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CASE-BASED LEARNING

Complications of Case 1
Lucy was a 28-year-old teacher with dysmennorhoea and dys-
laparoscopic surgery pareunia. Her BMI was 16 and she had no relevant medical or
surgical history. She was admitted for laparoscopic treatment of
suspected mild endometriosis. A routine pneumoperitoneum was
Oliver P O’Donovan
achieved with Veress entry via the umbilicus. Palmer’s test was
Arvind Vashisht normal and initial gas pressures were between 4 and 6 mmHg.
An umbilical trocar was inserted without difficulty.
When comparing the risks of laparoscopic versus open sur-
Abstract gery, the largest increase in risk is seen at the time of entry of
General principles in the prevention, recognition, management and either Veress needle or of trocar. The RCOG/British Society for
follow-up of common laparoscopic complications are illustrated Gynaecological Endoscopy (BSGE) guideline “Preventing entry-
using three example cases. The examples given are of major vessel, related gynaecological laparoscopic injuries” (formerly RCOG
urinary tract and bowel injuries, but also provide a framework on Green Top Guideline No. 49) details the incidence of complica-
which to hang discussion of other relevant issues such as key surgical tions and techniques to minimise them. Based on large multi-
principles, team work, laparoscopic equipment and devices, consent, centre trials of tens of thousands of women, it suggests the risk of
risk management and duty of candour and patient communication. major complication is between 1.4 and 5.7 in 1000, with bowel
Keywords intraoperative complications; laparoscopy; postoperative injury being about twice as common as urological injury and six
complications times as common as vessel injury.
The guideline above gives a clear summary of recommended
techniques and repetition is not necessary here, but in this case
Introduction entry appears to have been routine and the correct tests per-
formed. It is common but not exclusive practice to empty the
Once the realm of only specialist surgeons, laparoscopic oper-
bladder (to minimise risk of injury to a distended bladder), and a
ating is now practised widely by virtually all gynaecologists. This
three stage check of correct Veress placement should be per-
transition has occurred in the large part due to the clear benefits,
formed before the gas flow and pressure are turned-up (see
technological advances, and improvement in both acquisition
Box 1). The technique chosen may vary depending on history
and teaching of the necessary skills. As a result the number and
and physical characteristics.
complexity of laparoscopic gynaecological procedures increases
The BSGE/RCOG guideline recommend a Hasson (open) or
year on year. All surgical procedures carry risk and laparoscopy
Palmer’s entry in women “who are very thin” due to the narrow
is no exception; on the contrary it brings a host of its own specific
distance between the skin and the aorta, and also in the morbidly
complications. Through the use of case examples we will sum-
obese as even a slight deviation from the base of the umbilicus
marise and highlight the prevention, recognition and manage-
may result in a large distance from the skin to the peritoneum
ment of major risks particularly pertinent to laparoscopy.
Complications can be categorised by severity, incidence,
timing (immediate, early or late) and by the body system or
organ affected. Awareness, anticipation, prevention and correc- The three-stage check for correct Veress needle entry
tion are the cornerstones of minimising their occurrence and
morbidity. Palmer’s testeAttach a saline filled 10 ml syringe to the Veress
Fortunately severe complications are rare, but this means that needle. First aspirate; if the Veress is in the bowel or a blood vessel
we rarely practice their management and, as the time of the you may see bowel contents or blood. Next inject; if you are not in a
incident is likely to be stressful, we would do well to think about space it may be difficult. Finally either remove the syringe from the
how one would manage situations ahead of their occurrence. needle or the plunger from the syringe, and the meniscus should
This might include practising relevant skills or techniques and drop freely if the end of the needle is unobstructed.
writing protocols for potential adverse circumstances. Obstetri-
cians regularly carry out simulations or drills to practice optimal Gas pressure testeWhen the Veress is correctly placed within the
management of emergency situations, but as yet this has not peritoneal cavity the starting gas pressure should be less than 8e10
taken-off in gynaecology. There is no reason why it should not mmHg.
and there are programs and courses available which aim to do
exactly this. Abdominal examinationeThe abdomen should be seen to fill sym-
metrically. If not there is concern that it is filling a localised structure
such as the bowel or stomach. Surgical emphysema suggests the
needle is extraperitoneal. The abdomen should be percussed to
Oliver P O’Donovan BSc MBBS MRCOG is an ST 7 Trainee in Advanced demonstrate a resonant sound and loss of liver dullness in the right
Laparoscopic Surgery at University College London Hospital, UK. upper quadrant.
