This surgical technology case takes place in Michigan and involves an elderly female patient with a past medical history of bilateral salpingo-oopherectomy, rectocele and cystocele repair with a recurrence of pelvic organ prolapse. To treat these conditions, the patient underwent a bladder suspension and hysterectomy with vaginal prolapse repair. The surgery was performed with the assistance of the DaVinci robot. Intra-operatively, the OB/GYN noted an incisional hernia from a previous surgery and undertook an elective procedure to repair it. He did not gain informed consent from the patient’s husband to do so, and the patient was not informed pre-operatively that there was a potential for this procedure to be performed. During the hernia repair, the OB/GYN included the bowel in the hernia repair and perforated the patient’s bowel,however he did not recognize this in the OR and the patient was closed. The patient subsequently became septic, which was also not recognized by the treating OB/GYN. He cosigned orders that the patient be discharged despite her lack of urine output, hypoactive bowel sounds, and worsening abdominal distention and pain. The patient was not discharged and was subsequently diagnosed with sepsis, peritonitis and intra-abdominal compartment syndrome.
Question(s) For Expert Witness
- 1. How often do you perform the gynecological procedures that this patient underwent?
- 2. What is the protocol for checking for bowel injury prior to closing a patient?
- 3. What is the protocol for gaining informed consent intra-operatively?
Expert Witness Response E-008679
This case is within my expertise. My clinical practice focuses on vaginal surgery, but I participate frequently in combined surgeries involving laparoscopic and abdominal benign GYN surgery, most often for prolapse and/or incontinence. I am trained and certified in DaVinci robotic surgery. If a surgeon suspects an injury to the bowel, then careful inspection of the bowel (“running the bowel”) should be undertaken. Surgeons are generally accorded broad judgment to undertake additional procedures for unexpected intraoperative findings. The decision to consult with family is left to their discretion. The risk of causing a complication as a result of a non-planned procedure is always of concern.