title: Root cause analysis of internal hernia and Roux limb compression after laparoscopic Roux-en-Y gastric bypass using observational clinical human reliability assessment.
abstract: BACKGROUND
  Internal hernia (IH) and Roux limb compression (RC) are recognized complications after retrocolic laparoscopic Roux-en-Y gastric bypass for obesity. The aim of the present study was to systematically identify the surgical technical errors leading to these complications.
  
  
  METHODS
  An observational clinical human reliability assessment approach was used to analyze the operating videos of 3 groups: an IH group (n = 12), a Roux compression group (n = 13), and a control group (no complications, n = 21). Two investigators, unaware of the outcomes, reviewed all videos, using special rating software. All errors were categorized using the external error mode system and further described if a direct consequential error (e.g., bleeding) was found.
  
  
  RESULTS
  An analysis of data showed that, on average, more errors occurred in the complication groups than in the control group (IH 5.85, Roux compression 3.54, control .90, P < .001). The strongest differences were found for missing intermesenteric stitches on both sides of the Roux limb. Logistic regression analysis showed that a missed stitch between the mesentery of the Roux limb and the transverse mesocolon was an independent predictor for IH (B = 1.727, P = .025). No technical or consequential errors could be identified as responsible for RC.
  
  
  CONCLUSIONS
  The observational clinical human reliability analysis is a useful method to identify operative failure. For retrocolic, retrogastric laparoscopic Roux-en-Y gastric bypass, a systematic approach for the closure of the transverse mesenteric window might prevent IH complications.
authors: Department of Surgery and Cancer, Imperial College London, London, United Kingdom. ahmed.ahmed@imperial.nhs.uk
authors: Ahmed R
authors: AR
authors: Ahmed
authors: Danilo
authors: D
authors: Miskovic
authors: Thormela
authors: T
authors: Vijayaseelan
authors: William
authors: W
authors: O'Malley
authors: George B
authors: GB
authors: Hanna
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D002983:Clinical Competence / Q000592:standards*; D003251:Constriction, Pathologic / Q000209:etiology; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects*; D046449:Hernia, Abdominal / Q000209:etiology*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D019300:Medical Errors / Q000009:adverse effects* / Q000517:prevention & control; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D015588:Observer Variation; D011183:Postoperative Complications / Q000517:prevention & control; D060891:Root Cause Analysis; D014741:Video Recording