CASE-BASED LEARNING
Complications of
laparoscopic surgery
Oliver P O’Donovan
Arvind Vashisht
Abstract
General principles in the prevention, recognition, management and
follow-up of common laparoscopic complications are illustrated
using three example cases. The examples given are of major vessel,
urinary tract and bowel injuries, but also provide a framework on
which to hang discussion of other relevant issues such as key surgical
principles, team work, laparoscopic equipment and devices, consent,
risk management and duty of candour and patient communication.
Keywords intraoperative complications; laparoscopy; postoperative
complications
Introduction
Once the realm of only specialist surgeons, laparoscopic oper-
ating is now practised widely by virtually all gynaecologists. This
transition has occurred in the large part due to the clear benefits,
technological advances, and improvement in both acquisition
and teaching of the necessary skills. As a result the number and
complexity of laparoscopic gynaecological procedures increases
year on year. All surgical procedures carry risk and laparoscopy
is no exception; on the contrary it brings a host of its own specific
complications. Through the use of case examples we will sum-
marise and highlight the prevention, recognition and manage-
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-
tion are the cornerstones of minimising their occurrence and
morbidity.
Fortunately severe complications are rare, but this means that
we rarely practice their management and, as the time of the
incident is likely to be stressful, we would do well to think about
how one would manage situations ahead of their occurrence.
This might include practising relevant skills or techniques and
writing protocols for potential adverse circumstances. Obstetri-
cians regularly carry out simulations or drills to practice optimal
management of emergency situations, but as yet this has not
taken-off in gynaecology. There is no reason why it should not
and there are programs and courses available which aim to do
exactly this.
Oliver P O’Donovan BSc MBBS MRCOG is an ST 7 Trainee in Advanced
Laparoscopic Surgery at University College London Hospital, UK.
Conflicts of interest: none declared.
Arvind Vashisht MA MD MRCOG is a Consultant Obstetrician and
Gynaecologist at University College London Hospital, UK. Conflicts
of interest: none declared.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7
Case 1
Lucy was a 28-year-old teacher with dysmennorhoea and dys-
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
achieved with Veress entry via the umbilicus. Palmer’s test was
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-
gery, the largest increase in risk is seen at the time of entry of
either Veress needle or of trocar. The RCOG/British Society for
Gynaecological Endoscopy (BSGE) guideline “Preventing entry-
related gynaecological laparoscopic injuries” (formerly RCOG
Green Top Guideline No. 49) details the incidence of complica-
tions and techniques to minimise them. Based on large multi-
centre trials of tens of thousands of women, it suggests the risk of
major complication is between 1.4 and 5.7 in 1000, with bowel
injury being about twice as common as urological injury and six
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
entry appears to have been routine and the correct tests per-
formed. It is common but not exclusive practice to empty the
bladder (to minimise risk of injury to a distended bladder), and a
three stage check of correct Veress placement should be per-
formed before the gas flow and pressure are turned-up (see
Box 1). The technique chosen may vary depending on history
and physical characteristics.
The BSGE/RCOG guideline recommend a Hasson (open) or
Palmer’s entry in women “who are very thin” due to the narrow
distance between the skin and the aorta, and also in the morbidly
obese as even a slight deviation from the base of the umbilicus
may result in a large distance from the skin to the peritoneum
The three-stage check for correct Veress needle entry
Palmer’s testeAttach a saline filled 10 ml syringe to the Veress
needle. First aspirate; if the Veress is in the bowel or a blood vessel
you may see bowel contents or blood. Next inject; if you are not in a
space it may be difficult. Finally either remove the syringe from the
needle or the plunger from the syringe, and the meniscus should
drop freely if the end of the needle is unobstructed.
Gas pressure testeWhen the Veress is correctly placed within the
peritoneal cavity the starting gas pressure should be less than 8e10
mmHg.
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
demonstrate a resonant sound and loss of liver dullness in the right
upper quadrant.
NB. These are not evidence based checks, but considered best
practice.