Conflicts of interest: none declared. NB. These are not evidence based checks, but considered best
Arvind Vashisht MA MD MRCOG is a Consultant Obstetrician and practice.
Gynaecologist at University College London Hospital, UK. Conflicts
Box 1
of interest: none declared.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7 213 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
CASE-BASED LEARNING

and difficult or failed entry. Entry at Palmer’s point (3 cm below important to note that if control is not rapidly achieved laparot-
the left costal margin in the mid-clavicular line) is safest in those omy as described above should not be delayed.
at significant risk of umbilical adhesions, unless there is history In cases resulting in clotting abnormality or large raw areas of
of surgery in the left upper quadrant or splenomegaly. The tissue, the insertion of a drain should be considered. They pro-
stomach must be emptied (by means of a temporary oro- or vide a “window” into the abdomen to warn of ongoing blood loss
nasogastric tube) beforehand to avoid gastric injury. Threshold and help to reduce the risk of collections. They should be
for the use of Palmer’s point should be low as umbilical adhe- removed as soon as there is confidence there is no ongoing
sions may occur in up to 50% of those with previous midline bleeding in order to reduce patient discomfort, encourage
incisions and 23% of transverse incisions. Although the inci- mobility and because they can become sites of infection.
dence of relevant adhesions following Caesarean section is not Meanwhile the anaesthetic team fluid resuscitated the patient,
known, it is thought to be less than other surgery and there are first with crystalloids and colloids and then O negative blood and
wide-ranging hypotheses as to why this might be. cross-matched blood when it became available (all given through
A 2015 Cochrane review included 46 RCTs examining 13 a rapid infuser and warmer). Fresh frozen plasma (FFP) was
different entry techniques. Overall the conclusion was, “that given at a 1:1 ratio with each unit of blood after the first 2 units.
there was insufficient evidence to recommend the use of one Tranexamic acid 1 g IV was given. The anaesthetic team inserted
entry technique over another”. The evidence was noted as being central and arterial lines and spoke to the on-call intensive care
of generally very low quality, but there was a statistically sig- doctor to inform them of the need for a bed on the intensive care
nificant decrease in failed entry in the open versus closed groups, unit (ITU). Although the haemocue at one point showed a hae-
and decreased vascular injury and failed entry with direct trocar moglobin of 67 g/dl, the patient remained relatively stable and
entry versus Veress technique. It has been estimated that trials clotting results were normal, so on the advice of the consultant
involving upwards of 800,000 patients would be required to haematologist no cryoprecipitate or platelets were given.
demonstrate a reliable difference in the safety of entry Resuscitation of the patient is the realm of the anaesthetist but
techniques. it is important that the surgeon has a good understanding so they
On 360 degree review of the abdominal cavity significant can support their colleague and participate in informed decision
blood and a rapidly expanding retroperitoneal mass were noted. making. Volume replacement should start quickly and be pre-
A major vascular injury was immediately diagnosed and a dictive so as not to “get behind”. All hospitals should have a
midline laparotomy performed without delay, the on-call major haemorrhage protocol that can be initiated and result in
vascular surgeon fast-bleeped to attend and the major haemor- the expedient arrival of blood products and expert support. Cell
rhage protocol initiated. At laparotomy it was difficult to visu- salvage equipment should be set-up as autologous transfusion is
alise the anatomy as the abdomen kept welling up with blood, so preferable, but there must not be a delay in transfusion. O
constant pressure was applied against the aorta and the negative blood should be given at a low threshold whilst await-
expanding pelvic swelling, until the arrival of the vascular team. ing autologous, group specific or fully cross matched blood.
