J R Soc Med 2001;94:331-332
© 2001 Royal Society of Medicine
Medicolegal consequences of postoperative intra-abdominal adhesions
Harold Ellis CBE FRCS
Human Sciences Research, King's College London, Hodgkin Building, Guy's
Hospital Campus, London SE1 1UL, UK
 |
SUMMARY
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Postoperative adhesions are an almost invariable consequence
of abdominal
and pelvic surgery. Their most important morbidity
is small-bowel obstruction,
but other sequelae include female
infertility and dyspareunia and increased
risk of visceral injury
at subsequent laparotomy or laparoscopy. Whether
chronic abdominal
pain is truly a consequence of adhesions is debatable,
although
it is likely to be accepted as an entity by both patients and
their
legal advisors. Of 14 successful claims dealt with by
a British medical
defence organization, 5 were for perforations
after laparoscopic division of
adhesions, 2 for adhesions after
laparoscopic surgery, 1 for infertility as a
result of adhesions
and 6 for delayed diagnosis of obstruction. General
practitioners,
surgeons and gynaecologists need to be aware of the increasing
burden
of medicolegal claims arising from these complications.
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INTRODUCTION
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Complications resulting from postoperative intra-abdominal adhesions
have
been the subject of increasing medicolegal litigation,
but hard facts are not
easily obtained. Repeated letters to
the National Health Service Litigation
Authority, which is the
body responsible for all NHS hospital litigation since
January
1990, have not been acknowledged. However, I have been greatly
helped
by Dr Stephen Green, of the Medical Defence Union, and
by Dr Jane Cowan, of
the Medical Protection Society, who have
provided details of patients' claims
and complaints that have
reached these organizations in recent years. Although
this information
is confined to claims made against general practitioners in
the
public and private sectors and against surgeons and gynaecologists
in
private practice, it does provide a picture of litigation
resulting from the
consequences of abdominal adhesions over
the past decade.
Adhesions are almost invariable after abdominal surgery. In our review of
210 laparotomies on patients who had undergone one or more previous abdominal
operations, 94% had adhesions; the exceptions were patients who had undergone
lower segment caesarean section or elective
appendicectomy1.
Today, abdominal surgery is extremely common in the western world. In 2645
necropsies, Robert Beart, at the University of Southern California in Los
Angeles, found evidence of previous abdominal operations, in 32%—a
figure that rose to 44% in those over sixty years of age (Personal
communication). We can infer, therefore, that nearly one-third of the adult
population have intra-abdominal adhesions. The great majority of these are
entirely symptomless; however, even a low morbidity in such a large group of
the population will result in a considerable surgical workload.
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FREQUENCY OF INTESTINAL OBSTRUCTION
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Far and away the most important morbidity from adhesions is
the development
of acute intestinal obstruction. Indeed, adhesions
are responsible for between
60% and 70% of all cases of small-bowel
obstruction in the western
world
2. In our own
study of 2708
laparotomies, 1% of the patients required surgery for adhesive
obstruction
within a year of surgery, half of these within the first four
weeks.
There is also a long-term risk of this complication; of 80 patients
admitted
with adhesive obstruction, 17 (21%) had had their initial laparotomy
ten
years or more
previously
1.
We have reported3
a study of the entire population of Scotland, some five million, based on
figures obtained from the Scottish NHS medical record linkage database in
Edinburgh. Patients were identified who had undergone open abdominal or pelvic
surgery in 1986 and who had no record of such surgery in the preceding five
years. These patients were followed up for ten years. Of the 29 790 patients
studied, 5.7% were readmitted with complications directly consequent on
adhesions, of which 3.8% required surgery. Of these readmissions, 22.1%
occurred in the first year after the initial surgery, but the remainder of
readmissions continued steadily over the ten-year period.
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MEDICOLEGAL CONSEQUENCES
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The following, in order of frequency, are the topics that, in
recent years
have led to complaints and claims against medical
practitioners: failure of
diagnosis, or delay in diagnosis;
bowel damage at adhesiolysis (at laparoscopy
more than at laparotomy);
chronic abdominal or pelvic pain; infertility or
risk of infertility;
starch granuloma consequent upon use of starch-powdered
gloves;
and failure to take precautions to prevent adhesion formation.
Between 1989 and 1999, the Medical Protection Society dealt with 13 claims
in which adhesions had been implicated. 9 of these involved general
practitioners; in all of them the complaint was of delayed or failed
diagnosis. 3 claims were made against gynaecologists—one for failure to
diagnose and two for bowel damage at adhesiolysis (one at surgery, the other
at laparoscopy). The final case involving a surgeon was, again, bowel damage
at operative division of adhesions.
