What are the steps towards abdominal surgery? Investigation and Diagnosis It is very important that all necessary tests are undertaken to investigate the patient s symptoms appropriately and an accurate diagnosis reached before surgery can even be considered. For example, if a patient passes blood in their stools, it may be necessary to take blood tests to find out whether there is an underlying condition. It may be that the blood results indicate that there is a suspicion of cancer and therefore the patient may be referred to the local specialist centre to undergo further tests such as an MRI scan, endoscopy or a colonoscopy. If a tumour is noted in the bowel the surgeon may decided that surgery is appropriate. The patient can then undergo the pre-operative assessment for the elective operation and be admitted to undergo the procedure. Surgeons do not always have the luxury of time to perform all of the investigations that they need. If a patient is admitted to hospital through the Accident and Emergency department with acute abdominal pain there may only be time to perform a MRI or CT scan which may or may not reveal the problem. It may then be necessary to proceed to emergency laparotomy where a patient s abdomen is opened to see whether the surgeon can identify the problem. When a patient undergoes elective surgery, the hospital can ensure that a surgeon of the appropriate grade and experience performs the operation. Informed Consent With the exception of patients admitted as an emergency, who are unconscious, patients should always be asked to sign as Consent Form before they undergo a procedure. A patient should be talked through the operation by the surgeon in terms that are understood by the patient. The surgeon should also clearly explain any complications that may arise during the operation. The complications should also be written on the consent form. If a patient understands the nature of the procedure and the risks that the operation involves and still signs to undergo the same then they have provided informed consent. Page 1 of 6
Only a surgeon who is capable of performing the operation themselves should take a patient s consent for an operation. For example, if it is only the Consultant within the surgical team who is capable of performing a particular operation then it should be the consultant that takes the consent from the patient, not one of his or her team. Common risks that you would expect to see on most Consent Forms for surgery are bleeding during the procedure, wound infection, wound breakdown and in abdominal surgery, the risk of an incisional hernia developing post-operatively. Surgery The operation itself should be undertaken with reasonable skill and care. All operations have recognised complications. If a recognised complication occurs it is very important that it is noted immediately and rectified. For example, damaging a patient s bowel during a hysterectomy would not necessarily be negligent but failing to notice that the bowel has been damaged and repairing it before closing the patient s abdomen may well be negligent. There may be more than one method to perform an operation. Different surgeons, even at the same hospital, may perform the same operation in different ways. Provided that there is a responsible body of surgeons that would perform the operation in the same way then the technique may not be negligent. Common Abdominal Operations Removal of the gall bladder (cholocystectomy) The development of gall stones is a common complaint and can lead to a condition called cholocystitis (inflammation of the gall bladder). Sometimes the symptoms can come and go. After investigations to confirm the existence of the gall stones and/or inflammation of the gall bladder, a patient will be referred for elective surgery to remove the gall bladder. If a patient has an acute attack they may present at hospital and require an emergency cholocystectomy. It is very important that the cholocystectomy is performed in a timely and appropriate manner to prevent the patient from becoming increasingly unwell. Page 2 of 6
Most cholocystectomies these days are performed by keyhole surgery following which a patient may be well enough to be discharged within 24 48 hours. Claims for medical negligence can arise if there has been a delay in diagnosisng cholcystitis and/or a delay in performing the cholocystectomy. Equally, if during the operation there is damage to the surrounding structures, including the common bile duct. Removal of the appendix (appendicectomy) Appendicitis is a condition that can strike at any time and is a medical emergency. If a patient presents at the Accident and Emergency department with abdominal pain, vomiting and a fever, appendicitis must be excluded. Once it has been determined that a patient does have appendicitis and the appendix must be removed they should be referred for emergency surgery. It is very important that the surgery is undertaken quickly once the diagnosis has been made to prevent the appendix from rupturing. A ruptured appendix can lead to a patient developing peritonitis or even cause death. Peritonitis is inflammation and infection of the thin tissue that lines the abdomen. Peritonitis can lead to the development of a large number of adhesions which is web-like scar tissue that wraps itself around the organs. Adhesions can make subsequent surgery very difficult and cause other problems such as obstruction of the bowel. Removal of a tumour A common cause for abdominal surgery is cancer of the digestive tract. If diagnosed early enough it may be possible to operate to remove a tumour in its entirety either with or without a course of chemotherapy or radiotherapy before or after surgery. It is important that the surgery is conducted by a surgeon of appropriate experience and that all risks are discussed with the patient. If the tumour is in the bowel then it is sometimes necessary to remove the section of the bowel containing the tumour and then reattach the two ends of the bowel together. Often it is necessary for the patient to have a colostomy or ileostomy (depending whereabouts in the bowel the tumour was situated) where a section of the bowel is brought outside the body to allow waste to collect hygienically in a bag. This gives the bowel an opportunity to heal. In time it may be Page 3 of 6
