Patient Information

Principals Of Informed Consent And A Discussion On  Surgical Complications

Although consent  for procedures is typically given on paper, consent is a dynamic and evolving  process that occurs from the time of first doctor–patient contact to the time  of surgery itself. I always prefer you to have a detailed understanding of your  condition, its natural history if left untreated, surgical alternatives,  potential medical treatment and the option of no treatment at all. Some  conditions, depending on complexity, will take several consultations in order  to fully elucidate before surgery or other treatment can be planned. Surgery has  changed enormously over the last 100 years and continues to develop as newer  technologies and the IT revolution takes place. Many gynaecological procedures  that carried significant morbidity and recovery time in days gone by are now  performed routinely via a minimally invasive or laparoscopic approach, and as  day surgery. The trend to day surgery has partly been driven by the increased requirement  for speedy recovery and to minimize the cost of treatment. Hospital facilities  have also changed dramatically during this time and in the hospitals in which I  work, the latest equipment and facilities for post-operative care, are  available. All this means that operative risk is also at its lowest in history  but it is important to realise that no matter how skilled the surgeon, however  well equipped the hospital and operating theatre and however minor the  procedure, there is no such thing as zero risk. It is very important that you  are aware of the risks, however small they may be, inherent in any surgical  procedure. Detailed discussions regarding the nature and risks of surgery may  be found on this website under the appropriate link. The risks of a procedure  are weighed up against the benefits of the procedure. If the risks outweigh the  benefits of the operation then it may be considered inappropriate to proceed.

Classically, surgical textbooks classify complications  as immediate, delayed and late: Immediate

These occur at  the time of the operation. They principally relate to bleeding from major blood  vessels. This may be related to the difficulty of the operation and in fact may  be unavoidable because of the high vascularity of a particular area. Blood  transfusion in gynaecological surgery is extremely rare but may be required in  certain specific cases, again, if the risks of blood transfusion are outweighed  by the benefits of proceeding. When operating within the abdominal and pelvic  cavity other organs can be damaged during the procedure depending on the extent  of surgery and the condition for which the procedure is being performed.  Generally quoted risks with laparoscopy include an approximately 1:2000 chance  of damage to the bowel or a 1:3000 chance of damage to major blood vessels. By  performing Hasson cannulation, the risk of the latter is virtually eliminated.  Bowel injuries can be recognised intra-operatively and repaired via a  laparoscopic route during the procedure, but rarely recognition may be delayed. Very rarely a  laparoscopy must be converted to laparotomy in order to complete the procedure  safely.

Delayed Complications

These  principally relate to infection and occur within the first twenty-four to  seventy-two hours post surgery. Infection may affect the bladder, lungs or  occasionally the operative site. Infections only very rarely arise from  hospital instruments or environment and generally arise from the patient’s own  bacterial flora. Occasionally an infection may lead to dissolution of blood  clots at the operative site resulting in a recurrence of bleeding or secondary  haemorrhage.  A “clean” wound has a  baseline infection rate of around 4-6%; this is reduced to around 2% with  prophylactic antibiotics.  Venous  thromboembolism may also occur in the days to weeks following major  surgery.  Prophylactic Low Molecular  Weight Heparin (LMWH) is given as routine DVT prophylaxis in my surgical  practice.

Late Complications

Late  complications are related to scar thickening or irregularity which may occur in  some people because they have a tendency to keloid scar formation. This  typically occurs in those of dark skinned races. Adhesion formation may occur  if abdominal procedures have been performed. I liberally use adhesions barriers  in my surgery but no adhesion barrier has yet been found to be perfect and  adhesions may still occur. Formation of adhesions is very variable from person  to person and differs according to the type of surgery and skill for which it  is performed. Generally speaking, skilfully performed laparoscopic surgery  carries a much lower risk of adhesions than open surgery. Late and delayed  complications may also include such rare occurrences as late wound  complications such as herniation, change in hormonal status after a hysterectomy  even if the ovaries are left behind, pain around the wound site or recurrence  of the original condition for which the procedures was performed. It is obviously  very difficult for me to go through every type of complication in detail.  Complications vary enormously with the type of operation, the extent of the  disease and the individual characteristics of the patient. There is no doubt  that all complications are more frequent in those of increased body mass index  and in smokers. Some elderly patients may also be at increased risk.  If you do have  any questions or queries regarding the complications of a procedure by all  means write these down and contact me before the surgery. I am also very happy  to see you again in the consulting suites for further discussion prior to  proceeding to surgery. I am also happy for you to postpone your surgery to  allow further time to think about the operation or discuss other aspects or  concerns you may have.

In conclusion,  my priority is for you to have the very best operation with the best outcome  using the best techniques, tools and procedures at our disposal.

Post-Procedure Care

After leaving  the operating theatre you will usually have a drip or intravenous line  in-situ.  This is to maintain your  hydration as you will have been fasting for a period of hours prior to the  procedure.  You will be care for in the  Recovery area of the Operating Theatre which involves one on one care by a  specialist member of the nursing staff.   This is to monitor for excessive vaginal bleeding or other complications  and allows time for recovery after the anesthetic.  In the case of day surgery, after around one  to two hours you will be offered something to eat or drink if appropriate, will  be able to change back into your street clothes and arrangements for discharge  will be initiated.  Dr Thomas will  indicate if you are required to stay in hospital.  Many cases are performed as day surgery.

Post-Discharge Care

Most  patients should be able to resume their regular activities within one to two  days.  Mild cramping and spotting may  occur over a few hours or days.  Cramping  can be treated with non-steroidal anti-inflammatory medications such as  Naprogesic or Nurofen in combination with Panadol, Panadeine 8 or 15.  Whilst you are actively bleeding it is wise  to avoid tampons and to refrain from intercourse.  Bathing is allowed but swimming in public  pools should be avoided.  The next  menstrual period usually occurs within four to six weeks of the procedure and  may not be the same as your regular period.   Excessive bleeding after the procedure is uncommon although I am unable  to give you an exact figure as to how long the bleeding will persist.  You should notify me should you develop a  fever (temperature greater than 37.5 degrees), pain or cramping that does not  respond to regular doses of simple analgesics or lasting greater than  forty-eight hours, bleeding involving clots or foul smelling vaginal discharge.