How was this ureter damaged?

October 1, 2009

During laparoscopic hysterectomy, injury to adjacent organs is a known complication. But the inability to explain the mechanism of surgery and the complications that occur postoperatively often make risks difficult to defend in court.

THE FACTS

On April 8, the 50-year-old married plaintiff was admitted to the defendant hospital center by the defendant gynecologist for a laparoscopic-assisted hysterectomy, which was being done to relieve chronic pelvic pain, severe dysmenorrhea, and menometrorrhagia. Prior endometrial sampling showed no evidence of carcinoma and a preoperative pelvic sonogram revealed bilateral ovarian cysts and an enlarged uterus that had resulted from myomas. The surgeon performed a laparoscopic-assisted vaginal hysterectomy, right salpingo-oophorectomy, and left oophorectomy. The patient left the operating room in good condition and the operative report indicates that the surgeon encountered several omental adhesions, an enlarged globular-shaped uterus, and a 4-cm right ovarian cyst with dense adhesions to the pelvic sidewall. The OR report reflects that lysis of adhesions in the right pelvic sidewall was done "under direct visualization of the ureter." A 2:30 PM nursing note indicates that Foley output was adequate, but at 10:00 PM, another nursing note indicates that the patient was complaining of discomfort at the catheter site. The resident subsequently ordered the Foley removed, and there was no further mention of the patient's urinary status prior to her discharge on the morning of April 10.

THE PATIENT WAS RE-ADMITTED ON JUNE 14 to urology with a diagnosis of right ureteral injury and right distal ureteral-vaginal fistula. A urologist performed a right ureteral re-implantation; the procedure was modified to the transabdominal approach when adhesions were discovered. When the surgeon reached the ureter he found it was "supple with a nice bleeding edge," and he had no difficulty re-inserting the ureter and repairing the fistulous track. Two days after surgery, the nephrostomy tube was removed and the patient was discharged home without complaint the following day.

ALLEGATIONS

The plaintiff alleged that the gynecologic surgeon should have converted the laparoscopic-assisted hysterectomy to an open hysterectomy once adhesions in the abdomen were identified. She further asserted that he should have placed ureteral stents and that he failed to tack and/or "stick up" the pelvis or otherwise support the pelvis intraoperatively and that he failed to identify the ureters intraoperatively, or to inform the patient preoperatively of the risk of injury to the ureters. As a result, she complained of an inability to have intercourse due to right vaginal wall pain, an inability to sit more than 2 hours at a time without significant pain, along with pain in crossing her legs, bending over, or reaching up for objects.