possible for the colostomy or ileostomy to be reversed to allow the patient to return to normal bowel function. Where a section of the bowel has been reattached it is very important that a patient s observations are monitored carefully to look for any signs of the bowel breaking down and patient developing peritonitis. It is also very important to monitor a patient s fluid balance (how much fluid a patient is drinking compared with how much they urinate). Dehydration can be a problem where a patient s bowel has been joined together. Surgery for Ulcerative Colitis/Crohn s disease Ulcerative Colitis is a type of inflammatory bowel disease that affects the lining of the colon and the rectum. Symptoms include diarrhoea that can be severe in nature; blood and pus in the stools, abdominal and rectal pain. Ulcerative colitis can be managed by medication but severe cases can require surgery to remove the colon and can even involve closure of the rectum. If this is the case then the patient will require a permanent ileostomy to manage their bowel movements. Surgery of this type is very serious. Usually, all medication will have failed to work and the symptoms be intolerable before proceeding to surgery. It is very important that all risks and benefits of the procedure are explained to the patient very carefully. As well as the risks involved in the procedure itself, a permanent ileostomy means a complete lifestyle change. Crohn s disease is another type of inflammatory disease but can affect any part of the digestive tract from the mouth to the rectum. Symptoms can differ depending on which part of the tract is affected. Badly affected parts of the bowel may be removed but the condition cannot be cured by surgery. Before this type of surgery is undertaken it is usual that all medication will have been attempted. A patient with Crohn s disease must be counselled carefully before proceeding to surgery as they must be made aware that it will not cure their disease. Hernia repair A common abdominal operation is to repair a hernia. A hernia is where a part of the bowel protrudes through a weakness in a wall of muscle. Hernias are generally referred to as umbilical if the occur around a patient s tummy button; hiatus if the bowel pushes up Page 4 of 6
through the diaphragm or inguinal if they occur in the groin area. A hernia can occur naturally, sometimes after lifting something heavy or doing strong, manual work. Many people live with hernias for some time. If a hernia has become symptomatic then a patient may be referred for elective surgery to repair it. This usually involves the surgeon opening the area, ensuring that all the bowel is pushed back through the muscle and a mesh being inserted to strengthen the area. Hernias can also be incisional. This is where a patient has already undergone abdominal surgery and the muscles have been cut and therefore weakened. As a result the patient can then get a hernia at the site of the original operation. If there is a risk of a patient developing an incisional hernia following an operation on their abdomen it is important that a surgeon warns them of this. Adhesions Adhesions are scar tissue that develop in bands around the internal organs following surgery. Each patient is affected differently. Two patients may undergo the same operation, but only one may develop serious adhesions. The risk of adhesions is made worse if a patient has had more than one operation and markedly increased if they have had some kind of infection such as peritonitis. If adhesions are severe they can cause a range of problems including obstruction of the bowel. If the problem is serious it can require further surgery to divide the adhesions and release the bowel. Post-operative Care Following any operation it is very important for the surgeons, doctors and nursing staff to monitor a patient s observations carefully. Low blood pressure and a quick pulse rate can indicate problems post-operatively, such as internal bleeding. It is important that if a portion of the bowel has been removed and the ends rejoined that staff monitor signs and symptoms of a bowel leak. Markers in a patient s blood can indicate this is happening. If there is a bowel leak it may be necessary to transfer the patient immediately for emergency surgery to repair the leak to prevent the patient from Page 5 of 6
developing peritonitis. Equally, where the bowel has been rejoined it is very important that the patient s fluid balance is maintained as dehydration can cause real problems in such circumstances. Abdominal surgery is a very wide area and this is intended as an overview of the topic only. Surgery of this kind is a large undertaking and can often been very traumatic for the patient involved. Not only do they have to go through a difficult operation but if they are left with a colostomy or ileostomy post-operatively it can mean a complete change to their way of life. Even if this is not the case there can be long term repercussions on what the person can tolerate to eat or in their bowel habit both of which can be very debilitating. If you have been affected by these issues or have undergone any area of abdominal surgery and believe there may have been a problem, please contact our specialist team who would be very happy to discuss the issues with you. Page 6 of 6