The vascular team arrived ten minutes later and diagnosed a tear Bedside tests such as haemocue and blood gas results can be
in the inferior vena cava. They repaired the tear and were used to guide red cell replacement. In major haemorrhage clot-
satisfied with the result. Two large drains were left in-situ. ting factors are used up and lost quickly and must be replaced to
There is no argument that in the event of major vessel injury maintain clotting function and prevent disseminated intravas-
immediate (midline) laparotomy is required with control of cular coagulation. Coagulation function should be monitored by
bleeding until a suitably trained, preferably vascular, surgeon laboratory and bedside testing (e.g., thromboelastograph) and
arrives. Both the aorta and vena cava are retroperitoneal and it is replacement guided by the haematologists. Where there is no
difficult or impossible to clamp or tie them without significant time to await results, battle field experience and large civilian
dissection. Initial actions therefore should be application of prospective trials have shown a ratio of 1 unit of FFP to every
pressure, volume replacement, and triggering of a major hae- unit of blood improves outcome, and this should be started
morrhage protocol. Senior expert assistance should be sought, “blind”. The randomised controlled CRASH-2 trial included more
which may include several specialties such as gynaecology, ob- than 20,000 major haemorrhage patients in 40 countries and
stetrics (who are familiar with massive blood loss), anaesthetics, showed a 10% decrease in mortality in those patients given the
haematology, and general surgery (especially in units where anti-fibrinolytic tranexamic acid compared to those given pla-
vascular support is not on site). Ideally a vascular surgeon cebo, with earlier administration having a greater effect.
should attend to repair the damage by suturing or patching the Lucy was extubated later that day and after 48 hours on ITU
defect or using endovascular prostheses. was transferred to the vascular ward where she made a good
There may be debate over the best way to manage laparo- recovery. All the teams involved fully debriefed Lucy and her
scopic injury of small to medium sized blood vessels, and the family as to the events which had occurred. The lead surgeon
method chosen will depend heavily on the experience, skills and had an honest and candid discussion with them and apologised.
confidence of the operating surgeon and the equipment and A serious untoward incident investigation was carried out by the
support available to them. Methods to control bleeding lapa- risk management team, and although it was felt to be a known
roscopically include direct pressure, clamping the vessel with a complication of the procedure, it was commented that in patients
laparoscopic instrument, laparoscopic suturing, the use of bipo- with a low BMI (and children) consideration should be given to
lar energy or other sealing devices and the use of clotting agents. open (Hasson) entry for pneumoperitoneum. This learning point
Turning up the gas pressure to 20e25 mmHg may additionally was disseminated to all surgeons and trainees.
assist haemostasis in low-pressure bleeding. It is however

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7 214 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
CASE-BASED LEARNING

The location for recovery post-operatively is crucial. Obvi- recognised specialist should be in attendance to advise and aid if
ously a major insult such as this requires close observation and required. Repair of a small bladder injury is a relatively straight
monitoring, and the most suitable staffing and equipment is on forward procedure for a skilled surgeon. This can be achieved in
an intensive care unit. Deterioration would be picked up and either one or two layers using a 2-0 or 3-0 synthetic absorbable
acted on rapidly. Once stabilised and showing signs of recovery suture. The crucial points are that the defect is identified in its
careful consideration should be given to the most appropriate entirety, the location of the ureters is established (and stents
place of step-down care; in this case a vascular ward where the inserted if there are any concerns regarding their proximity or
nursing and medical staff are practised in recognising and man- integrity), that the repair is water tight and the bladder kept
aging vascular repair problems. empty for 10e14 days to allow healing. Ideally the repair should
It is crucial that an open, honest, candid and apologetic dis- be done in such a way that the urothelium is rolled-in or inverted
cussion with the patient of any complication occurs at the earliest as it is more likely to be water-tight.
opportunity. Not only do patients have a right to and deserve a The catheter should be of a good calibre to reduce the chances
full explanation, but it is important that they can relay this his- of blockage and retention as that would likely compromise the
tory to medical professionals before future care. It is a common repair. The patient may represent with pain associated with
observation that many complaints and medico-legal cases can be retention and/or uroperitoneum and urosepsis. Whilst some
avoided by good communication between clinicians and their haematuria is expected following a repair, if there is concern
patients and a sincere apology. Apology should not be seen as an about significant risk of catheter blockage, e.g., heavily blood
admission of guilt or negligence and is appreciated and important stained or clotted urine, a suprapubic catheter should also be
even when the surgeon is not “at fault”. placed. This can also be helpful in cases of severe injury as the
urinary catheter can be removed but the suprapubic clamped and
Case 2 not removed until successful voiding is established.
