An obese man of 41 was admitted for varicose vein surgery and the operation was delegated to an SHO assisted by a surgical registrar. While dissecting the sapheno-femoral junction during the Trendelenburg procedure, severe bleeding was encountered. A tear was found in the medial aspect of the femoral vein close to its junction with the saphenous vein. Under the supervision of the consultant surgeon, the registrar repaired the lesion with a continuous catgut suture. The haemorrhage was completely controlled and the registrar did not feel that he had produced any narrowing of the blood vessel.
Within a week the patient's thigh was swollen and tender along the lines of the long saphenous and femoral veins. A probable deep venous thrombosis was diagnosed and anticoagulants were given, initially heparin and later warfarin. The patient was reviewed at intervals and the anticoagulants were continued for three months, but the leg was still swollen and painful six years later when the patient was examined independently in connection with his claim for compensation.
The MDU's surgical adviser was critical of the patient's care on a number of points:
- The delegation of an obese patient to relatively inexperienced surgeons.
- The damage to the femoral vein.
- The consultant's failure to scrub up and take over the repair personally.
- The choice of suture material - catgut causes an intense tissue reaction and is generally unsuitable for vascular repairs.
- A patch graft repair of the tear would have been better than a simple continuous suture.
- When the diagnosis of deep venous thrombosis was made, urgent venograms should have been done to assess potential narrowing of the vein and to provide a basis for a referral to a vascular surgeon for reconstructive surgery:'by treating conservatively with anticoagulants, the chance was lost to avoid permanent damage to the venous drainage from the leg.'.
For all these reasons, the health authority agreed that the claim should be settled. It became clear that the relatively young patient was considerably handicapped by all the symptoms and signs of chronic deep venous insufficiency, with an increased risk of recurrent deep venous thrombosis or superficial thrombophlebitis and that he was at a marked disadvantage on the labour market.
Settlement was negotiated for £97,000 as an immediate but provisional award, with a rider that the patient could apply for additional damages if he developed any of the following prior to his 65th birthday:
- Chronic ulceration of the leg.
- Skin carcinoma or other malignancy of the leg.
- Pulmonary embolism.
- Deep venous thrombosis.
- The necessity for surgical amputation of all or part of the left leg.
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