Laparoscopy Is Not Always the ‘Art of the Possible’

Undoubtedly, laparoscopy is one of the hallmarks of modern medicine. With reduced risk of infection and other complications, the choice to do closed surgeries is not only very popular with patients, but may well be the right medical decision.

Though technology now allows laparoscopy to be performed on more areas of the body, that is not to say that the surgery has no bounds. Sometimes, even accomplished laparoscopic surgeons should give open procedures their due. In one case, a very skillful surgeon ran into trouble with a patient’s difficult laparoscopy.

Dr. GS, a gynecological surgeon, had earlier treated the patient by performing a laparoscopic hysterectomy and left oophorcystectomy. Because of extensive adhesions encountered during that earlier surgery, however, Dr. GS had to convert to an open procedure. Also during that procedure, Dr. GS had to call in another surgeon for an emergency repair of a laceration of the rectosigmoid.

Three years later, the patient reported continuing pelvic pain. Dr. GS’s impression was endometrioma, rule out cyst adenoma. Before her admission for the surgery that Dr. GS recommended, the patient signed a consent form for “laparoscopy, possible laparotomy, possible bilateral salpingo-oophorectomy.” The printed consent contained a full page of warnings and authorizations.

During the laparoscopic surgery, the patient underwent “extensive enterolysis with deep pelvic dissection, right ureterolysis, and right salpingo-oophorectomy.” The operative findings included extensive adhesions among the cul-de-sac, the transverse colon, the left and right sidewalls and the sigmoid colon. The right ovary, which was enlarged to 6 cm in diameter by endometrioma, tightly adhered to the right pelvic sidewall and colon. The technical procedure stated that the adhesions were lysed with a combination of sharp and blunt dissection without interruption of the serosal integrity of the colon. Hemostasis was good with blood loss at 100 cc.

Over the next two days, however, the patient’s condition deteriorated to the point of requiring another exploratory laparoscopy, which developed to an exploratory laparotomy with drainage of a pelvic abscess and resection of the distal ileum. Ten days later, the patient underwent another open procedure for abscess drainage and a wound closure with Marlex mesh.

In a subsequent lawsuit, the patient alleged that Dr. GS failed to properly advise her of the additional risk of laparoscopic versus open procedure and that he negligently performed the surgery.

Upon review, the experts and Dr. GS himself could not conclude how the perforation actually occurred. The liability focus, however, was not necessarily on what happened during the surgery and its aftermath as it was on the problems Dr. GS should have foreseen in planning a laparoscopic surgery on a patient with history of surgical bowel perforation. The case ultimately resolved prior to trial.

In this particular case, the patient-plaintiff admitted in deposition how much Dr. GS had done for her in the past, how much she trusted him, and what an excellent physician she believed him to be. It may well have been that this very solid physician-patient relationship led each to place too much trust in a laparoscopic solution to the patient’s medical needs.

Gordon Ownby is CAP-MPT’s general counsel. Comments on Case of the Month may be directed to gownby@cap-mpt.com.