Box 1
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 CASE-BASED LEARNING
and difficult or failed entry. Entry at Palmer’s point (3 cm below
the left costal margin in the mid-clavicular line) is safest in those
at significant risk of umbilical adhesions, unless there is history
of surgery in the left upper quadrant or splenomegaly. The
stomach must be emptied (by means of a temporary oro- or
nasogastric tube) beforehand to avoid gastric injury. Threshold
for the use of Palmer’s point should be low as umbilical adhe-
sions may occur in up to 50% of those with previous midline
incisions and 23% of transverse incisions. Although the inci-
dence of relevant adhesions following Caesarean section is not
known, it is thought to be less than other surgery and there are
wide-ranging hypotheses as to why this might be.
A 2015 Cochrane review included 46 RCTs examining 13
different entry techniques. Overall the conclusion was, “that
there was insufficient evidence to recommend the use of one
entry technique over another”. The evidence was noted as being
of generally very low quality, but there was a statistically sig-
nificant decrease in failed entry in the open versus closed groups,
and decreased vascular injury and failed entry with direct trocar
entry versus Veress technique. It has been estimated that trials
involving upwards of 800,000 patients would be required to
demonstrate a reliable difference in the safety of entry
techniques.
On 360 degree review of the abdominal cavity significant
blood and a rapidly expanding retroperitoneal mass were noted.
A major vascular injury was immediately diagnosed and a
midline laparotomy performed without delay, the on-call
vascular surgeon fast-bleeped to attend and the major haemor-
rhage protocol initiated. At laparotomy it was difficult to visu-
alise the anatomy as the abdomen kept welling up with blood, so
constant pressure was applied against the aorta and the
expanding pelvic swelling, until the arrival of the vascular team.
The vascular team arrived ten minutes later and diagnosed a tear
in the inferior vena cava. They repaired the tear and were
satisfied with the result. Two large drains were left in-situ.
There is no argument that in the event of major vessel injury
immediate (midline) laparotomy is required with control of
bleeding until a suitably trained, preferably vascular, surgeon
arrives. Both the aorta and vena cava are retroperitoneal and it is
difficult or impossible to clamp or tie them without significant
dissection. Initial actions therefore should be application of
pressure, volume replacement, and triggering of a major hae-
morrhage protocol. Senior expert assistance should be sought,
which may include several specialties such as gynaecology, ob-
stetrics (who are familiar with massive blood loss), anaesthetics,
haematology, and general surgery (especially in units where
vascular support is not on site). Ideally a vascular surgeon
should attend to repair the damage by suturing or patching the
defect or using endovascular prostheses.
There may be debate over the best way to manage laparo-
scopic injury of small to medium sized blood vessels, and the
method chosen will depend heavily on the experience, skills and
confidence of the operating surgeon and the equipment and
support available to them. Methods to control bleeding lapa-
roscopically include direct pressure, clamping the vessel with a
laparoscopic instrument, laparoscopic suturing, the use of bipo-
lar energy or other sealing devices and the use of clotting agents.
Turning up the gas pressure to 20e25 mmHg may additionally
assist haemostasis in low-pressure bleeding. It is however
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7
important to note that if control is not rapidly achieved laparot-
omy as described above should not be delayed.
In cases resulting in clotting abnormality or large raw areas of
tissue, the insertion of a drain should be considered. They pro-
vide a “window” into the abdomen to warn of ongoing blood loss
and help to reduce the risk of collections. They should be
removed as soon as there is confidence there is no ongoing
bleeding in order to reduce patient discomfort, encourage
mobility and because they can become sites of infection.
Meanwhile the anaesthetic team fluid resuscitated the patient,
first with crystalloids and colloids and then O negative blood and
cross-matched blood when it became available (all given through
a rapid infuser and warmer). Fresh frozen plasma (FFP) was
given at a 1:1 ratio with each unit of blood after the first 2 units.
Tranexamic acid 1 g IV was given. The anaesthetic team inserted
central and arterial lines and spoke to the on-call intensive care
doctor to inform them of the need for a bed on the intensive care
unit (ITU). Although the haemocue at one point showed a hae-
moglobin of 67 g/dl, the patient remained relatively stable and
clotting results were normal, so on the advice of the consultant
haematologist no cryoprecipitate or platelets were given.
