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Complications following bilateral breast reduction, abdominoplasty, and liposuction (03HDC05435)
Download Complications following bilateral breast reduction, abdominoplasty, and liposuction (03HDC05435) (PDF 158Kb)
(03HDC05435, 28 October 2005)
Breast and general surgeons ~ Private hospital ~ Liposuction
~ Bilateral breast reduction ~ Preoperative marking ~
Abdominoplasty ~ Postoperative complications ~ Preoperative
information ~ Cosmetic surgery ~ Visiting surgeon ~ ACC ~ Medical
misadventure ~ Hernia repair ~ Team surgery ~ Limit of competency ~
Documentation ~ Rights 4(1), 4(2), 6(1)(a), 6(1)(b), 6(1)(d),
6(1)(e)
A 51-year-old woman complained about the care provided by a
private hospital when she underwent a bilateral breast reduction
("mammoplasty"), an abdominoplasty with abdominal liposuction, and
liposuction of the upper arms. At the time, the woman weighed
108kg, and had a clinical history of hypertension, depression, and
left-sided sciatica. She had chosen to have three procedures
performed together to save time and the need for repeat general
anaesthetics. Her surgery was performed by two breast/general
surgeons and a locum general surgeon, with assistance from a breast
surgeon visiting from overseas. During surgery, an umbilical hernia
was encountered and repaired. The woman subsequently experienced
postoperative complications (bleeding and infections). She lost
both a nipple and her umbilicus through necrosis, and required
surgery. She subsequently required corrective surgery.
It was ultimately the lead surgeon's responsibility to make a
safe decision to proceed with the surgery on the day. Doctors are
not beholden to their patient's requests to provide clinically
inappropriate services. His decision to simultaneously perform two
major surgical procedures and liposuction was ill-advised and
clinically inappropriate. In relation to this issue, he did not
exercise reasonable care and skill, and breached Right 4(1). The
surgeon's decision to engage two other surgeons to perform the
abdominoplasty and liposuction - even if under his supervision -
was unsafe, unwise, and inconsistent with the Medical Council's
guidelines regarding collaboration and teamwork. In these
circumstances the lead surgeon breached Rights 4(1) and 4(2).
The lead surgeon was responsible for ensuring that appropriate
approval and temporary registration had been obtained to legitimise
the visiting surgeon's attendance and any participation in surgery
on his patients. The decision to allow her to participate was a
breach of Right 4(2). The blood supply to the woman's nipple was
impaired. The lead surgeon failed to perform the bilateral
mammoplasty with reasonable care and skill, and breached Right
4(1).
It was held that the decision to provide upper arm liposuction
should have been made in consultation with a plastic surgeon. The
lead surgeon performed a procedure that was inappropriate for his
patient's circumstances, and did not perform it to an appropriate
standard, breaching Rights 4(1) and 4(2).
Ultimately, each surgeon was responsible for ensuring that the
abdominal surgery was provided with reasonable care and skill,
irrespective of who performed specific aspects. Abdominoplasty was
a major surgical procedure for the woman and, given her weight and
medical history, it was inappropriate to combine it with any other
procedure. Combining it with abdominal liposuction undoubtedly
contributed to the three-month delay in her wounds healing. The
lead surgeon and two other surgeons were held to have breached
Rights 4(1) and 4(2).
A patient's signature on a form is not in itself proof that all
necessary information has been provided in a way that enables the
patient to understand it. The nature of the proposed surgery
(though not all the technical details) must be explained.
The lead surgeon failed to convey a balanced assessment of the
risks and benefits of simultaneous surgery, together with a frank
explanation of the qualifications, responsibilities, and status of
the surgeons who were to be involved. In these circumstances, he
breached Rights 6(1)(a), 6(1)(b), and 6(1)(d).
The lead surgeon should have explained to the woman the results
of her surgery and the nature of her complications, and advised her
of the plan for her postoperative management, including the shared
care arrangement. His failure to provide this information in the
postoperative period was held to be a breach of Rights 4(2),
6(1)(a), and 6(1)(e).
In relation to record-keeping, both the lead surgeon and the
other breast/general surgeon failed to meet the standards expected
of experienced surgeons participating in a major surgical procedure
in a private hospital. Accordingly, they breached Right 4(2).
The lead surgeon and the other breast/general surgeon were
referred to the Director of Proceedings, who issued proceedings
against the lead surgeon. The Health Practitioners Disciplinary
Tribunal found that the lead surgeon failed to gain informed
consent from the woman; failed to maintain adequate records; and
failed to provide adequate postoperative information. The surgeon
appealed the Tribunal's finding of professional misconduct. The
appeal against the Tribunal's substantive decision was allowed, but
only to a limited extent - one finding in relation to a
sub-sub-particular of the charge being set aside. Otherwise, the
Tribunal's substantive findings stand. The High Court substituted a
fine of $5,000 for the $7,500 fine imposed by the Tribunal. Other
penalties imposed by the Tribunal, including a recommendation of a
competence review, were not disturbed on appeal. The Director was
entitled to costs on the appeal, it having been largely
unsuccessful.
The Director did not issue proceedings in relation to the other
surgeon.
Link to Health Practitioners Disciplinary Tribunal decision:
http://www.hpdt.org.nz/portals/0/med0637ddecdp070anon.pdf