14LEGAL MEDICOMAGAZINESponsored by:Endometrial Ablation & Bowel InjuryEndometrial ablation has now firmly established itself as an excellent surgical option to treat heavy periods. There are a number of different automated devices available of which Novasure, using bi-polar radio-frequency energy, is the market leader. All these ablation techniques use different energy modalities to essentially destroy the endometrium, the lining of the uterus. This reduces menstrual blood loss and has been shown in clinical studies to be a safe, effective day case/outpatient treatment.Like all surgical procedures complications, potentially serious can occur. However in studies, endometrial ablation has a much lower complication rate than hysterectomy. The most serious complication occurs if the uterus is perforated, during initial dilation of the cervix or during the placement of the device, bowel injury can occur and the patient may present with life-threatening peritonitis.Without prompt treatment usually involving a laparotomy and sometimes a stoma the patients life may be threatened. Patients typically have a stormy post-operative course on ITU but thankfully generally recover. A claim generally follows alleging breach of duty.Having participated in ablation studies, and in the past consulted with manufacturers, during the regulatory process to allow these devices to be used in routine clinical practice, the manufacturers devise a very clear and concise protocol – Instructions For Use (IFU) which is robustly tested in clinical trials. The IFU lists which patients are suitable, and not suitable for each specific ablation procedure and gives a clear UPDATE IN SELECTED GYNAECOLOGY MEDICO-LEGAL ASPECTSBy Mr Ellis Downes FRCOG, Consultant Obstetrician and Gynaecologiststep-wise guide as to how the procedure should be performed.If a complication occurs during endometrial ablation, and it can be shown the surgeon has deviated from the IFU and introduced their own procedures 'that’s how I do it', then the case is impossible to defend and prompt settlement is recommended.Montgomery Principle and GynaecologyAll readers will be intimately familiar with the Montgomery Principle, initially developed following a sad obstetric complication. This firmly established that doctors have a duty to discuss all treatment options with patient, including their risks and benefits, to allow the patient to decide which treatment modality they prefer.When instructed by a legal colleague following a surgical mishap, one of the first parts of the records I turn to are the outpatient notes where the patient is initially assessed following a GP referral, examined, and a treatment plan formulated. All too often I see poor documentation by the doctor of management options, this makes defending a subsequent problem much more challenging.A recent instruction was of a case of haemorrhage after a vaginal hysterectomy performed for heavy periods. The patient needed repeat surgery to stop the bleeding, had a six unit blood transfusion and a prolonged stay in hospital. The claimant, assisted by her legal team and expert, argued that alternative treatment options were not discussed with her, and had they been so, she would not have chosen a hysterectomy. The poor documentation made this point difficult to defend and a settlement was negotiated.Ellis Downes FRCOG is a Consultant Obstetrician and Gynaecologist based in London. He has an active clinical practice, specialising in endoscopic surgery and urogynaecology. He receives over thirty instructions annually and is a member of The Faculty of Expert Witnesses (FEW).