Continued part 1, part 2 of ebook Medicolegal issues in obstetrics and gynaecology provide readers with content about: general gynaecology; abdominal hysterectomy; diagnostic and operative laparoscopy; ectopic pregnancy and miscarriage; urogynaecology; vaginal repair and concurrent prolapse and continence surgery; colposuspension and autologous fascial sling; laparoscopic prolapse surgery; infertility, subfertility and the menopause; fertility testing and treatment decisions;... Please refer to the part 2 of ebook for details!
Part IV General Gynaecology Swati Jha and Janesh Gupta Abdominal Hysterectomy 36 Thomas Keith Cunningham and Kevin Phillips 36.1 Background Hysterectomy is one of the most common surgical procedures for managing benign gynaecological disease such as, abnormal uterine bleeding, fibroid uterus, and prolapse, with reportedly 30% of women in the US by the age of 60 undergoing the procedure [1] Up until the 1990s the vast majority of hysterectomies were performed either vaginally or abdominally and this may have varied from region to region depending on the training undertaken The advances in laparoscopic surgery have allowed hysterectomies to be performed totally laparoscopically or laparoscopically assisted with the uterus being removed vaginally Gynae-oncologists now offer laparoscopic hysterectomies for certain stages of endometrial cancer (NICE IPG 356) [2] 36.2 M inimum Standards and Clinical Governance Issues NICE have recently issued guidance that hysterectomy should not be performed as a first line treatment for heavy menstrual bleeding (HMB) Hysterectomy should only be considered when other medical treatments have failed (NICE CG44) [3] This includes a trial of levonorgestrel- releasing intrauterine system, for at least 12 months, transexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptive pills or norestesterone daily from days to 25 of the menstrual cycle in women with no or small 8 mm should be sutured Umbilical primary port 37 Diagnostic and Operative Laparoscopy sites often not require closure of the sheath, although each case should be assessed individually However, in very slim patients, consideration should be given to closure of the sheath of all ports 37.2.3.6 Post-operative Care Any patient who has undergone laparoscopic surgery should improve steadily in the days following surgery Patients should be informed therefore to contact the hospital directly if they develop increasing abdominal pain, a pyrexia or become systemically unwell Any patient presenting in the post-operative phase with the above features should be assumed to have a visceral injury until proven otherwise The white cell count and C-reactive protein levels should be monitored and if there is any concern over a perforation, a CT scan should be performed Clearly if bowel or vascular damage has occurred a laparotomy should be undertaken, but in more borderline cases a diagnostic laparoscopy can be performed 37.3 Reasons for Litigation Litigation may arise from the following • Failure to warn of the risks including laparotomy and visceral injury • Failure to adhere to the Guidance of prevention on entry related injuries • Intra-operative visceral damage (bowel, bladder or blood vessels) • Failure to diagnose visceral damage at the time of surgery • Failure to close ports adequately 37.4 Avoidance of Litigation Pre-operative counseling should be thorough and comprehensive allowing the patient time to consider all treatment options and whether the risks of surgery are justified in relation to the potential benefits 215 A surgeon should ensure that they are adequately trained for the procedures they are undertaking The surgeon should rigidly adhere to the same criteria for diagnostic laparoscopy in both private and NHS practices A lack of indication for surgery could leave a surgeon open to litigation should a recognized complication arise in an otherwise competently performed procedure The primary port should be inserted in a standard technique If a complication should arise in a case when a non-standard technique is used, the onus would be on the surgeon to demonstrate that their method was based on sound surgical concepts Secondary ports should be inserted under direct vision Visceral injury during this part of the procedure would be hard to defend Close the rectus sheath in all port sites greater than 8 mm A high index of suspicion should be maintained for any patient presenting with potential signs of visceral or vascular damage Appropriate investigations should be undertaken early and if necessary repeatedly Should a complication occur, an appropriate specialist colleague should be asked to attend promptly; a substandard repair of any trauma would only compound the potential adverse outcome and in turn, the risk of a successful litigation Any complication should be discussed fully and frankly with the patient at the time and then again in clinic a few weeks later A surgeon should maintain a prospective record of their surgical practice along with their complication rate 37.5 Case Study Greenall v ST Helens & Knowsley Hospitals NHS Trust (2009) During a diagnostic laparoscopy the claimant suffered a vascular injury to her aorta with the formation of a large haematoma It was identified during surgery when her blood pressure fell significantly and as a result an emergency laparotomy was performed A vascular surgeon was called A Baxter 216 from a neighbouring hospital and they detected a perforation on the right side of the claimant’s aorta, above the right common iliac artery This was caused by a failure to insufflate the abdomen sufficiently during the laparoscopy The perforation was subsequently closed The claimant spent several weeks in hospital and suffered extreme pain and immobility during the recovery She required assistance in her day to day activities and suffered occlusion of her right common iliac needing several angioplasties Liability was admitted by the Trust and an out of court settlement for £40,000 made Learning points include the need to adhere to basic principles during abdominal entry for a laparoscopy Mere detection of an injury is not a guarantee against litigation if adequate precautions to prevent it from happening have not been taken Key Points: Diagnostic and Operative Laparoscopy • Fully informed consent in line with Montgomery and the GMC • A clinician should not attempt procedures without adequate training • Primary and secondary ports should be inserted using sound, proven techniques • A high index of suspicion for visceral injury should be maintained should a patient become unwell post-operatively Clear and thorough note-keeping on pre-operative discussions, the procedure itself, as well as a prospective log of operation numbers and any complications will facilitate the defence of any claim References Green-top guideline 49 Preventing entry-related gynaecological laparoscopic injuries London: RCOG; 2008 Ahmad G, Duffy JMN, Phillips K, Watson A. Laparoscopic entry techniques (protocol) Cochrane Database Syst Rev 2007;3:CD006583 https://doi.org/10.1002/14651858.CD006583 ... International Publishing AG, part of Springer Nature 20 18 S Jha, E Ferriman (eds.), Medicolegal Issues in Obstetrics and Gynaecology, https://doi.org/10.1007/978-3-319-78683-4_39 22 1 A Cutner 22 2 for at... Keith.Cunningham@hey.nhs.uk; Kevin.Phillips@hey.nhs.uk © Springer International Publishing AG, part of Springer Nature 20 18 S Jha, E Ferriman (eds.), Medicolegal Issues in Obstetrics and Gynaecology,... Springer International Publishing AG, part of Springer Nature 20 18 S Jha, E Ferriman (eds.), Medicolegal Issues in Obstetrics and Gynaecology, https://doi.org/10.1007/978-3-319-78683-4_40 22 5