Objective: To analyse factors associated with a ureteric injury.
Design: Retrospective accident analysis.
Setting: Deep endometriosis surgery in a tertiary referral centre.
Sample: Video recording of a surgical accident was analysed by six gynaecologists.
Methods: A 26-year-old woman underwent laparoscopy for deep endometriosis that involves the rectosigmoid and left ureter. Post operatively left ureter transection was identified and corrected by laparoscopy. Interventions were recorded and reviewed independently.
Main outcome measures: Changes in surgical behaviour that could be measured were identified using the video recording. Results During the intervention, the periods of uncontrolled bleeding (P < 0.0001) and the duration of laser activation (P = 0.013) increased progressively. Simultaneous laser activation and bipolar coagulation only occurred at the end of surgery (seven episodes). Fatigue could not be measured.
Conclusion: Unconscious acceleration of surgery, possibly as a consequence of fatigue, is suggested as a contributing factor for an error of judgement.