Intraoperative Rare Complication of Excision of a Large Loop Transformation Zone

Myat San Yi¹*, Ei Mon Mon Kyaw¹, Soe Lwin³, Mon Mon Yee²,

Tin Moe Nwe³, Khin Than Yee³

¹Suri Seri Begawan Hospital, Kuala Belait, Brunei Darussalam.

²Newcastle University Medicine Malaysia, Johor, Malaysia.

³Royal College of Medicine Perak, Universiti of Kuala Lumpur, Ipoh, Malaysia.

*Corresponding Author E-mail: myatsanyee@gmail.com

ABSTRACT:

The case study discussed patient oriented quality care can enhance patient safety and increase the competency of healthcare professionals, even when they follow standard operating procedures and deal with unforeseen complications in performing LLETZ. This case report aims at validating the qualitative routine procedures against rare and complicated cases of LLETZ. The case concludes that every surgery should be performed carefully and properly to avoid unnecessary aftereffects in order to maintain efficient quality control. Simple and normal procedures were carried out by surgeons performing to the best of their abilities, competently, and with careful attention to patient safety. Though complications arose and were difficult and uncommon, the trained professional successfully navigated the procedure in such circumstantial emergencies.

KEYWORDS: Large Loop Excision of Transformation Zone, Cervical intraepithelial neoplasia, Loop Electrosurgical, Excision Procedure (LEEP).

INTRODUCTION:

Since its creation by Dr. Sheldon Weinstein in the 1970s, the Large Loop Excision of Transformation Zone (LLETZ), a type of surgery that removes a small portion of the cervix to treat cervical cell alterations, has been shown to be very effective, reduced blood loss, and inexpensive^{1, 2}.

One of the literature reveals the technique of LLETZ, a new method of management for women with an abnormal cervical smear which offers the advantages of conization with those of local destruction.³A large loop of thin wire forms a diathermy electrode that allows deep excision of the transformation zone with minimal tissue damage. The tissue removed can be examined histologically.

It is accepted by most clinicians as a safe, user-friendly out-patient procedure. It rose to its fame with the concept appearing to provide the most reliable specimens for histology with the least morbidity^4.Evidence based thoughts of literature states that Large-loop excision of the transformation zone (LLETZ) is popular treatment for women with cervical intraepithelial neoplasia (CIN) before long-term effectiveness and safety have been fully evaluated. LLETZ is also effective when used as a repeat procedure^.The advantage of this procedure far outweighs the risk and its success rate is around 90%. The post-operative morbidity is unremarkable in most cases. The complications are infection, bleeding, abnormal vaginal discharge and preterm labour in the long-term. Cervical incompetence and cervical stenosis are recognized outcomes in future. It is a case report on LLETZ with a rare intraoperative complication which we encountered in our practice.

The case study on how superior care can enhance patient safety and enhance the competency of healthcare providers even when using standard operating procedures on rare and intricate Large Loop Excision of Transformation Zone (LLETZ). This case study supports the ideas that, while a straightforward and routine procedure may encounter an uncommon complication at any time, the medical team's professionalism and their ability to be open, truthful, and forthright uphold their duty of condour and can gradually reduce mishappenings and prevent morbidity.

CASE:

Large Loop Excision of Transformation Zone, where the clinician managed intraoperative complication of LLETZ with routine procedure rare though it is a rare and complicated case. A patient R, 44 Yr, P5 with CIN 2 who opted for LLETZ procedure. During the procedure- LLETZ loop excised the whole posterior lip as well as it perforated the posterior vaginal wall at POD. Doctors proceeded with immediate action at that time was to proceed with posterior vaginal wall repair to save bleeding and prolapse of intestines through POD. Following a laparotomy/hysterectomy, intraoperative findings showed that the anterior lip was the only remnant remaining after the cervical segment had been cut in half obliquely. The HPE results verified that the right ovary's cystic mature teratoma and CIN 2 were clearly removed from the margin. The remnant of the cervix (the anterior lip) was unable to be identified after this complication happened.

AIM AND OBJECTIVE:

The aim of this case report is to share the author's experience and to raise awareness of this rare and intraoperative complication encountered in their practice.

