Medicolegal Issues

Using Chandler et al.'s data discussed previously, the U.S. claims were more likely to have an indemnity payment than those foreign, but this value was not statistically significant. The mean payment for National Association of Insurance Commissioners severity and outcome codes for 2 to 5 was $18,000; for codes 6 and 7 (significant and major permanent, respectively) was $654,000; and if the outcome was fatal the payment was $351,000. A summary of their claims outcome data is summarized in Table 4 (47).

Complications of laparoscopic surgery are a major concern for the patient and the surgeon. There is no doubt that the incidence of injury is proportional to the skill and experience of the surgeon.

The reasons for these observations are probably related to the mechanical disadvantages of working within a confined environment, isolating the surgeon from the normal tactile and sensory ability that is taken for granted with a patient opened. These drawbacks may be overcome in the future by even more advanced digital fusion technologies such as robotic-assisted surgery and microrobotic surgery, virtual reality simulation similar to aviation trainers, endoluminal surgical techniques, and genetic manipulation (136).

Why would a urologist who has spent half a life time training and improving own skills at open urologic surgery wish to start a laparoscopic practice? The only answer lies in the fact that things go well, as they most often do, the patient does much better having not been traumatized to the degree that occurs during standard operative techniques. As Sir Alfred Cushieri (137) has so eloquently phrased, "the ego of the surgeon must always be subservient to the needs of the patient."

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