Care provided during Laparoscopic Cholecystectomy surgery
A consumer complained that in April 1997, during Laparoscopic Cholecystectomy surgery, the provider, a surgeon, cut her muscle and liver causing significant blood loss. Further to this the consumer complained that a theatre nurse had cut the tip off her finger during surgery and as a result the consumer was required to undergo blood tests for HIV and Hepatitis B. In addition, the consumer complained that she sustained a collapsed lung following the surgery.
The complaint was received by the Commissioner on 5 June 1997 and an investigation undertaken.
Information was obtained from:
- The Consumer
- The Provider/Surgeon
Operation and medical notes and a surgical expert opinion were obtained.
Outcome of Investigation
The consumer was referred to the surgeon for the treatment of multiple gallstones and acute inflammation of the gallbladder. At a preoperative consultation in early April 1997 the surgeon explained the Laparoscopic Cholecystectomy surgical procedure to the consumer and arranged for her admission to hospital six days later. The surgery was performed under general anaesthetic and the gallbladder removed.
The gallbladder was reached by the use of instruments (called trochars) that are inserted through the abdominal wall, which requires the dividing of some muscle mass. During the surgery the surgeon noticed that an artery within a muscle was bleeding and he extended the incision in order to suture the artery and thereby stop the bleeding. It is not possible to determine the amount of blood lost during the surgery although the consumer's preoperative haemoglobin level was 139 and post operatively her haemoglobin level was 130, still within the normal range of 115 to 155. The blood loss following the surgery can be measured as small because the resulting haematoma was small. The surgical expert advised that although the haematoma was small it "would be sufficient to give rise to persisting discomfort. A haematoma incites an inflammatory response which is the reason for the discomfort. This complication is an uncommon but well recognised one in both laparoscopic and open surgery. In open surgery it's possible to deal with the vessel as it can be tied off immediately, but in laparoscopic surgery it's not always apparent at the time of trochar insertion but should be looked for with trochar removal. This is what was done".
While the consumer was being readied for transfer to the recovery area a nurse who was cleaning the surgical instruments cut the side of her thumb requiring two stitches. The following day a laboratory technician advised the consumer that she was to have blood tests because a theatre nurse had cut off the tip of her finger during the operation. This information was an error and an accurate account of the injury is contained in the incident report completed on the day of surgery. Later that day the consumer questioned the surgeon about the incident and the surgeon advised her of the injury sustained by the nurse and that the injury had occurred after the operation had finished. In addition, the surgeon advised the consumer of the hospital protocol regarding needle stick or sharp injuries and, in accordance with this policy, the consumer was tested for HIV and Hepatitis B.
The consumer had suffered an upper respiratory infection prior to her surgery but two days before surgery she advised the surgeon that her GP had checked her lungs and they were clear. On the day following surgery the consumer experienced breathing difficulties. A chest x-ray was taken and this revealed some minor failure of the lung to expand, a condition known as atelectasis, which is common in patients who undergo upper abdominal surgery. This is different from a collapsed lung where the lung partially deflates due to injury. Pain relief and physiotherapy were administered and found to be effective.
Two days after surgery the consumer complained to the surgeon of pain in her back and rib area. The surgeon advised the consumer that after cutting the gallbladder from the liver there is sometimes bleeding or bile ooze from the liver which can cause this type of pain after surgery but the liver itself is not cut, nor was it cut in the consumer's case.
The surgeon provided the Commissioner with a copy of a newly published patient handout about Laparoscopic Cholecystectomy.
The Code of Health and Disability Services Consumers' Rights
Right to Services of an Appropriate Standard
1) Every consumer has the right to have services provided with reasonable care and skill.
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Opinion: No Breach
In my opinion, the surgeon did not breach Right 4(1) or Right 4(2) of the Code of Health and Disability Services Consumers' Rights.
The investigation found that the surgeon used reasonable care and skill in the placement of the instruments required to be inserted in order to expose the gallbladder. When it became apparent on removal of one of the instruments, that an artery was bleeding within the cut muscle, the surgeon responded promptly and appropriately by suture ligating the bleeding vessel.
The surgeon had professional obligations to both the consumer and the hospital he was operating in to advise the consumer of the injury sustained by a theatre nurse and to take reasonable action to ensure that infection control was maintained in the interest of patient safety. It is my opinion that testing the consumer for HIV and Hepatitis B was a prudent and reasonable action in the circumstances.
The investigation found that the consumer did not suffer a collapsed lung following the surgery. Further to this, the investigation found no evidence that any lack of reasonable care and skill on the part of the surgeon contributed to the breathing difficulties experienced by the consumer after the surgery. It is my opinion that the surgeon took reasonable actions to diagnose and treat the atelectasis suffered by the consumer.
I support the surgeon's intention to provide patients with a copy of the newly published Royal Australasian College of Surgeons' Patient Handout for Laparoscopic Cholecystectomy. In my opinion, it is likely that if the consumer had had access to this detailed information some of her concerns may have been more swiftly alleviated.
I will be taking no further action on this matter and the file will now be closed.
For further information, contact: HDC Communications Section (09) 373 1060.