Key points

Gynaecologists willing to set up a viable laparoscopic service need to:

1. ✓ be familiar with the General Medical Council’s guidance on consent

2. ✓ be aware of the relevant RCOG guidance and clinical governance guidelines

3. ✓ have satisfactory training and supervision before carrying out laparoscopic surgery independently

4. ✓ undertake laparoscopic surgery where there is a facility of appropriate surgical equipment and supply of blood products

5. ✓ put in place a coordinated system to deal with laparoscopic emergencies

6. ✓ introduce and insist on a system of close postoperative monitoring

7. ✓ demonstrate acute awareness of signs of postoperative complications

8. ✓ audit their outcomes to help redesign and reconfigure the service

9. ✓ understand that setting up a safe and effective service will enhance patient choice and improve outcomes.

Introduction

Gynaecological operative laparoscopy has progressed significantly over the past two decades. Initially, the routine application of endoscopic techniques only occurred for relatively straightforward procedures. However, advances in endoscopic equipment and the development of structured surgical training, combined with the acceptance of the advantages of laparoscopy, has led to the application of minimal access surgery in most areas of operative gynaecology.

Over 250,000 women undergo laparoscopic surgery in the UK each year. Improving the standards of safety and surgical care is an essential principle in the establishment of new gynaecological services. The benefits of diagnostic and operative laparoscopic surgery in terms of reduced postoperative pain, shorter hospitalisation, earlier return to normal activities when compared with laparotomy, need to be balanced against the potential increased risks associated with minimal access surgery, such as vascular and organ damage. A 10-year report (1991–2000) from a major Australian medical defence organisation indicated that, although obstetric claims were more expensive, gynaecological claims were more frequent and operative laparoscopy was the second most common group of procedures involved in claims after hysterectomy. Medical Defence Union (UK) data demonstrate that, over the past 10 years, it has opened 534 files with varying grades of claims regarding laparoscopic surgery.

Since 2005, the National Health Service Litigation Authority (NHSLA) has dealt with 224 claims pertaining to laparoscopic surgery in gynaecology, of which 138 have resulted in damages paid. Of these 224 claims, 204 have been for six most frequently occurring causes (Figure 13.1). The graph shows that the highest number of claims has been for intraoperative problems.