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.
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 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.
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.
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.