Characterizing 'near miss' events in complex laparoscopic surgery through video analysis

This descriptive study aims to analyze intraoperative technical errors in successful laparoscopic bariatric procedures, highlighting the importance of identifying subclinical incidents for improving surgical quality. A secondary review of 54 unedited recordings from a university-based bariatric program revealed 66 events across 38 recordings, with 66% of these requiring additional interventions such as hemostasis or suture repair. The most common incidents included minor bleeding and thermal injuries, with key error mechanisms identified as inadequate force application and poor visualization during critical surgical tasks.

The findings underscore the potential for enhancing surgeons' awareness of technical errors through systematic review of successful procedures. By understanding the underlying error patterns, surgeons can better prepare for cases, reduce the likelihood of adverse outcomes, and improve overall surgical education and quality initiatives. This proactive approach may contribute to minimizing surgical risks and optimizing patient safety.