The Medical Defence Union was able to supply more comprehensive
information. This organization has a membership of some 22 000 general
practitioners, 500 gynaecologists and 720 general/vascular surgeons. Over the
six years 1994-1999 it received 77 claims pertaining to abdominal adhesions,
as follows: failure to diagnose or delay in diagnosis, 21; visceral injury at
laparoscopy, 12; visceral injury at laparotomy, 10; pain, dyspareunia,
infertility, 7; failure to use ‘Sepracoat’, 1; failure to warn of
risk, 1; and various (including death during adhesiolysis, miscarriage
following), 25.
Over an eleven-year period, 14 cases were settled out of court by the
Medical Defence Union, the range being £7960-124 261, average per case
£50 765. These 14 cases comprised:
- Perforations after laparoscopic division of adhesions, 5
- Adhesions after laparoscopic surgery, 2
- Infertility as a result of adhesions, 1
- Delayed diagnosis of obstruction, 6
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STARCH GRANULOMAS
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Cases of intra-abdominal starch granulomas, often presenting
as
postoperative intestinal obstruction, were extensively reported
in the
1960s
4, resulting
from the starch on surgical gloves.
Since 1971 the US Food and Drug
Administration have required
warnings of the starch hazard on glove packets,
and since 1983
powder-free gloves have been commercially available. Because
of
the almost universal use of such gloves in the UK, there
seem to have been no
cases of litigation on this count. There
were three court cases concerning
starch granulomas in the USA
in 1969, 1970 and 1974.
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WHAT ARE THE LESSONS TO BE LEARNED?
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Surgeons, gynaecologists and general practitioners must be alert
to the
possibility that obstructive symptoms early and late
after abdominal surgery
are likely to be caused by adhesions.
Delayed diagnosis can result in gangrene
and even perforation
of the strangulated bowel, with substantial morbidity and
mortality.
The question of chronic abdominal pain as a result of adhesions is a
difficult one. The clinical features of acute and of recurrent subacute
intestinal obstruction are well known. Whether ‘grumbling’
abdominal pain can result directly from adhesions is debatable. Most surgeons
in the UK doubt the organic basis of this syndrome, which is particularly seen
after gynaecological surgery. Clearly, millions of people with postoperative
adhesions remain pain-free for life. However, the judiciary are more likely to
believe post hoc, propter hoc and to side with the complainant. It is
easier to understand how a tethered ovary in the pelvis might result in
dyspareunia.
The risk of visceral injury, especially of gut perforation, when adhesions
are divided at reoperation has lately been quantified in a retrospective
study. Workers from the University Hospital at
Nijmegen5 showed
that inadvertent enterotomy occurred in no fewer than 52 (19%) of 270 patients
undergoing relaparotomy, with 7 deaths (13%) compared with 16 (7%) in the
remaining 218 patients. Independent risk factors for injury to the bowel were
obesity, age and three or more previous laparotomies. A similar study of
incidence and risk factors for laparoscopic adhesiolysis would be welcome.
Clearly, patients need to be warned of this danger preoperatively and surgeons
need to be alert to it, ready for immediate repair of any injury. For injuries
sustained at laparoscopy, this will mean conversion to an open operation.
Although adhesion formation is almost invariable after laparotomy, surgeons
should take all reasonable precautions to limit its extent and, in particular,
try to prevent adhesions to small intestine with their risk of bowel
obstruction. Starch-powdered gloves must be avoided. Peritoneal defects and
the pelvic floor should be left open since these rapidly reperitonealize.
Anastomoses should be covered by omentum, which should be drawn down under the
inner aspect of the laparotomy incision. There is obvious need for the
development of effective and safe antiadhesion agents.
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REFERENCES
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-
Menzies D, Ellis H. Intestinal obstruction from adhesions; how big
is the problem? Ann R Coll Surg Engl1990; 72:60
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Ellis H. The magnitude of adhesion related problems. Ann
Chir Gynaecol 1998;87:9
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Ellis H, Morgan BJ, Thompson JN, et al. Adhesion related
hospital readmissions after abdominal and pelvic surgery: a retrospective
cohort study. Lancet1999; 353:1476
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Ellis H. Pathological changes produced by surgical dusting powders.
Ann R Coll Surg Engl1994; 76:5
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Van der Krabben AA, Dijkstra FR, Nieuwenhuijzen M, et al.
Morbidity and mortality of inadvertent enterotomy during adhesiotomy.
Br J Surg2000; 87:467
-71[Medline]
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SUMMARY
INTRODUCTION