Resuscitation of the patient is the realm of the anaesthetist but
it is important that the surgeon has a good understanding so they
can support their colleague and participate in informed decision
making. Volume replacement should start quickly and be pre-
dictive so as not to “get behind”. All hospitals should have a
major haemorrhage protocol that can be initiated and result in
the expedient arrival of blood products and expert support. Cell
salvage equipment should be set-up as autologous transfusion is
preferable, but there must not be a delay in transfusion. O
negative blood should be given at a low threshold whilst await-
ing autologous, group specific or fully cross matched blood.
Bedside tests such as haemocue and blood gas results can be
used to guide red cell replacement. In major haemorrhage clot-
ting factors are used up and lost quickly and must be replaced to
maintain clotting function and prevent disseminated intravas-
cular coagulation. Coagulation function should be monitored by
laboratory and bedside testing (e.g., thromboelastograph) and
replacement guided by the haematologists. Where there is no
time to await results, battle field experience and large civilian
prospective trials have shown a ratio of 1 unit of FFP to every
unit of blood improves outcome, and this should be started
“blind”. The randomised controlled CRASH-2 trial included more
than 20,000 major haemorrhage patients in 40 countries and
showed a 10% decrease in mortality in those patients given the
anti-fibrinolytic tranexamic acid compared to those given pla-
cebo, with earlier administration having a greater effect.
Lucy was extubated later that day and after 48 hours on ITU
was transferred to the vascular ward where she made a good
recovery. All the teams involved fully debriefed Lucy and her
family as to the events which had occurred. The lead surgeon
had an honest and candid discussion with them and apologised.
A serious untoward incident investigation was carried out by the
risk management team, and although it was felt to be a known
complication of the procedure, it was commented that in patients
with a low BMI (and children) consideration should be given to
open (Hasson) entry for pneumoperitoneum. This learning point
was disseminated to all surgeons and trainees.
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 CASE-BASED LEARNING
The location for recovery post-operatively is crucial. Obvi-
ously a major insult such as this requires close observation and
monitoring, and the most suitable staffing and equipment is on
an intensive care unit. Deterioration would be picked up and
acted on rapidly. Once stabilised and showing signs of recovery
careful consideration should be given to the most appropriate
place of step-down care; in this case a vascular ward where the
nursing and medical staff are practised in recognising and man-
aging vascular repair problems.
It is crucial that an open, honest, candid and apologetic dis-
cussion with the patient of any complication occurs at the earliest
opportunity. Not only do patients have a right to and deserve a
full explanation, but it is important that they can relay this his-
tory to medical professionals before future care. It is a common
observation that many complaints and medico-legal cases can be
avoided by good communication between clinicians and their
patients and a sincere apology. Apology should not be seen as an
admission of guilt or negligence and is appreciated and important
even when the surgeon is not “at fault”.
Case 2
Sarah was a 44-year-old undergoing total laparoscopic hyster-
ectomy with conservation of ovaries for menorrhagia. She
delivered both her sons by caesarean section and at the time of
surgery it was noted that the bladder was very adherent to the
uterus. The surgeon struggled to find a clear plane in the utero-
vesical fold to reflect the bladder. An intraoperative bladder
patency check was performed by filling the bladder with meth-
ylene blue. It revealed a 1 cm hole in the midline of the bladder
close to the dome.
Sarah’s story is a good example of a case in which complex-
ities and difficulties can be predicted. The history of two cae-
sareans suggests that the bladder may be adherent to the uterus
making reflection difficult. When consenting for surgery, as well
as describing the generic risks of surgery and an individual
procedure, it may be necessary to tailor the details of consent to
the individual. In this case it would be wise to inform the patient
that her surgical history increases the risks of the procedure,
especially with regards to visceral injury.
The surgeon recognised their difficulties and resulting risk to
the bladder intra-operatively, and appropriately checked and
discovered the injury. A prudent surgeon is always aware of the
possibility of complications and operates with conscious caution,
but is also on the look out for signs that they may have already
occurred. If there is any doubt about the possibility of a
complication, appropriate checks should be performed. Many
complications can be remedied acutely with less adverse conse-
quences for the patient than if left unchecked and undetected.
