. Moreover, the patients’ parents said that they were not clearly informed by the surgeons, although all of them had signed the confirmed consent, and some parents said that itwas not the operating surgeon to show them the informed consent. From the technical point of view, in all cases we saw that the informed consents of the operations written by the surgeons were not very accurate as well as the description of the operation was too synthetic, summed up in few lines without the details necessary to defend the surgeon. Probably, considering the ever-increasing number of lawsuits for compensation against surgeons, it is crucially important that the operating surgeon should verbally inform the patient’s parents at least 24 hours before the operation and then make them sign the informed consent. The presence of a witness—who is going to sign the consensus too—on signing the consent can be an useful device to attest that the surgeon has given a correct and complete information to the patient’s parents. Of extreme importance are the attention and the greatest accuracy of the surgeon in giving a detailed description of the surgical operation in the registry of operations also in routine operations, such as inguinal hernia, impalpable testis, and cholecystectomy. In our opinion, the international scientific associations, such as the IPEG, APSA, andEUPSA, should define some guidelines on the treatment of single pathologies, which could be adopted by laparoscopic surgeons in their clinical practice. Some guidelines have been already published by few associations (e.g., IPEGguidelines) but they tackle only very fewoperations. In addition, it is important for the surgeon to refer to the international literature, and therefore, laparoscopic surgeons should publish also the case studies on the complications of the operations and not only on the successes or improvements in laparoscopic surgery. Surely the national associations can play an important role in defending prosecuted laparoscopic surgeons, as it has been done by the Italian Society of Videosurgery in Infancy, which constituted a medico-legal commission of experts in laparoscopy that gives free assistance to its members being prosecuted following a laparoscopic operation. We believe that court actions against laparoscopic surgeons will represent a crucial problemin laparoscopy in the following years, and only through the joint work of scientific associations and the minimally invasive surgeons groups it will be possible to reduce it, which is ever increasing almost in Italy. Indeed, if it is not reduced it will produce a great increase in the cost of the surgeons’ insurance policies, with further devastating impacts on the whole National Health Service.