ABSTRACT
BACKGROUND: Ureteric injury is a complication of gynaecological surgery that can cause significant morbidity for the patient and is a leading cause of litigation in many countries. OBJECTIVES: To determine patient characteristics, peri-operative circumstances and clinical and legal outcomes of ureteral injuries associated with gynaecological surgery. PATIENTS AND METHODS: This is a retrospective review of 20 cases of ureteric injury during benign gynaecological surgery. MAIN OUTCOME MEASURES: All cases were assessed for the following variables-patient characteristics, indications for surgery, injury, postoperative symptoms and presentation, and clinical and legal outcomes. RESULTS: Risk factors associated with ureteric injury included obesity, previous laparotomic pelvic surgery, pelvic adhesions, large pelvic masses and intra-operative bleeding. 70% (14/20) of ureteral injuries were diagnosed after discharge. 50% (10/20) of patients had a complicated post-operative course and 45% (9/20) of cases resulted in unfavourable legal outcomes (settlement or lost at trial) for the surgeon. The conduct of surgery and the failure to act in a timely fashion postoperatively were the most frequent reasons for adverse clinical and unfavourable litigation outcomes for the surgeon. CONCLUSIONS: Intra-operative surgical consultation and ureteral identification should be considered if there is concern for ureteral involvement in the surgical field. Ureteric injury may not constitute negligence if it is demonstrated that the surgeon provided reasonable care that would be expected during the peri-operative phases. WHAT IS NEW: This review identifies patient characteristics and peri-operative variables that correlate with poor clinical and legal outcomes after ureteric injury.
ABSTRACT
BACKGROUND: Resectoscopic injuries to bowel and/or vessels, although rare, can be catastrophic, resulting in significant patient harm including death and can provoke medicolegal litigation. OBJECTIVE: To examine indications, preoperative risk factors, perioperative findings and intervention, and clinical outcomes of resectoscopic injuries. MATERIALS AND METHODS: Eleven cases of resectoscopic complications were reviewed by one author (G.A.V.) for medicolegal purposes. After grouping of the complications, one case for each complication was selected, edited and reconstructed to reflect and highlight all potential complications associated with monopolar resectoscopes (26F, 9-mm) and nonconductive distending medium. Although these cases are reconstructed from actual complications, they do not reflect specific cases of medicolegal opinions and outcomes. Indications for resectoscopic surgery included abnormal uterine bleeding and/or infertility in premenopausal women. RESULTS: Injuries were associated with uterine perforation resulting in hemorrhage or bowel injury; urinary bladder injury without uterine perforation; and thermal injuries to lower genital tract and dispersive electrode site. CONCLUSIONS: Resectoscopic complications are associated with any one or a combination of trauma during uterine access or intra-operatively, excessive fluid intravasation of distending medium or thermal injuries from applied energy. Uterine perforation in the presence of distorted anatomy (e.g. uterine fibroids) may be considered as a known and accepted complication. Lower genital tract and dispersive electrode site burn occur due to inherent design of monopolar resectoscopes. Appropriate intra- and post-operative intervention minimizes adverse clinical and medicolegal outcomes. Lack of post-operative vigilance and inappropriate delay in investigation and intervention is associated with adverse clinical and, potentially, unfavourable legal outcomes. WHAT IS NEW?: Reviewing resectoscopic complications raises awareness; provides insight for avoidance, recognition and timely intervention to minimise adverse clinical and medicolegal outcomes.
ABSTRACT
BACKGROUND: Gynaecologic pelvic tumours are very common and they can present with a variety of symptoms depending on their size, location, pathophysiology and histogenesis. Infrequently, some pelvic tumours are found in the retroperitoneal space presenting with similar symptoms. Our objective is to present our experience and review of pertinent literature on miscellaneous retroperitoneal tumours. METHODS: Four women with retroperitoneal tumours (one schwannoma, one granulosa cell tumour and two hindgut (tail gut) cysts)) were encountered during routine laparoscopy (3 cases) and laparotomy (one case). Following multidisciplinary consultation and additional imaging, all tumours were removed by laparotomy with one case provoking litigation due to ureteral and bowel injury. RESULTS: Using these four cases, and additional cases from the literature, we highlight the potential pitfalls and provide an algorithm to minimize risks and adverse clinical and legal outcomes associated with unexpected retroperitoneal tumours. The algorithm includes resisting the impulse/temptation to remove or biopsy these tumours, requesting intra-operative consultation(s), obtaining additional detailed imaging to characterize these tumours, providing appropriate counselling to patients, obtaining informed consent, and consulting the appropriate surgical teams. At times, an interdisciplinary approach may prove to be the best course of action in order to optimize treatment and ensure patient safety. CONCLUSION: If a retroperitoneal tumour is unexpectedly encountered, it is imperative to have intra-operative consultation (if available), to not attempt excision or biopsy, and to subsequently obtain post-operative multidisciplinary consultations, specific imaging, and information gathering in order to treat these heterogeneous masses as safely as possible.