The urologist on-call attended and oversaw the gynaecologist
repairing the defect in one continuous layer of vicryl. The bladder
was filled again and integrity demonstrated. The rest of the
procedure was completed without complication. Sarah made a
good recovery, and after 2 days was discharged home with a
urethral catheter in-situ and a leg bag. After 14 days she returned
for a cystogram which showed no leak, and she passed a trial
without catheter in the outpatient setting.
Even if you possess the skills and know-how to repair a
complication, unless it is something which you do regularly, a
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7
recognised specialist should be in attendance to advise and aid if
required. Repair of a small bladder injury is a relatively straight
forward procedure for a skilled surgeon. This can be achieved in
either one or two layers using a 2-0 or 3-0 synthetic absorbable
suture. The crucial points are that the defect is identified in its
entirety, the location of the ureters is established (and stents
inserted if there are any concerns regarding their proximity or
integrity), that the repair is water tight and the bladder kept
empty for 10e14 days to allow healing. Ideally the repair should
be done in such a way that the urothelium is rolled-in or inverted
as it is more likely to be water-tight.
The catheter should be of a good calibre to reduce the chances
of blockage and retention as that would likely compromise the
repair. The patient may represent with pain associated with
retention and/or uroperitoneum and urosepsis. Whilst some
haematuria is expected following a repair, if there is concern
about significant risk of catheter blockage, e.g., heavily blood
stained or clotted urine, a suprapubic catheter should also be
placed. This can also be helpful in cases of severe injury as the
urinary catheter can be removed but the suprapubic clamped and
not removed until successful voiding is established.
Whenever there is injury to the bladder the surgeon must
consider the position of the tear in relation to the ureteric orifices.
If there is any doubt they may be damaged or obstructed by a
suture, a cystoscopy should be performed, and it may be
necessary to insert ureteric stents. These are usually removed
about 6 weeks later after retrograde contrast studies have
demonstrated free drainage of urine. Ureteric reimplantation is
required in the worst case scenario of a persistent stricture.
The ureter runs close to the gynaecological organs and should
be identified before starting most procedures and regularly
throughout the operation. The most high-risk area is at the level
of the cervix (particularly during hysterectomy) followed by at
the level of the pelvic brim near the infundibulopelvic ligament.
Radiological studies have shown that the ureter is on average
only about 2 cm lateral to the cervix, and in 12% of cases, less
than 0.5 cm. This distance is likely reduced in cases of cervical
pathology. Caution should always be taken when operating in
proximity to the ureter, especially with electro-cautery or
advanced sealing and cutting devices where thermal spread may
cause injury not evident at the time of the operation. The same is
true where significant ureterolysis has been performed as it may
strip the blood supply causing delayed ischaemic injury. In sit-
uations where there is concern a stent should be placed and
followed up as above.
Although classic presentation of ureteric injury is with flank
pain, peritonitis, prolonged ileus, and/or fever, but it should al-
ways be considered in an ill post-operative patient. Undiagnosed
ureteric injury usually presents in the first few days, but may be
delayed even up to a few weeks, particularly in cases of thermal
injury. A CT urogram is the imaging modality of choice.
If a partial or total transection of the ureter is recognised intra-
operatively it may be possible to re-anastamose at the time. This
should be done by a urologist with a tension-free, stented,
watertight anastomosis ideally surrounded by peritoneum or
omentum with placement of retroperitoneal drains. It is less
successful after an interval when the ends are inflamed and
fibrosed. In such a case, ureteric reimplantation is generally
preferred.
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 CASE-BASED LEARNING
Unfortunately 10 days later she was seen in clinic complaining
of copious clear, watery vaginal discharge. A vesico-vaginal fis-
tula was suspected and confirmed on CT urogram. The urologists
took over her care and performed a laparoscopic fistula repair
with omental patch. A subsequent cystogram and successful
TWOC were performed. A further cystogram was performed one
week later which also confirmed no defect. When seen in the
clinic 3 months later, she was happy to have been cured of her
menorrhagia, and was thankful to the surgical team for the
speed, professionalism and coordination of her care following
her complications. She had no long-term adverse sequelae from
her additional complication.
