Clinical Review
2014 Update on minimally invasive gynecology
The cesarean scar defect: A common etiology of abnormal uterine bleeding
During surgery, the ObGyn discovered that pelvic adhesions had distorted the patient’s anatomy; he converted to laparotomy, which left a larger scar. Two days after surgery, the patient was found to have a bowel injury and underwent additional surgery that included placement of surgical mesh, leaving an enlarged scar.
PATIENT'S CLAIM: The ObGyn was negligent in injuring the patient’s bowel during hysterectomy and not detecting the injury intraoperatively. Her scars were larger because of the additional repair operation.
PHYSICIAN'S DEFENSE: Bowel injury is a known complication of the procedure. Many bowel injuries are not detected intraoperatively. The ObGyn made every effort to prevent and check for injury during the procedure.
VERDICT: An Illinois defense verdict was returned.
Uterus and bowel injured during D&C: $1.5M verdict
A 56-year-old woman underwent hysteroscopy and dilation and curettage (D&C). During the procedure, the gynecologist recognized that he had perforated the uterus and injured the bowel and called in a general surgeon to resect 5 cm of the bowel and repair the uterus.
PATIENT'S CLAIM:The patient has a large abdominal scar and a chronically distended abdomen. She experienced a year of daily pain and suffering. The D&C was unnecessary and improperly performed: the standard of care is for the gynecologist to operate in a gentle manner; that did not occur.
PHYSICIAN'S DEFENSE:The D&C was medically necessary. The gynecologist exercised the proper standard of care.
VERDICT:A $1.5 million New Jersey verdict was returned. The jury found the D&C necessary, but determined that the gynecologist deviated from the accepted standard of care in his performance of the procedure.
Bowel perforation during myomectomy: $200,000 verdictA 44-year-old woman underwent hysteroscopic myomectomy. During the procedure the ObGyn realized that he had perforated the uterus. He switched to a laparoscopic procedure, found a 3-cm uterine tear, and converted to laparotomy to repair the injury. The postsurgical pathology report revealed multiple colon fragments.
Three days after surgery, the patient became ill and was found to have a bowel injury. She underwent bowel resection with colostomy and, a year later, colostomy reversal. She sustained abdominal scarring.
PATIENT'S CLAIM: The ObGyn was negligent in performing the myomectomy. He should have identified the bowel injury intraoperatively. When the pathology report indicated multiple colon fragments, he should have investigated rather than wait for the patient to develop symptoms.
PHYSICIAN'S DEFENSE: Uterine and colon injuries are known complications of the procedure and can occur within the standard of care. The ObGyn intraoperatively inspected the organs adjacent to the uterus but there was no evident injury. The patient’s postsurgical treatment was proper.
VERDICT: A $200,000 Illinois verdict was returned.
Injured ureter allegedly not treatedA 42-year-old woman underwent hysterectomy on December 6. Postoperatively, she reported increasing dysuria with pain and fever. On December 13, a computed tomography (CT) scan suggested a partial ureter obstruction. Despite test results, the gynecologist elected to continue to monitor the patient. The patient’s symptoms continued to worsen and, on December 27, she underwent a second CT scan that identified an obstructed ureter. The gynecologist referred the patient to a urologist, who determined that the patient had sustained a significant ureter injury that required placement of a nephrostomy tube.
PATIENT'S CLAIM: The gynecologist failed to identify the injury during surgery. The gynecologist was negligent in not consulting a urologist after results of the first CT scan.
PHYSICIAN'S DEFENSE: Uterine injury is a known complication of the procedure. The gynecologist inspected adjacent organs during surgery but did not find an injury. Postoperative treatment was appropriate.
VERDICT: The case was presented before a medical review board that concluded that there was no error after the first injury, there was no duty to trace the ureter, and a urology consult was not required after the first CT scan. A Louisiana defense verdict was returned.
