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Prepare to be flexible

01 February 2004

Ultrasound had revealed a mass in Ms G’s left ovary and her consultant, Ms A, recommended laparoscopy to rule out ovarian cancer. Ms G was peri-menopausal and a history of endometriosis and adhesions had been noted during a laparoscopy a few years earlier.

Ms A was unable to view the affected ovary because it was totally obscured by adherent loops of bowel, which were also adhering to the abdominal wall. The adhesions were too dense to cut with scissors, so she used diathermy to dissect them, removing only enough to confirm that the ovary was healthy.

The operation note said that the bowel was inspected and seemed to be intact, but ‘the possibility of thermal injury and a leak remains’.
There was, indeed, a perforation in the bowel and two days later Ms G was returned to theatre for a laparotomy with adhesiolysis and repair of the perforation. The perforation had occurred in the ileum ‘at ovarian adhesion site’.

Unfortunately, the repair did not resolve the problem and Ms G was subjected to a gastroscopy and sigmoidoscopy nine days later to investigate the continued passage of blood from the rectum. Five days after this she had another laparotomy and a small resection of the bowel was carried out because a small pelvic abscess had developed at the original perforation site.

The following year (about four months after the original laparoscopy) Ms G had another laparotomy, this time to carry out further adhesiolysis and a left oophorectomy.

The claim Ms G brought against Ms A alleged that she had been negligent in failing to perform the operation as a laparotomy, which would have reduced the risk of perforating the bowel. 

Expert opinion

We consulted an expert in gynaecology and he supported this view, saying that ‘the manipulations required to free adhesions [of the denseness found by Ms A] through the laparoscope are difficult, and the risk of thermal injury to the bowel in these circumstances is high. In my opinion, the patient would have been better served had Ms A made a decision to abandon the laparoscopic attempts to free the adhesions and had proceeded to open laparotomy, where the adhesions could have been dealt with much more easily and safely.’

Ms G was ‘plainly now more prone than the average person to develop further adhesions, which can produce intermittent abdominal discomforts due to partial obstruction, or … a complete obstruction which might require hospitalisation again…’

We settled the claim out of court.

Learning points

The benefits of laparoscopic surgery are self-evident, and there are good reasons for preferring it to open surgery. Once embarked on the operation, however, the surgeon should always be prepared to convert to open surgery if it is indicated. This possibility should be discussed with the patient beforehand and consent obtained so that the conversion can be made if it proves necessary.

If your view is obscured, there is uncontrolled bleeding, the equipment isn’t adequate for the job in hand (or fails), or the operation is taking too long, it is probably best to convert to open surgery, and then fully document your reasons for doing so.

Intra-abdominal adhesions are a relative contraindication to laparoscopy and the risk of encountering problems is therefore higher. This should be discussed with the patient and recorded in consent documents.