Even when managed appropriately complications may not
resolve without difficulty, or even lead to further complications
themselves. Abnormal signs and symptoms in a patient after a
complication should be treated with suspicion. Again, prompt
recognition, multidisciplinary involvement, quick corrective
management and clear patient communication are imperative to
determine a successful outcome.
Case 3
Susan was a 23-year-old student admitted at 23.00 hours with a
positive pregnancy test, spotting of blood per vaginum and se-
vere right sided abdominal pain. She was assessed by the on-call
gynaecology SHO in the accident and emergency department and
found to have guarding on abdominal examination. Ultrasound
confirmed free fluid in the pelvis. She was transferred directly to
theatre for a diagnostic laparoscopy plus treatment for a pre-
sumed ectopic pregnancy or haemorrhagic cyst. The on-call gy-
naecology registrar performed a right salpingectomy for a
ruptured ectopic pregnancy with a haemoperitoneum of about
200 mls.
Complications are more likely to occur in emergency situa-
tions and out of hours when people are often operating under
pressure with unfamiliar surroundings, equipment and teams.
We are chiefly concentrating on issues specific to laparoscopy,
but it would be remiss not to mention the importance of team-
work. Wherever possible surgery should be performed by
familiar, well rehearsed teams. Both scientific and lay literature is
littered with examples of problems when surgeons use unfamil-
iar equipment, environments or teams. Suboptimal conditions
and situations will arise and everything should be done to make
sure that risk is reduced, for example by using the World Health
Organisation’s surgical safety checklists.
Surgical procedures often require complicated equipment. No
team should operate with a piece of equipment with which they
are not familiar, and this is applicable for all staff and in all sit-
uations including emergencies. Where possible equipment and
set-up should be the same in all theatres. A team may struggle
performing a routine procedure in an emergency theatre with old
or different equipment when they are used to an “all singing all
dancing” fully integrated theatre for elective work. Efforts should
be made to optimise theatre set-up and position equipment
comfortably for the operating team to reduce fatigue and injury.
There are a myriad of devices on the market designed to make
surgery easier and safer. When well acquainted and used
correctly this is likely to be the case, however if not, the complete
opposite may be true. It is essential to make sure the whole team
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7
has been trained appropriately before a device is used. Safety is
the number one selling point so the medical technology industry
should very happy to provide this and continued support.
Susan was stable throughout the operation and discharged the
next day. Four days later she was readmitted with a peritonitic
abdomen and pyrexia. A CT suggested a perforation of the large
bowel. At laparoscopy in conjunction with the general surgeons a
0.5 cm hole was found in the sigmoid rectum discharging bowel
contents into the abdominal cavity. A laparoscopic segmental
resection was performed with formation of an ileostomy. The
abdominal cavity was thoroughly washed out and she had 48
hours of IV antibiotics before being discharged home 7 days later.
The ileostomy was reversed after 3 months.
Unwell or slow recovering patients should be treated with
suspicion and there should be a low threshold for imaging. The
expense and radiation dose is more than balanced by early
detection and management. The majority of bowel injury detec-
ted at the original operation can be oversewn easily, usually
laparoscopically, and this has very little consequence for the
patient. The current vogue amongst colorectal surgeons appears
even to let patients eat as tolerated straight away. Larger injuries
may require formation of an ileostomy to allow the injured bowel
to rest and repair and reduce the risk of leak. This can almost
always be reversed after about 3 months.
Classic presentation of unrecognised bowel injury is 12e36
hours after surgery (though often later with thermal or ischaemic
injuries) with symptoms and signs such as tender abdomen,
guarding, rebound, vomiting, quiet or absent bowel sounds and
signs of systemic illness e.g., tachycardia and pyrexia and a rise
in inflammatory markers. In delayed diagnosis the infection and
inflammatory response is likely to necessitate a bowel resection
with stoma formation. Not only is this a large undertaking which
comes with its own risks (such as anastomotic leak) but it may
result in permanent functional bowel symptoms, especially if the
resection is low (low anterior resection syndrome).
