NEGLIGENT FISTULAE
A fistula is a pathological communication between one hollow organ and another or the outside of the body. Fistulae which are most commonly the subject of medical malpractice litigation involve urinary tract or bowel.
As a general rule for bowel fistulae, if the plaintiff has Crohn's Disease, cancer or Diverticular Disease, it is hard to prove iatrogenic causation, because spontaneous fistula is well-recognised in these conditions.
Though surgical complications cause the majority of bowel fistulae[1], this does not necessarily mean that surgical technique was substandard. With appropriate management, the majority eventually heal[1a].
Pathological communication between bladder and vagina is a regular complication of gynecological surgery, particularly simple abdominal hysterectomy. It is not always preventable, and usually occurs in the absence of risk factors[1b] ,[2]. These include the presence of endometriosis, previous surgery on the uterus, particularly caesarian section and conisation of the cervix, and prior radiation therapy[1b].
PRACTICE POINT In the presence of risk factors for urinary fistula during gynecological surgery, look for
1. special precautions to protect bladder and ureters
2. filling of the bladder by catheter to identify damage early.
The bladder may be stretched by faulty operative technique, or unknowingly punctured[3], during dissection from vagina and cervix. The abnormal channel into the vagina then develops postoperatively[3].
Early recognition of damage to the bladder is the key to minimizing complications. During or after surgery the bladder can be filled with dye to identify a puncture site. A combination of symptoms should alert the surgeon to unrecognised injury[3]:
PRACTICE POINT Postoperative indicators of damage to the bladder:
1. severe abdominal pain
2. abdominal distension
3. slow return of bowel function
4. blood in urine
5. irritability of the bladder
Copyright © 2008 Electronic Handbook of Legal Medicine