Bowel Damage During Sterilisation
If you have suffered internal organ damage during gynaecological surgery, have you been the victim of medical negligence? In this article we explore the topic in further detail, helping you establish whether you have the grounds for a claim.
If you cannot find the information you are looking for, please contact us and speak to one of our specialist solicitors.
Laparoscopic sterilisation
According to the Royal College of Obstetricians and Gynaecologists, around 25,000 laparoscopic sterilisations are carried out every year in the UK. It is therefore a very common procedure.
The operation involves inflating the abdominal cavity with gas, normally carbon dioxide. There are two methods of entering the abdomen – the blind approach using a Verres needle or the open Hassan approach, sometimes favoured by general surgeons.
The blind approach
The traditional approach is the blind approach, whereby a Verres needle is inserted through the umbilicus (belly button) into the abdominal cavity. A Verres needle is a thin, sharp needle that contains a blunt ended spring-loaded plunger designed to help protect the bowel from injury.
After the abdomen has been inflated with carbon dioxide gas to an appropriate pressure and volume, a sharp pointed trocar is inserted into the peritoneal cavity through the umbilicus. This is then removed and replaced by a laparoscope, through which the peritoneal contents can be visualised. Usually there is a video camera applied to the end of the scope and the image is relayed to a screen in the operating theatre.
A second port is inserted into the lower abdomen through which an instrument can be inserted in order to block off the fallopian tubes – ordinarily in the UK Filshie clips will be used.
Why is it called the blind approach?
When inflating the abdominal cavity with gas through a Verres needle, and then inserting the primary trocar through the umbilicus, the surgeon cannot see inside the abdomen. Instead he/she relies on a sense of feel and appropriate technique to insert these instruments.
Once the laparoscope is inside the peritoneal cavity, the use of further instruments and the insert of further ports should be under direct vision and the surgeon should be able to see precisely what is happening.
The risk of bowel injury
There is always a risk of bowel injury associated with any abdominal surgery, and it is well recognised that there is a risk of bowel injury associated with laparoscopic injury. Overall, the risk of bowel injury at laparoscopy is in the region of one to four per 1000 cases.
While some medical experts suggest that with careful attention to correct technique bowel injury can always be avoided, most would not agree with this. Rather, the majority of medical experts suggest that correct attention to proper technique will minimise the risk of bowel injury but will never entirely remove this risk.
One group of patients who are at particularly increased risk of bowel injury at the time of laparoscopic surgery are those who have adhesions to their anterior abdominal wall. Indeed, if the bowel is adherent to the back of the abdominal wall at the site where the Verres needle or the primary trocar is inserted, it may be impossible to avoid causing bowel injury during the insertion of the Verres needle/trocar.
A small bowel injury from the Verres needle may be of no consequences. However, injury from the primary trocar will usually result in more serious problems.
Technique of entry
Because of the risks associated with the blind approach, it may be considered whether the Hassan approach might be preferable.
There has been significant discussion amongst medical professionals about whether it is safer to perform an open Hassan approach for laparoscopy where the layers of abdominal wall are opened under direct vision (favoured by many general surgeons), or whether it is safer to perform a blind entry using a Verres needle (favoured by most gynaecologists).
There have been many case series looking at the risks of bowel injury associated with the two techniques and it is quite clear that neither technique is demonstrably safer than the other from the point of view of bowel injury.
Other causes of bowel injury
Along with the inserted of the Verres needle or the primary trocar, bowel injury can also occur during sterilisation due to:
- The insertion of the secondary trocar into the lower abdomen
- Use of the diathermy
- The instruments used for cutting
Is a bowel injury negligent?
In the event that a bowel injury is caused during the insertion of the primary trocar, the surgeon will not be deemed negligent. As mentioned above, when the Verres needle or the primary trocar is inserted, it may be impossible to avoid causing bowel injury.
On the other hand, in the event that the bowel injury is caused during the insertion of the secondary trocar, then this can only be due to substandard care. Secondary ports should always be inserted under direct vision and the surgeon should easily be able to avoid bowel injury with the insertion of the secondary trocar.
With regards to the use of surgical cutting instruments and surgical diathermy, these should be used carefully under direct vision. The careful surgeon should always be able to avoid injury using scissors or diathermy instrumentation because these are used under direct vision. Therefore if the bowel injury is caused in this manner, it may be that there is a case of substandard care.
Failure to diagnose a bowel injury
Ideally, when a bowel injury is sustained during a sterilisation is should be diagnosed and repaired before the close of the operation. If the surgical team fail to spot the injury, has there been a case of medical negligence?
Again, it depends upon the time the injury occurred. When the bowel is injured by the insertion of a primary trocar it can often be very difficult to see since the telescope will pass by, or through, the very injury that need to be seen. Hence it is very difficult to detect. Probably around half of such injuries are not seen at the time of the original surgery.
But if the bowel injury occurs from the insertion of the secondary trocar, it should be identified and repaired before the end of the procedure.
Speak to a solicitor
If you have suffered a bowel injury during a sterilisation procedure and would like to know whether you are entitled to pursue a claim for negligence, please get in touch with us today. We specialise in medical negligence claims and will be able to advise you further.
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