Ms.X , a 45 year old patient, presented
with a 20 weeks size fibroid . She was morbidly obese
,weighing about 90 kg. She had also undergone 2 previous LSCS.
She wanted laparoscopic hysterectomy.
Laparoscopic Assisted Vaginal Hysterectomy
was done for the patient. The surgery was difficult,
considering the size of the fibroid and the adhesions caused
as a result of 2 previous surgeries. The primary trocar was
passed through an intra-umbilical incision. The omentum was
seen to hang like curtains as soon as the scope was put in.
After sufficient adhesiolysis, LAVH was done successfully.
However, post-operatively, the patient had
non-specific abdominal symptoms. She did not have vomiting and
had passed flatus, but on the whole she was not comfortable. A
plain X-ray abdomen did not show multiple fluid levels ,
putting at rest, any thought of serious obstruction.
Ultrasonography showed normal peristalsis and absence of
significant fluid in the abdomen. However, after five days,
she started passing green discharge vaginally. She did not
have any pain, or abdominal distension. As it did not abate,
in view of this unusual finding, it was decided to open the
At laparotomy, on the 7th
post-operative day, the omentum was seen to have linear focal
areas of necrosis. An extensive search through a midline
abdominal incision did not reveal any perforation in the
intestine whatsoever. Histopathology showed fat-necrosis of
A retrospective analysis of the surgery was
done. Robie’s grasper, a rotating bipolar cautery was used to
cauterize the pedicles. Ordinarily, a bipolar cautery allows
current to pass through its prongs only when they are in
contact with the tissue. The current is generated only at the
level of cauterization. Electric current does not arc to the
surrounding tissues as is wont to happen with the use of
unipolar current. When unipolar current is used, the
electrical circuit is completed when the current passes from
the point of cautery to the point where the plate is kept
under the skin of the patient through the tissues in between.
As a result the high electrical current generated arcs and may
pass to adjacent tissues inadvertently. In the case described,
the bipolar cautery used may have had leaks somewhere along
it’s shaft, allowing electric current to pass through it. The
omentum being in touch with the shaft got heated up resulting
To test the fact, a wet mop was kept on the
table, and the shafts of all the bipolar instruments in the
hospital were placed on it one by one with current being
allowed to pass through the prongs on the instrument. It was
seen that while the mop did not get heated up when other
bipolar graspers where placed on it, it did get heated when
the Robie’s grasper was placed on it along it’s shaft.
Conclusion: Retrospectively it is the author’s opinion,
that in such cases, where the only symptom was vaginal
discharge, laparotomy could be averted. Conservative
management could be done, laparotomy being kept as a reserve
procedure for a later date, if and when the patient develops
any serious abdominal problem. Finally, although a good
carpenter does not blame his instruments, a good endoscopic
surgeon should be aware of instrument-related problems for
prompt detection and management of surgical problems.