To share their views on confronting rare complications in patient condition arose when the medical team proceeded with simple and routine procedure.

CASE PROCEEDINGS AND DISCUSSION:

Patient R, 44 years female, P5 with CIN 2 opted for LLETZ procedure. In this case patients cervix was small and during the procedure, the LLETZ loop excised the whole posterior lip along with the posterior vaginal wall, resulting in a perforation at Primary Pouch of Douglas (POD). The remnant of the cervix (the anterior lip) was unable to be identified after this complication happened. Through that perforation at POD, a mobile mass was felt at the upper part of the pelvis. No gut was felt and assumed that there was no thermal injury to the gut, the mobile mass felt through POD might be the free end of the uterus.

Immediate and timely action was taken by informing theater team members, anaesthetist and gynaecologist (consultant) to proceed with posterior vaginal wall repair to secure bleeding and prolapse of intestines through POD perforation. And the excised cervix part was sent for laboratory examination.

Here the medical team confronted with challenging issues that concerned with how to proceed for the further post-LLETZ follow-up as the cervix could not be identified even though it was not excised completely. Here in the aftermath of existing challenging conditions of patient professionals the medical team proceeded and performed their duty of candour considering what is best for the patient. Proceedings continued with CT scan, which revealed a right ovarian cyst likely dermoid of 4.3 x 6 cm. Uterus was at its normal site.

Without any delay the professional team came out with timely decision and proceeded with a laparotomy with or without hysterectomy aiming to confirm the extent of the injury, to excise the remaining cervical tissue (in view of CIN2), to restore the proper vaginal vault for further follow-up, and to remove the right ovarian cyst.

Intraoperative findings indicated that Cervix was sliced into half obliquely and the anterior lip was the only remnant left behind. It was too small to get recognized by a vaginal examination. Regarding the perimenopausal age with the diagnosis of CIN2 along with incomplete excision on LLETZ and the ovarian cyst, hysterectomy was performed with patient’s consent. Proper vault closure was made abdominally for future follow-up.

The histopahthological examination (HPE) results confirmed the margin was clearly excised with CIN 1 and cystic mature teratoma right ovary. Uterus found normal.

In this case the complication was resolved with a two-step procedure as there was no prior knowledge of the right ovarian cyst. In this situation the medical professionals made a wise and justifiable decision to confirm the diagnosis with a CT scan before surgery. Hysterectomy was performed in view of restoring vault abdominally, excising the remaining cervical tissue and tackling incidental finding of right ovarian cyst at perimenopausal age.

CONCLUSION:

A simple and routine procedure can also arise a rare complication. Each and every surgery should be conducted carefully and thoroughly to avoid unnecessary aftereffects. Competency and safety of the patient are interrelated and once the complication arises, it should be corrected in the best interest of the patient. Duty of candour needs to follow in any mishaps. Learning curve has to be fulfilled systematically and gradually to avoid morbidity. This fact has been demonstrated in the current case, which shows that surgeons who gave their all, competently, and with careful attention to patient safety performed simple and routine procedures; even so, when a challenging and uncommon complication emerged, the specialists were able to succeed the surgery in such circumstances.

CONFLICT OF INTEREST:

There is no conflict of interest between authors.

REFERENCES:

1. Darby A. Loop Electrosurgical Excision Procedure (LEEP), embryo.asu.edu. Retrieved 2023-11-16.

2. Kornovska YI, Tomov ST, Yordanov AD. LLETZ procedure in an outpatient setting: applicability and cost-effectiveness. Journal of Biomedical and Clinical Research. 2022; 15(1): 58-64.

3. Prendiville W, Cullimore J, Norman SU. Large loop excision of the transformation zone (LLETZ). A new method of management for women with cervical intraepithelial neoplasia. BJOG: An International Journal of Obstetrics and Gynaecology. 1989 Sep; 96(9): 1054-60.

4. Martin‐Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO, Keep SL. Surgery for cervical intraepithelial neoplasia. Cochrane Database of Systematic Reviews.

Received on 15.06.2024 Modified on 11.07.2024

Research J. Pharm. and Tech 2024; 17(8):3945-3947.

DOI: 10.52711/0974-360X.2024.00612