Whenever there is injury to the bladder the surgeon must
Sarah was a 44-year-old undergoing total laparoscopic hyster-
consider the position of the tear in relation to the ureteric orifices.
ectomy with conservation of ovaries for menorrhagia. She
If there is any doubt they may be damaged or obstructed by a
delivered both her sons by caesarean section and at the time of
suture, a cystoscopy should be performed, and it may be
surgery it was noted that the bladder was very adherent to the
necessary to insert ureteric stents. These are usually removed
uterus. The surgeon struggled to find a clear plane in the utero-
about 6 weeks later after retrograde contrast studies have
vesical fold to reflect the bladder. An intraoperative bladder
demonstrated free drainage of urine. Ureteric reimplantation is
patency check was performed by filling the bladder with meth-
required in the worst case scenario of a persistent stricture.
ylene blue. It revealed a 1 cm hole in the midline of the bladder
The ureter runs close to the gynaecological organs and should
close to the dome.
be identified before starting most procedures and regularly
Sarah’s story is a good example of a case in which complex-
throughout the operation. The most high-risk area is at the level
ities and difficulties can be predicted. The history of two cae-
of the cervix (particularly during hysterectomy) followed by at
sareans suggests that the bladder may be adherent to the uterus
the level of the pelvic brim near the infundibulopelvic ligament.
making reflection difficult. When consenting for surgery, as well
Radiological studies have shown that the ureter is on average
as describing the generic risks of surgery and an individual
only about 2 cm lateral to the cervix, and in 12% of cases, less
procedure, it may be necessary to tailor the details of consent to
than 0.5 cm. This distance is likely reduced in cases of cervical
the individual. In this case it would be wise to inform the patient
pathology. Caution should always be taken when operating in
that her surgical history increases the risks of the procedure,
proximity to the ureter, especially with electro-cautery or
especially with regards to visceral injury.
advanced sealing and cutting devices where thermal spread may
The surgeon recognised their difficulties and resulting risk to
cause injury not evident at the time of the operation. The same is
the bladder intra-operatively, and appropriately checked and
true where significant ureterolysis has been performed as it may
discovered the injury. A prudent surgeon is always aware of the
strip the blood supply causing delayed ischaemic injury. In sit-
possibility of complications and operates with conscious caution,
uations where there is concern a stent should be placed and
but is also on the look out for signs that they may have already
followed up as above.
occurred. If there is any doubt about the possibility of a
Although classic presentation of ureteric injury is with flank
complication, appropriate checks should be performed. Many
pain, peritonitis, prolonged ileus, and/or fever, but it should al-
complications can be remedied acutely with less adverse conse-
ways be considered in an ill post-operative patient. Undiagnosed
quences for the patient than if left unchecked and undetected.
ureteric injury usually presents in the first few days, but may be
The urologist on-call attended and oversaw the gynaecologist
delayed even up to a few weeks, particularly in cases of thermal
repairing the defect in one continuous layer of vicryl. The bladder
injury. A CT urogram is the imaging modality of choice.
was filled again and integrity demonstrated. The rest of the
If a partial or total transection of the ureter is recognised intra-
procedure was completed without complication. Sarah made a
operatively it may be possible to re-anastamose at the time. This
good recovery, and after 2 days was discharged home with a
should be done by a urologist with a tension-free, stented,
urethral catheter in-situ and a leg bag. After 14 days she returned
watertight anastomosis ideally surrounded by peritoneum or
for a cystogram which showed no leak, and she passed a trial
omentum with placement of retroperitoneal drains. It is less
without catheter in the outpatient setting.
successful after an interval when the ends are inflamed and
Even if you possess the skills and know-how to repair a
fibrosed. In such a case, ureteric reimplantation is generally
complication, unless it is something which you do regularly, a
preferred.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7 215 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
CASE-BASED LEARNING

Unfortunately 10 days later she was seen in clinic complaining has been trained appropriately before a device is used. Safety is
of copious clear, watery vaginal discharge. A vesico-vaginal fis- the number one selling point so the medical technology industry
tula was suspected and confirmed on CT urogram. The urologists should very happy to provide this and continued support.
took over her care and performed a laparoscopic fistula repair Susan was stable throughout the operation and discharged the
with omental patch. A subsequent cystogram and successful next day. Four days later she was readmitted with a peritonitic
TWOC were performed. A further cystogram was performed one abdomen and pyrexia. A CT suggested a perforation of the large
week later which also confirmed no defect. When seen in the bowel. At laparoscopy in conjunction with the general surgeons a
clinic 3 months later, she was happy to have been cured of her 0.5 cm hole was found in the sigmoid rectum discharging bowel
menorrhagia, and was thankful to the surgical team for the contents into the abdominal cavity. A laparoscopic segmental
speed, professionalism and coordination of her care following resection was performed with formation of an ileostomy. The
her complications. She had no long-term adverse sequelae from abdominal cavity was thoroughly washed out and she had 48
her additional complication. hours of IV antibiotics before being discharged home 7 days later.
