This case involves a middle-aged male patient who suffered complications after undergoing a robotic-assisted prostatectomy in order to treat early-stage prostate cancer. The surgery was performed with the assistance of a da Vinci robotic surgery system, which was noted to have taken place without complications. However, unbeknownst to the operating physician, the patient had suffered a perforation of his small bowel during the course of the procedure. Several hours after the conclusion of the procedure, the patient began to complain of severe abdominal pain. In response, the patient was moved to the intensive care unit, where it was noted that his condition continued to deteriorate. It was eventually discovered that the man had developed a serious infection as well as sepsis, forcing the man to remain in the hospital for several months and to undergo extensive rehabilitation for the better part of a year.
Question(s) For Expert Witness
- 1. Do you routinely treat patients similar to the one described in the case?
- 2. Have you ever had a patient develop the outcome described in the case?
- 3. What is the proper follow-up protocol following prostatectomy by way of da Vinci surgery?
- 4. Should the surgeon have checked for leakage prior to closing?
Expert Witness Response E-014220
This is a clear case of an intraoperative unrecognized bowel perforation during robotic assisted laparoscopic prostatectomy (RALP). The result of this complication and delay in diagnosis in the post-operative period led to a prolonged recovery of several months, compared to a normal recovery of a few weeks following RALP. I routinely manage men with locally advanced prostate cancer with surgery (i.e. RALP) similar to the case described above. I have not experienced a bowel perforation any of the RALP I’ve performed. Bowel injury is an accepted intraoperative complication for any conventional/robotic assisted laparoscopic surgery in the abdomen and/or pelvis, i.e. RALP. They usually happen at three points of the operation. The time when the pneumoperitoneum is being established either with Veress needle or Hassan technique, placement of the laparoscopic ports in the abdomen, and during difficult dissection involving bowel (such as lysing bowel adherent to the abdominal wall). Patients with a history of prior abdominal surgeries, and intraabdominal infection or bleeding are at higher risk for bowel injury in these types of surgeries. However an unrecognized injury to bowel during laparoscopic surgery, like RALP, would be regarded as a deviation from the standard intraoperative care. The generally accepted protocol in confirming bowel integrity is to carefully inspect the intra-abdominal contents that are in close proximity to the site where the pneumoperitoneum is established and where the ports are placed. Also, if there is any dissection of bowel performed in the procedure that segment of bowel needs to be thoroughly inspected.