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15LEGAL MEDICOMAGAZINESponsored by:Laparoscopic Surgery ComplicationsOver the last few years there has been a significant rise in laparoscopic surgery in gynaecological practice. Open procedures (laparotomies) are now performed much less commonly. At laparoscopy, instruments are used with the assistance of a video camera to allow surgical procedures to be performed. To enter the abdomen involves placing a special needle through the umbilicus, inflating with carbon dioxide to distend the abdomen and then inserting surgical trochars into the abdomen, this method (known as the 'Veress needle technique') is the commonest in UK gynaecological practice. It will be understood therefore that the initial insertion of the veress needle, to distend the abdomen, and umbilical trochar to allow the laparoscope to be put into the abdominal cavity are essentially blind techniques. While inserting the instruments into the abdominal cavity initially, bowel, bladder or even major blood vessels may be damaged. This may cause life-threatening injuries which need rapid corrective treatment. For a straightforward diagnostic laparoscopy the risk of bowel injury is in the order of 1-2 per thousand patients, for more advanced operative laparoscopies 5-8 per thousand.Evidence based guidelines have been developed by the Royal College of Obstetricians & Gynaecologists (RCOG) and the British Society of Gynaecological Endosccopy (BSGE) detailing the techniques for entering the abdomen which have been shown to be the safest with the lowest risk of complications.Generally speaking if the surgeon has used a recognised technique and has a complication on initial entry, this is defendable. Once a pneumo-peritoneum has been established and the initial umbilical port has been safely inserted, if there were any complications during insertion of additional (accessory) ports, this is indefensible.Mesh in GynaecologyThe story of mesh in gynaecology is a tragic one which has affected many women. In trying to develop new ideas to help treat vaginal prolapse, a growing clinical problem which can be challenging to treat, medical device manufacturers five to ten years ago introduced a range of meshes to be used surgically to help reinforce weak vaginal tissues during the prolapse repair. These meshes were often introduced with minimal research studies and 'similarity' regulatory approval.Sadly they had a high complication rate of erosion, vaginal discharge, painful sexual intercourse or damage to bladder and or bowel. Most of these meshes have now been withdrawn from the market. I have been instructed on a number of cases of mesh related complications, the vast majority of which were settled in favour of the claimant.In UK practice currently, I believe there is virtually no role in their use for first time (primary) prolapse surgery. For patients who develop a subsequent prolapse after surgery, needing repeat surgery, some meshes may have a limited role to improve long-term outcomes.The prolapse mesh controversy should not be confused with the mesh used to treat bladder incontinence via the sub-urethral approach. The tension free vaginal tape (TVT) is one of the commonest procedures performed to treat urinary stress incontinence. This mesh is much smaller and narrower than prolapse meshes and has a much lower complication rate, although erosion may still occur.