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A galling omission

01 August 2004

Mr W suffered symptoms of gallstones. He saw Mr P, who recommended a laparoscopic cholecystectomy. Mr W had previously had open surgery to treat ‘morbid obesity’.

Mr P used standard techniques to obtain a pneumoperitoneum and operated through a 10mm port. There were multiple adhesions, which required division via a port in the right iliac fossa. Mr P eventually decided to abandon the procedure due to ongoing technical difficulties and an inability to adequately visualise the operative field.

Mr P decided not to convert to open surgery because of the length of time the procedure had already taken.

Postoperatively Mr W developed signs of an acute abdomen with erythema and swelling in the abdominal wall over the left iliac fossa. At laparotomy a perforation of the sigmoid colon was found, which was repaired. Mr P performed a wide debridement of the abdominal wall, which was left unsutured.

Mr W had a difficult postoperative course, needing further laparotomies due to the identification of further colonic perforations. He ended up with a diverting, defunctioning ileostomy. A second opinion was called for and another surgeon closed the abdominal wall and inserted multiple drains. A further procedure to excise a fistula was needed during Mr W’s prolonged recovery.

A claim alleging negligence by Mr P was launched by Mr W. The particulars included poor judgment in choosing a laparoscopic route for surgery (in an obese patient who’d had previous surgery), inadequate consent and poor postoperative monitoring and care.

Expert opinion

We consulted a surgical expert who examined the consent given for the procedure. The expert found that Mr P hadn’t discussed the potential complication of damage to other structures during the introduction of trocars or dissection. The expert noted ‘ … in view of the patient’s history … the possible risks and complications should have been discussed in detail and the question of damage to intra-abdominal structures should have been mentioned.’

In light of this opinion we settled the claim.

Learning points

In order for consent to be considered as informed, relevant potential complications pertinent to the individual patient’s circumstances must be discussed and documented.

When considering laparoscopic surgery in an individual with a higher chance of complications specific to this surgical route, full and frank information about these risks must be given to the patient, in order that they can decide to proceed with the surgery in full knowledge of the possible dangers.

In the UK the GMC’s guidance on gaining consent for procedures can be seen here.