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Nobody's perfect

01 February 2004

Mr Q had received conservative treatment for a prolapsed intervertebral disc, to no avail. The pain in his back was preventing him from working and he was keen to have the disc removed. He consulted an orthopaedic surgeon, Mr S, who explained the procedure and its possible outcomes, good and bad, to him. After considering his options and weighing the risks and benefits, Mr Q decided to undergo the operation.

Mr S performed a microdiscectomy at L3/4.He employed his usual precautions against penetrating the anterior annulus by taking pre- and intra-operative radiographs to estimate the depth of the operative field and by using the hinge of the pituitary rongeur as a depth gauge.

His normal practice was to use a binocular-vision microscope with axial lighting and magnification through which he could see the depth of the disc and the hinge. The operation was somewhat complicated by bleeding – there was a venous ooze that could not be successfully cauterised as, according to the operation notes, ‘microscopic view was limited for unknown reasons’.

Mr Q was discharged home three days after the operation. Two days later he told a friend that he was feeling unwell and, the following day, was admitted to hospital by ambulance because of extreme abdominal pain. A laparotomy revealed a large quantity of free blood in the abdominal cavity. The source was a small laceration in the aorta at the junction of the posterior aspect of the left common iliac artery. This was sutured.

The operation lasted six hours. During mobilisation of the aorta the inferior mesenteric artery was ligated, resulting in ischaemia in the left colon. The ischaemic section was removed and a colostomy fashioned.

The next day Mr Q was returned to theatre for more surgery, as it appeared that he was still bleeding intra-abdominally. About one and a half litres of sero-sanguinous fluid was evacuated from the abdominal cavity. There was no obvious bleeding from the aorta, but there was some from the left upper quadrant.

The patient’s condition did not improve and there was evidence of necrosis in the bowel near the colostomy site. Over the next few days, his temperature rose, his blood pressure fell, and there were increasing signs of sepsis, leading surgeons to undertake yet another operation to investigate.

No sepsis was detected, but there was a large haematoma in the lower part of the abdominal cavity. The abdomen was washed out and the necrotic part of the bowel was removed.

Despite these measures, Mr Q’s deterioration continued. Six days later, a further laparotomy was unable to identify a cause for his lack of progress. Sadly, his condition failed to improve and he eventually died some five weeks after the original microdiscectomy. His death was attributed to multi-organ failure and septicaemia, shock and haemorrhage.

Mr Q’s wife brought proceedings against Mr S, claiming that he had ‘negligently caused the pituitary rongeur to operate beyond the anterior annulus above the L3/4 intervertebral discs and thereby cutting into the aorta with the rongeur’. She sought considerable damages, given that Mr Q had left dependant children behind.

Damage to the aorta is a rare but recognised complication of microdiscectomy.

Expert opinion

Taking the advice of experts in orthopaedics who examined the details of the case, we elected to defend the claim. The experts considered Mr S’s surgical technique and management of the patient sound and they could find no evidence of negligence. At trial, the judge took the same view, finding in Mr S’s favour.

Learning points

Sometimes things go wrong, despite people’s best efforts to make sure they go right. The practice of medicine has made great strides over the past few decades in reducing mortality and morbidity rates, but cannot (and will probably never be able to) make surgery completely risk-free.

Because mortality rates are so low, people no longer expect to die from routine surgery and, unfortunately, it comes as an enormous shock to the relatives when an otherwise fit and healthy patient succumbs to a complication. They will often assume that the surgeon is to blame and, being angry and hurt, pursue a claim to the bitter end. The court, however, will not necessarily share the view that the death has been caused by negligence.

Our success in defending this claim was aided by Mr S’s thorough documentation of the technique he employed. Moreover, his preoperative preparation and intra-operative precautions were gold-standard.