If there is any suspicion of injury to the recto-sigmoid colon a
“jacuzzi test” should be performed at the time of surgery. This
involves filling the pelvis with saline and introducing air under
pressure through the rectum so as to create bubbles if a hole is
present. This should be performed with a rigid sigmoidoscope as
it is difficult to achieve the required pressure with other
commonly used instruments such as a bladder syringe. The sig-
moid should be occluded proximally by holding it against the
pelvic brim. Concern about injury to the rest of the bowel re-
quires a bowel surgeon to methodically inspect (“run”) the
bowel to look for damage.
Risk of damaging the bowel can be reduced by emptying the
pelvis of bowel before starting the procedure. This can be ach-
ieved by positioning the patient head down, gently moving the
bowel behind the pelvic brim (using atraumatic graspers and
only holding the epiploici), releasing any adhesions and even
suspending the bowel from an epiploici if required (in much the
same way as you might suspend an ovary).
The registrar reviewed the video of the salpingectomy with his
clinical supervisor and the bipolar forceps were seen to burn the
large bowel whilst being removed from the abdomen. As a result
of this incident changes were made in training and out of hours
operating policy.
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 CASE-BASED LEARNING
Risk management process
Identify
Uncover, recognise and describe risk
Analyse
Determine likelihood and consequence of risk
Evaluate
What is the magnitude of risk? Is the risk acceptable?
Treat
Modification to achieve acceptable risk
Monitor
Has acceptable risk been achieved?
Figure 1
The six A’s of surgical complications
Aware
Anticipate
Avoid
Acknowledge
Amend
Apologise
Box 2
Although complications are upsetting, awkward and perhaps
embarrassing, they occur for all surgeons. As well as employing
all the necessary steps for identification and management, com-
plications should be reflected upon and used as learning oppor-
tunities in the never ending quest to lower surgical morbidity and
improve patient outcomes.
It is good practice to discuss the events with everyone involved
and also with mentors to identify lessons to help the team develop
and restore confidence. As discussed previously, these lessons
should be shared with others for all their and their patients’
benefit. Specific individual, procedural or system measures or
protocols may be put in place after risks are highlighted (Figure 1).
After any significant incident the hospital’s risk management
team should carry out an investigation to identify lessons, and
where possible put measures in place to avoid repeat. This
learning should be disseminated widely for the benefit of all
medical staff and their patients. It should also be communicated
with the effected patient or parties as it will be important to them
that potential failings have been recognised and measures taken
to prevent recurrence.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:7
Conclusion
The advantages of laparoscopy and advances in surgical
technology mean more and more procedures are performed
this way. Every possible precaution should be taken to avoid
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
with issues when they arise; this may be supported by simu-
lation training and emergency protocols. Expert multi-
disciplinary help should be summoned without delay. The
incidence of complications can be reduced by strong team
work, optimising the theatre environment and familiarity with
instruments.
Complications are an inevitability of operating. It is vital that
the patient is consented properly and that in the event of diffi-
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
without blame (Box 2). A
FURTHER READING
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.
Organization, World Health. WHO surgical safety checklist and
implementation manual 2008. Available from: (Last accessed on 10
Aug 2015).
Sutton CJG, Philips K, ACot RCOG. Preventing entry-related gynae-
cological laparoscopic injuries. RCOG Green-top Guidel 2008.
Practice points
C Identify high risk patients and tailor consent appropriately.
C Put in place risk minimisation strategies (e.g., Palmer’s point
entry, ureteric stents, WHO check list, colorectal specialist or
urologist present at operation).
C Operate with conscious caution and constant awareness of pos-
sibility of complication.
C There should be low threshold for complication specific tests
(e.g., methylene blue in the bladder, jacuzzi test).
C Multi-disciplinary specialist advice and help should be sought on
identification of a complication, with early intervention.
C A high index of suspicion should be maintained in the post-
operative period with a low threshold for imaging or
investigation.
C Open, honest discussion should be had with the patient and
include an apology.
C No blame investigation should be carried out, with shared
learning from complications and instigation of risk reduction
strategies.
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