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Accidental Puncture or Laceration in Colorectal Surgery: A Quality Indicator or a Complexity Measure?

Kin, Cindy M.D.1; Snyder, Karen R.N.2; Kiran, Ravi P. M.D.1; Remzi, Feza H. M.D.1; Vogel, Jon D. M.D.1

doi: 10.1097/DCR.0b013e3182765c43
Original Contribution: Benign Colorectal Disease

BACKGROUND: Accidental puncture or laceration during a surgical procedure is a patient safety indicator that is publicly reported and will factor into the Centers for Medicare and Medicaid’s pay-for-performance plan. Accidental puncture or laceration includes serosal tear, enterotomy, and injury to the ureter, bladder, spleen, or blood vessels.

OBJECTIVE: This study aimed to identify risk factors and assess surgical outcomes related to accidental puncture or laceration.

DESIGN: This is a retrospective study.

SETTINGS: This study was conducted in a single-hospital department of colorectal surgery.

PATIENTS: Inpatients undergoing colorectal surgery in which an accidental puncture or laceration did or did not occur were selected.

MAIN OUTCOME MEASURES: The primary outcomes measured were surgical complications, length of stay, and readmission.

RESULTS: Of 2897 operations, 269 had accidental puncture or laceration (9.2%) including serosal tear (47%), enterotomy (38%), and extraintestinal injuries (15%). Accidental puncture or laceration cases had more diagnoses of enterocutaneous fistula (11% vs 2%, p < 0.001), reoperative cases (91% vs 61%, p < 0.001), open surgery (96% vs 77%, p < 0.001), longer operative times (186 vs 146 minutes, p = 0.001), and increased length of stay (10 vs 7days, p = 0.002). Patients with serosal tears had entirely similar outcomes to those without an injury, whereas patients with enterotomies had increased operative times and length of stay, and patients with extraintestinal injuries had higher rates of reoperation and sepsis (p < 0.05 for all).

LIMITATIONS: This study was limited by the loss of sensitivity due to grouping extraintestinal injuries.

CONCLUSIONS: Accidental puncture or laceration is more likely to occur in complex colorectal operations. The clinical consequences range from none to significant depending on the specific type of injury. To make accidental puncture or laceration a more meaningful quality indicator, we advocate that groups who use the measure eliminate the injuries that have no bearing on surgical outcome and that risk adjustment for operative complexity is performed.

1 Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio

2 Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio

Financial Disclosures: None reported.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, TX, June 2 to 6, 2012.

Correspondence: Cindy Kin, M.D., Stanford University, Stanford Hospital and Clinics, Department of Surgery, 300 Pasteur Dr, H3680K, Stanford, CA 94305. E-mail:

© The ASCRS 2013