Even when managed appropriately complications may not The ileostomy was reversed after 3 months.
resolve without difficulty, or even lead to further complications Unwell or slow recovering patients should be treated with
themselves. Abnormal signs and symptoms in a patient after a suspicion and there should be a low threshold for imaging. The
complication should be treated with suspicion. Again, prompt expense and radiation dose is more than balanced by early
recognition, multidisciplinary involvement, quick corrective detection and management. The majority of bowel injury detec-
management and clear patient communication are imperative to ted at the original operation can be oversewn easily, usually
determine a successful outcome. laparoscopically, and this has very little consequence for the
patient. The current vogue amongst colorectal surgeons appears
Case 3 even to let patients eat as tolerated straight away. Larger injuries
may require formation of an ileostomy to allow the injured bowel
Susan was a 23-year-old student admitted at 23.00 hours with a
to rest and repair and reduce the risk of leak. This can almost
positive pregnancy test, spotting of blood per vaginum and se-
always be reversed after about 3 months.
vere right sided abdominal pain. She was assessed by the on-call
Classic presentation of unrecognised bowel injury is 12e36
gynaecology SHO in the accident and emergency department and
hours after surgery (though often later with thermal or ischaemic
found to have guarding on abdominal examination. Ultrasound
injuries) with symptoms and signs such as tender abdomen,
confirmed free fluid in the pelvis. She was transferred directly to
guarding, rebound, vomiting, quiet or absent bowel sounds and
theatre for a diagnostic laparoscopy plus treatment for a pre-
signs of systemic illness e.g., tachycardia and pyrexia and a rise
sumed ectopic pregnancy or haemorrhagic cyst. The on-call gy-
in inflammatory markers. In delayed diagnosis the infection and
naecology registrar performed a right salpingectomy for a
inflammatory response is likely to necessitate a bowel resection
ruptured ectopic pregnancy with a haemoperitoneum of about
with stoma formation. Not only is this a large undertaking which
200 mls.
comes with its own risks (such as anastomotic leak) but it may
Complications are more likely to occur in emergency situa-
result in permanent functional bowel symptoms, especially if the
tions and out of hours when people are often operating under
resection is low (low anterior resection syndrome).
pressure with unfamiliar surroundings, equipment and teams.
If there is any suspicion of injury to the recto-sigmoid colon a
We are chiefly concentrating on issues specific to laparoscopy,
“jacuzzi test” should be performed at the time of surgery. This
but it would be remiss not to mention the importance of team-
involves filling the pelvis with saline and introducing air under
work. Wherever possible surgery should be performed by
pressure through the rectum so as to create bubbles if a hole is
familiar, well rehearsed teams. Both scientific and lay literature is
present. This should be performed with a rigid sigmoidoscope as
littered with examples of problems when surgeons use unfamil-
it is difficult to achieve the required pressure with other
iar equipment, environments or teams. Suboptimal conditions
commonly used instruments such as a bladder syringe. The sig-
and situations will arise and everything should be done to make
moid should be occluded proximally by holding it against the
sure that risk is reduced, for example by using the World Health
pelvic brim. Concern about injury to the rest of the bowel re-
Organisation’s surgical safety checklists.
quires a bowel surgeon to methodically inspect (“run”) the
Surgical procedures often require complicated equipment. No
bowel to look for damage.
