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Surgical error during hysterectomy (13HDC01557)
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(13HDC01557, 21 June
Obstetrician and gynaecologist ~ Gynaecology ~
Menometrorrhagia ~ Hysterectomy ~ Surgical error ~ Colostomy ~
Record keeping ~ Open disclosure ~ Rights 4(1), 4(2)
A 46-year-old woman consented to undergoing a total vaginal
hysterectomy performed by an obstetrician and gynaecologist
(OB/GYN) at a public hospital. During the procedure, initial
attempts by the OB/GYN to open the Pouch of Douglas (the extension
of the peritoneal cavity between the rectum and the posterior wall
of the uterus) failed. The OB/GYN then mistakenly identified the
woman's bowel wall as the Pouch of Douglas and attempted to open
it, causing a perforation to the woman's bowel.
The OB/GYN then stopped the procedure and sought assistance from
another OB/GYN. The other OB/GYN found that the woman had extensive
adhesions of the "uterus, tubes [and] ovaries, to the side walls
and posterior wall of [the] pelvis". Due to the difficulties with
the vaginal hysterectomy, they converted to an abdominal
The OB/GYN contacted a general surgeon and requested his
assistance with repairing the perforation to the woman's bowel. The
general surgeon was unsure about being able to close the
perforation entirely, so decided to perform a loop colostomy. The
abdominal hysterectomy was then completed.
The OB/GYN and the woman have different recollections of what
was discussed after the surgery. There are no records of any
conversations during which the OB/GYN told the woman that she had
made an error during the surgery, which resulted in her having
perforated the woman's bowel.
The OB/GYN had been involved in prior adverse events at the
It was held that the OB/GYN's failure to seek advice or
assistance from a more senior colleague and convert to an abdominal
procedure earlier, plus her mistake in incising incorrectly
identified tissue amounted to a serious departure from expected
standards. Accordingly, the OB/GYN failed to provide services to
the woman with reasonable care and skill and breached Right 4(1).
Her poor standard of record-keeping amounted to a breach of
professional standards and, accordingly, she breached Right 4(2).
Criticism was also made of the OB/GYN's failure to openly disclose
the surgical error in a way that was adequately understood by the
Adverse comment was made about the DHB's systems for identifying
and reporting serious surgical events.
The Commissioner recommended that the OB/GYN apologise to the
woman for her breaches of the Code and that the Medical Council of
New Zealand undertake a review of the OB/GYN's competence should
she return to practise medicine in New Zealand.
The Commissioner also made recommendations to the DHB regarding
extra credentialing for advanced surgical procedure and reviewing
its process for identifying serious surgical morbidity.