This case involves a female patient in Hawaii who underwent a total hysterectomy in response to a uterine cancer diagnosis some months prior to the date of the incident in question. The surgery took longer than expected, as the operating surgeon took occasional tissue samples from the patient and sent them to pathology in order to gauge the extent of the cancer. As a result of the delays this process caused, the patient was kept in a surgical position that had a known risk of peripheral nerve injury for an extended period of time. Reports from the operation noted that devices typically used to minimize the risk of injury were not used, and the patient’s position was not shifted or otherwise altered over the course of several hours. When the patient woke up, she immediately noticed weakness and loss of sensation in her leg. The patient continued to suffer from a loss of leg function after the surgery, which forced her to quit her job in retail service.
Question(s) For Expert Witness
- 1. Do you routinely provide anesthesia for hysterectomies?
- 2. Have you ever had a patient develop this outcome?
- 3. What measures should be taken to prevent nerve injuries to patients during this procedure?
Expert Witness Response E-009321
I routinely provide anesthesia for hysterectomies – both trans-abdominal and vaginal. I have never had a patient sustain a nerve injury of this nature. Typically, for a vaginal hysterectomy, the patient needs to be in stirrups. We use padded leg rests that avoid the possibility of metal from so-called “candy cane” supports compressing the common peroneal nerve and causing foot drop. Femoral nerve injury has only been described in a few cases of vaginal hysterectomy. It is much more common in abdominal hysterectomy, where the mechanism of injury is from the compression of the nerve between the self-retaining retractor and the pelvic wall. In this position, it is a much rarer complication that is thought to result from excessive flexion of the thigh leading to abduction and rotation of the hip joint beyond 45 degrees. It is believed to be more common in thinner women, those with diabetes, or those who are smokers. The course is usually self limited.
Expert Witness Response E-001455
I do provide anesthesia for patients undergoing hysterectomies. In private practice this was a routine procedure I provided anesthesia for: the important issue here is the lithotomy position. It is well documented in the literature that this position places patients at increased risk for peripheral nerve injury. Therefore, positioning is paramount and must be well-documented. Thankfully, because of careful positioning, I’ve not had a patient with this complication. I have been a clinical anesthesiologist for 20 years and have practiced in both private and academic settings, however more than 90% of my time is spent as a clinician.