team should operate with a piece of equipment with which they
Risk of damaging the bowel can be reduced by emptying the
are not familiar, and this is applicable for all staff and in all sit-
pelvis of bowel before starting the procedure. This can be ach-
uations including emergencies. Where possible equipment and
ieved by positioning the patient head down, gently moving the
set-up should be the same in all theatres. A team may struggle
bowel behind the pelvic brim (using atraumatic graspers and
performing a routine procedure in an emergency theatre with old
only holding the epiploici), releasing any adhesions and even
or different equipment when they are used to an “all singing all
suspending the bowel from an epiploici if required (in much the
dancing” fully integrated theatre for elective work. Efforts should
same way as you might suspend an ovary).
be made to optimise theatre set-up and position equipment
The registrar reviewed the video of the salpingectomy with his
comfortably for the operating team to reduce fatigue and injury.
clinical supervisor and the bipolar forceps were seen to burn the
There are a myriad of devices on the market designed to make
large bowel whilst being removed from the abdomen. As a result
surgery easier and safer. When well acquainted and used
of this incident changes were made in training and out of hours
correctly this is likely to be the case, however if not, the complete
operating policy.
opposite may be true. It is essential to make sure the whole team

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7 216 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
CASE-BASED LEARNING

Conclusion
Risk management process The advantages of laparoscopy and advances in surgical
technology mean more and more procedures are performed
Identify this way. Every possible precaution should be taken to avoid
Uncover, recognise and describe risk complications, detect them at the time of occurrence and
manage them expediently. All surgeons operating lapa-
roscopically should possess the knowledge and skills to deal
Analyse with issues when they arise; this may be supported by simu-
Determine likelihood and consequence of risk
lation training and emergency protocols. Expert multi-
disciplinary help should be summoned without delay. The
Evaluate
incidence of complications can be reduced by strong team
What is the magnitude of risk? Is the risk acceptable? work, optimising the theatre environment and familiarity with
instruments.
Complications are an inevitability of operating. It is vital that
Treat the patient is consented properly and that in the event of diffi-
Modification to achieve acceptable risk culties the patient is approached openly and with honesty and
apology. Complications are an opportunity for learning and
improvement in care and should be investigated thoroughly and
Monitor without blame (Box 2). A
Has acceptable risk been achieved?

FURTHER READING
Figure 1 Ahmad Gaity, Gent David, Henderson Daniel, O’Flynn Helena,
Phillips Kevin, Watson Andrew. Laparoscopic entry techniques.
Cochrane database Syst Rev 2015; 8. http://dx.doi.org/10.1002/
14651858.CD006583.pub4.
The six A’s of surgical complications
Organization, World Health. WHO surgical safety checklist and
implementation manual 2008. Available from: (Last accessed on 10
Aware
Aug 2015).
Anticipate
Sutton CJG, Philips K, ACot RCOG. Preventing entry-related gynae-
Avoid
cological laparoscopic injuries. RCOG Green-top Guidel 2008.
Acknowledge
Amend
Apologise

Box 2
Practice points
Although complications are upsetting, awkward and perhaps
embarrassing, they occur for all surgeons. As well as employing C Identify high risk patients and tailor consent appropriately.
all the necessary steps for identification and management, com- C Put in place risk minimisation strategies (e.g., Palmer’s point
plications should be reflected upon and used as learning oppor- entry, ureteric stents, WHO check list, colorectal specialist or
tunities in the never ending quest to lower surgical morbidity and urologist present at operation).
improve patient outcomes. C Operate with conscious caution and constant awareness of pos-
It is good practice to discuss the events with everyone involved sibility of complication.
and also with mentors to identify lessons to help the team develop C There should be low threshold for complication specific tests
and restore confidence. As discussed previously, these lessons (e.g., methylene blue in the bladder, jacuzzi test).
should be shared with others for all their and their patients’ C Multi-disciplinary specialist advice and help should be sought on
benefit. Specific individual, procedural or system measures or identification of a complication, with early intervention.
protocols may be put in place after risks are highlighted (Figure 1). C A high index of suspicion should be maintained in the post-
After any significant incident the hospital’s risk management operative period with a low threshold for imaging or
team should carry out an investigation to identify lessons, and investigation.
where possible put measures in place to avoid repeat. This C Open, honest discussion should be had with the patient and
learning should be disseminated widely for the benefit of all include an apology.
medical staff and their patients. It should also be communicated C No blame investigation should be carried out, with shared
with the effected patient or parties as it will be important to them learning from complications and instigation of risk reduction
that potential failings have been recognised and measures taken strategies.
to prevent recurrence.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7 217 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.