How could a surgeon make the same EXACT mistake twice in a row? Doesn’t it seem unlikely that an experienced surgeon would ever do something like this?
The case below helps explain how sometimes in medicine we may miss the learning opportunities that our mistakes present us.
The first patient in question is a 40 year old woman who undergoes a laparoscopic hysterectomy to remove an enlarged uterus that contains fibroids and has been causing excessive bleeding. During the course of the surgery, the uterus is extracted out of the patient through the vagina. Given the large size of the uterus, it actually is too big to be removed easily, and instead is very forcible removed. As a result of this forceful vaginal extraction of the enlarged uterus, the vagina of the patient rips. The surgeon comments that they should have never tried to vaginally deliver such a large uterus, and repairs the tears in the patient’s vagina. The rest of the operation is concluded without any other complications. The patient recovers and goes home without any other complications.
One month later a second patient, who is a 45 year old woman, undergoes the same procedure for the exact same reason (with the same surgeon). During the procedure the same thing occurs: the uterus is quite enlarged, is forced out of the vagina, which in turn causes it to tear and bleed. The surgeon comments that they should have never tried to vaginally deliver such a large uterus, and repairs the vaginal tear. Later as the operation is being concluded, the surgeon blames the medical student who is assisting for one of the vaginal tears that occurred. The suggestion is made that perhaps when the catheter was inserted by the student at the beginning of the procedure this caused one of the tears to occur, even though all of the bleeding occurred only after the vaginal extraction of the uterus (hours after the catheter was placed). The patient recovers and goes home without any issues, however the medical student goes home upset about what had happened that day.
AT WHAT POINT DID THE FOREST BECOME LOST IN THE TREES?
It seems that during the second operation it was not in the forefront of the surgeon’s mind to think about how to avoid unnecessary damage to the vagina. Even though this same issue had happened only a month ago, there was not an opportunity for the surgeon to take a step back and think critically about how to avoid repeating the initial mistake that was made. The bigger picture of surgery is to limit the damage that is done to the body of the patient, and for the sake of speed often times things like this will happen where “forceful” maneuvers are conducted that end up causing some tearing/bleeding unnecessarily.
WHY SHOULD WE NOT THINK ITS COMPLETELY “CRAZY” THAT THIS HAPPENED?
During the first procedure it can make a lot of sense how the surgeon might have been willing to force the uterus through the vagina. Especially at that time perhaps it was not clear that such a maneuver would cause the vagina to tear. And with the pressures of surgery and the desire to limit the time that the patient is under anesthesia, it can make sense why one would be willing to try and see if a vaginal extraction (which can be the fastest way to remove the uterus) would be pursued.
During the second procedure it seems to make less sense why this same error would be repeated, however it is important to realize that if the surgeon had forgotten about the previous episode of vaginal tearing, perhaps this was simply not in the forefront of their mind when vaginally delivering the second uterus. The life of a surgeon is hectic and busy. It is understandable why an issue like a vaginal tear/vaginal bleeding may be crowded out by other (more life threatening) considerations.
WHO CARES? WHAT WAS THE HARM IN WHAT HAPPENED?
In the grand scheme of things vaginal tearing/bleeding is not the WORST thing that could happened during a laparoscopic hysterectomy. With that in mind it is (as we will discuss more in the next section) a very avoidable complication, and it causes a few issues overall:
- More harm to the patient: vaginally delivering such an enlarged uterus will physically harm the patient causing tearing and bleeding. Our goals as physicians is to always minimize harm to the patients.
- Time: while the goal of the forceful vaginal extraction of the uterus was initially to save time, if the vagina tears, this will actually waste more time given that these tears will have to be surgically fixed. This defeats the entire purpose!
- Stress: wether it is on the part of the surgeon who feels guilty for harming the patient, or the medical trainee who is blamed for the vaginal tearing (because the surgeon has become upset), these types of avoidable complications always have a way of injecting unnecessary stress into the picture.
WHAT IS THE TEACHING POINT HERE? HOW DO WE AVOID THIS IN THE FUTURE?
The initial teaching point is to not take shortcuts that end up wasting more time! While the technical details are not worth going through here, surgically there is no reason that the uterus can not be cut into multiple pieces before it is extracted vaginally. There is absolutely no reason why a motivated surgeon could not have cut the uterus into smaller parts that were easier to remove from the vagina, while effectively avoiding any vaginal tearing/bleeding. It is true that this would take more time up front…however in the long run a lot of time would be saved because the patient would have no vaginal tearing.
Learn from your mistakes, so that you don’t repeat them! Tearing the vagina with the forceful uterus extraction was a learning moment for the operating surgeon. While this mistake may have been justified, making it again really begs the question as to why this happened again? In medicine often times when we make mistakes we are inclined to sweep them under the table (or blame others for our own missteps). Instead when you make a medical error meet it HEAD ON. As painful as it may be, make sure you understand why you made the mistake in the first place, and make sure to take steps to avoid repeating the error.
At the end of the day the etiology of this error is not terribly complicated. The uterus was simply too large to fit through the vagina without causing damage to it. The solution is that the uterus needs to either be cut into smaller pieces, or removed from a larger opening (such as one made in the abdomen of the patient). The solution is not to try and deliver yet another enlarged uterus vaginally in the same fashion, while expecting for the vagina not to be damaged this second time.
Page Updated: 09.28.2016