Appendicitis

1. Colitis – UC/Crohns Cancer Appendicitis Diverticulitis Rectal prolapse Obstetric sphincter injury Anal fistula

2. Appendicitis Diagnostic delay Liability – General Practice, A&E, Colorectal Surgery (resources) Causation – varying biology of inflammation progression not all perforation is avoidable Stump appendicitis

3. Colitis Ulcerative Colitis Acute colitis Daily Consultant gastroenterology and colorectal surgery review Emergency Colectomy technique – management of the rectal stump Cancer surveillance 1-5 yearly colonoscopy after 10 years with disease – depending on severity Surgery for low/high grade dysplasia Pouch Surgery poor result acceptable, unless wrong Pouch configuration Crohns Disease Resection Timing of surgery in the course of medical management Complications usually acceptable - criteria for/against anastomosis Missed anal Crohns Disease – the patient with repeated anal abscess/fistula procedures

4. Cancer Delayed Diagnosis remember the long (10-year) adenoma to carcinoma progression a missed polyp 7 years ago – probable large survival benefit 3-month delay in cancer diagnosis – probable small survival benefit Cancer Surgery anastomotic leak usually acceptable, but look at the technical detail ureteric injury usually unacceptable consent for surgical excision after complete chemo/RT rectal cancer response

5. Diverticulitis Missed diagnosis as appendicitis or urinary infection, with wrong subsequent treatment Delayed diagnosis Sometimes the liability is GP or A&E, rather than colorectal surgery The young patient with frequent (unrecognised) attacks Causation depends on Hinchey grade and may be controversial Hartmans Procedure poor outcomes are frequent incisional hernia failure to reverse colostomy necessary for Hinchey 3/4, usually avoided if Hinchey 1/2

6. Rectal Prolapse Laparoscopic Ventral Mesh Rectopexy Specific indications, usually after failed conservative treatment Early published results were more encouraging than recent longer term results Poor patient selection, earlier LVMR recommendation in private patient context ongoing pain or defecation disorder Concerns about the variety of mesh used are usually not justified

7. Obstetric-related anal sphincter injury Causation simple if the injury would have been avoided but for obstetric liability, more complicated where the obstetric liability is a failure to primarily repair the tear Secondary/delayed repair Primary repair 39.4% “incontinence” at 12 months 51% “incontinence” at 78 months Incontinence would have been less severe if primary rather than delayed repair – based on individual case circumstances

8. Anal fistula Fistula anatomy (including on MRI scan report) not properly identified/described Management left to inexperienced staff who do the wrong operation/s Causation difficult because there will be some incontinence with acceptable treatment unacceptable treatment may result in months or years with perianal sepsis/wounds, and sphincter incontinence