Retrospective analysis 1973-82

Total of 128 cases of bowel injury

37% on entry

35% associated with adhesiolysis

Equal regardless of mode of surgery

75% small bowel

72% at uncomplicated surgeries

Total of 110 cases of bowel injury

37.3% on entry

38.2% associated with adhesiolysis

Equal regardless of mode of surgery

75.5% small bowel

5279 hysterectomies reviewed

No statistical significance between approach and organ injury

Bowel injury was associated with adhesiolysis

10yr review

0.08% risk bowel injury in diagnostic and minor laparoscopic procedures

0.33% risk with major operative procedure

Decreased incidence with increased surgical experience

Perioperative diagnosis and immediate repair reduced likelihood of severe complications

307 patients

Complications occurred in 41 (13%)

The majority were bowel injuries at 11.4% (35 patients)

Predictive factors were prior› Abdominal myomectomy› Excisional endometriosis surgery

360 women undergoing laparoscopy after prior laparotomy

Increased adhesions if:› Midline laparotomy for gynaecological

reason› Supra-umbilical incision

21 (5.8%) had direct injury to omentum and bowel during their laparoscopic procedure

Occurs most commonly with› entry to peritoneum› adhesiolysis› Previous surgery

No difference in occurance with mode of approach (laparoscopic/vaginal/D&C)

Awareness of risk

Appropriate surgeon given risk

Timely recognition and management

Bowel Injury at Bowel Injury at HysterectomyHysterectomy

National WomenNational Women’’ssData 2008 Data 2008 --2011 inclusive2011 inclusive

Bowel Injury at HysterectomyBowel Injury at Hysterectomy

ACCESS databaseACCESS database

WomenWomen’’s Health Intelligence Units Health Intelligence Unit

All admissions and reAll admissions and re--admissions cross admissions cross referencedreferenced

NumbersNumbers

20082008--20112011

654 Hysterectomy 654 Hysterectomy proceduresprocedures

399 (61%) Abdominal399 (61%) Abdominal

158 (24.2%) Vaginal158 (24.2%) Vaginal

97 (14.8%) Laparoscopic97 (14.8%) Laparoscopic

0

100

200

300

400

500

600

700

Total Lap' Abd Vaginal

IntraIntra--operative complicationsoperative complications 20082008--20112011

Total Total HysterectomyHysterectomy

LaparoscopicLaparoscopicHysterectomyHysterectomy

AbdominalAbdominalHysterectomyHysterectomy

VaginalVaginalHysterectomyHysterectomy

nn 654654 9797 399399 158158

BladderBladderInjuryInjury

4 (0.6%)4 (0.6%) 00 4 (1%)4 (1%) 00

BowelBowelInjuryInjury

6 (0.9%)6 (0.9%) 00 6 (1.5%)6 (1.5%) 00

UreterUreterInjuryInjury

3 (0.5%)3 (0.5%) 00 3 (0.8%)3 (0.8%) 00

Bowel Injuries at HysterectomyBowel Injuries at Hysterectomy 20082008--20112011

6/6546/654

5/654 Recognised immediately, primary 5/654 Recognised immediately, primary repair, no long term consequencesrepair, no long term consequences

1/654 (0.15%) 1/654 (0.15%) -- unrecognisedunrecognised

Bowel Injury at HysterectomyBowel Injury at Hysterectomy1.1. 50yo, Superficial 50yo, Superficial SerosalSerosal Injury over Injury over caecumcaecum, at Pelvic Clearance , at Pelvic Clearance

for Endometrial Cancer. Recognised, primary repair, no for Endometrial Cancer. Recognised, primary repair, no sequelaesequelae2.2. 52yo Hysterectomy for benign fibroids, 52yo Hysterectomy for benign fibroids, adhesiolysisadhesiolysis, gen surgeon , gen surgeon

called, sigmoid dissection resulted in injury, recognised, and called, sigmoid dissection resulted in injury, recognised, and primary repair, no primary repair, no sequelaesequelae..

3.3. 41yo Hysterectomy for Fibroids, Entry Injury to small bowel, 41yo Hysterectomy for Fibroids, Entry Injury to small bowel, primary resection, and primary reprimary resection, and primary re--anastomosisanastomosis, no , no sequelaesequelae..

4.4. 67yo Pelvic clearance for complex mass and 67yo Pelvic clearance for complex mass and tortiontortion, , serosalserosal injury injury to sigmoid colon, recognised, and repaired, no to sigmoid colon, recognised, and repaired, no sequelaesequelae..

5.5. 40yo Hysterectomy for fibroids. Adhesions. Small bowel injury 40yo Hysterectomy for fibroids. Adhesions. Small bowel injury recognised and primary repair, no post op concerns.recognised and primary repair, no post op concerns.

6.6. 82yo, Large pelvic mass, Pelvic clearance, Bowel injury 82yo, Large pelvic mass, Pelvic clearance, Bowel injury unrecognised at time of surgery. Delayed recognition and unrecognised at time of surgery. Delayed recognition and subsequent death. SAC1 completed. Several system and quality subsequent death. SAC1 completed. Several system and quality recommendations implemented since.recommendations implemented since.

Key Outcomes from Key Outcomes from PeriPeri--operative operative Mortality reviewMortality review

Audit and present historical data to wider WomenAudit and present historical data to wider Women’’s Health Groups Health Group

Gynaecology medical and nursing staff will attend additional traGynaecology medical and nursing staff will attend additional training ining on the recognition and standardised management of critically ilon the recognition and standardised management of critically ill l patients patients --------> > CCrISPCCrISP and ALERT coursesand ALERT courses

Gynaecology nurses Gynaecology nurses -- rotations to the general surgical wards to rotations to the general surgical wards to enhance nursing critical care experienceenhance nursing critical care experience

A standardised nursing handover tool has been implemented in warA standardised nursing handover tool has been implemented in ward d 97, with education and support97, with education and support

An early warning score (EWS) system has been implemented into An early warning score (EWS) system has been implemented into ward 97 and charting of all abnormal vital signs on the observatward 97 and charting of all abnormal vital signs on the observation ion sheet now occurssheet now occurs

Ward 97 now consistently utilises the standardised clinical suppWard 97 now consistently utilises the standardised clinical support ort and communication systems in the hospitaland communication systems in the hospital

SummarySummary

Incidence of Unrecognised bowel injury at Incidence of Unrecognised bowel injury at hysterectomy in this DHB is consistent hysterectomy in this DHB is consistent with the international literature.with the international literature.

Key is Risk selection, preKey is Risk selection, pre--operative operative planning, imaging, and timely planning, imaging, and timely communication with colleagues. communication with colleagues. Teamwork and planning improves Teamwork and planning improves outcomes.outcomes.

AcknowledgmentsAcknowledgments

Lynn Sadler; Marjet Pot; Sue Fleming and Lynn Sadler; Marjet Pot; Sue Fleming and Team at WHI UnitTeam at WHI Unit

All the wonderful Registrars; SMO All the wonderful Registrars; SMO Colleagues Colleagues –– GynaeGynae -- AnaesthAnaesth and and Surgical Disciplines; Nursing; and of Surgical Disciplines; Nursing; and of course the expert Theatre Staff at NWHcourse the expert Theatre Staff at NWH

Questions and Comments??Questions and Comments??