Gynaecological impasse could trigger
May 14, 2011
A STANDOFF between specialists at Auburn Hospital could prompt changes to how gynaecological surgery is performed across NSW.
The escalating row, over a ban on a surgical device, is being closely observed by NSW Health, which will assess whether state-wide action is needed.
Two women have already been transferred from Auburn for emergency gynaecological procedures at Westmead Hospital, where the instrument – the Veress needle, which creates an opening for laparoscopic or keyhole surgery – can still be used.
The Auburn Hospital executive medical director, Geoff Brooke-Cowden, confirmed he had vetoed the Veress needle, used by most gynaecologists, saying it was unsafe.
At least two women have died since 1994 in NSW from accidents in which the Veress needle was a factor, he said, and another three had been seriously injured, including two at Auburn.
”I made the decision after the second incident,” said Associate Professor Brooke-Cowden, a general surgeon. ”I decided it was preventable and it wouldn’t happen again at my hospital. If it comes to an issue of patient safety I will act at every stage. It’s got nothing to do with personal prerogatives or fiefdoms … I think [the ban] should be applied across the state.”
The doctor must forcefully pierce the abdomen with the 12-centimetre Veress device, the blade of which then retracts. The cavity is then inflated and a surgical blade is introduced, followed by a camera.
The camera’s delayed insertion increased the likelihood of unnoticed injury to the bowel or blood vessels, Professor Brooke-Cowden said.
An alternative technique now recommended at Auburn, the Hasson cannula, was, ”put in under direct vision,” and without force, Professor Brooke-Cowden said, and had not been linked to injuries.
But gynaecologist Greg Jenkins, a visiting medical officer at Auburn, said the Veress ban was heavy-handed and doctors were, ”being forced to undertake a technique we’re not entirely comfortable with”.
The situation had resulted in ”patients with acute problems and in significant pain having their procedure delayed” by the transfer to Westmead eight kilometres away.
”I believe all entry techniques carry a degree of risk and each [doctor] is best to use the technique they are most familiar with,” Dr Jenkins said.
The chairwoman of the women’s health committee of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Louise Farrell, said the Veress needle was ”a safe entry technique in trained hands”. She agreed surgeons could see less with the Veress needle but said the Hasson technique carried a risk of internal scarring. ”There’s a tradeoff,” she said.
The Veress technique should not be used in very overweight or underweight women, she said, or after previous surgery that might have tethered the bowel to the abdominal wall.
A spokesman for the Royal Australasian College of Surgeons, Guy Maddern, agreed doctors using the Hasson technique were more likely to recognise an inadvertent injury, but said a ban on the Veress needle was ”inadvisable”.
An 2008 international review by the Cochrane Collaboration found research evidence was too limited to ”confirm safety of any particular technique”.
A spokeswoman for Western Sydney Local Health said the area was ”working closely with the relevant experts to ensure that available medical evidence informs decisions about using veress needle techniques”.
A NSW Health spokeswoman said current evidence supported the Veress needle. But the department would monitor the western Sydney deliberations, ”to see if any action needs to be taken at a state level”.