This case involves an 80 year old female patient with past medical history of hypertension, Crohn’s disease, cystocele, rectocele, vaginal vault prolapse and stress incontinence. She underwent a transvaginal, posterior repair with tension free vaginal tape and adhesiolysis. The operative notes state that there were significant intraabdominal adhesions between the small intestine and the anterior abdominal wall, and the small intestine and pelvic structures. On post-op day 2 the patient developed nausea and vomiting as well as fever. She soon became tachycardic, tachypneic and her Os sats dropped to the lower 90s. She was transferred to the ICU where she received IV fluids and Zosyn. CT of abdomen revealed subcutaneous emphysema along her abdominal wall extending from the symphysis pubis bilaterally. Additionally, there was fluid in the pelvis as well as free air around the bladder and bilateral atelectasis of the lower lobes. IV vancomycin was started. At 3 days post-op, a colonic injury was recognized and the patient was returned to the OR for celiotomy. Operative notes indicate perforation, iatrogenic, of small bowel with contamination of the intra-abdominal cavity with succus entericus. Following drainage and resection of part of the small intestine, she appeared to be improving. On post-op day 6 it was noted that there was bilious drainage from the chordal confines of the surgical wound. She was returned to the OR. Post op diagnosis was bile/bowel peritonitis with leaking bowel. There was re-exploration the following day and further drainage and washout was performed. The patient ultimately expired due to sepsis on post-op day 30 following a prolonged hospital stay.
Question(s) For Expert Witness
- 1. Do you routinely treat patients like the one described in this case?
- 2. How important is it to return the patient to the OR emergently when signs of infection develop?
Expert Witness Response E-008679
This is an elderly patient with inflammatory bowel disease undergoing what is described as a vaginal repair of prolapse and incontinence. In the middle part of the case abstract it describes findings that could only be obtained from a laparotomy or laparoscopy which would not generally be included in a vaginal repair of prolapse and incontinence. Either there was another problem for which she required abdominal surgery, or they suspected bowel injury at the time of the case and decided to open in order to explore further. Although bowel injury from a retropubic mid-urethral sling is a recognized complication, it is difficult to understand how they missed exactly the complication they were likely concerned about during an open or laparoscopic exploration of the abdominal cavity. There are definitely multiple questions here about what happened in this initial surgery. Given her age and significant medical comorbidities, unfortunately it is not surprising that she succumbed to the resulting infection and metabolic arrangements from bowel perforation.
Expert Witness Response E-005509
Bowel injury at the time of surgery can be very tragic. Once they are suspected or identified stabilizing the patient and containing and repairing the injury is required. Some concerns I have of this case; Why did they enter the intrabdominal space at all to correct her prolapse? The recognition of the injury is crucial especially when she was septic after a routine case. I have reviewed cases similar to this. I have personally treated a similar patient who was injured by a colleague.