Root cause analysis of internal hernia and Roux limb compression after laparoscopic Roux-en-Y gastric bypass using observational clinical human reliability assessment.

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.

CONCLUSION: 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.