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Perforated bowel during surgery and post-operative care


Sent to Health Experts February 06, 2006 3:41 p.m.

General Surgeon performed laparoscopic surgery on 69 year old woman with comorbidities of heart disease, hypertension and obesity. A recent CT scan was available for his review showing loops of bowel in ventral hernia were not dilated or obstructed. Patient had no pain from hernia. During repair using mesh (tension) he cut her small intestine 2.5 cm but failed to see it. His surgical report does not indicate that he ran the bowel before closing. Patient had severe 10/10 pain the following day and her Demerol was increased from 25mg to 50mg. She had a WBC of over 116 (granulacytes were 90.9%) and pulse of 100 to 110 where it stayed (her normal pulse was 60-70) and a temperature spike up to 101.5 degrees and pulse oximetry was 91 and blood pressure of 211\86 which dropped to 149/62 in 12 hours. Her glucose had jumped from 94 to 146 mg/dl; serum calcium was low at 8.3 mg/dl and potassium was high at 5.2 mmol. The patient was screaming for more pain medicine when she was awake. The doctor did not prescribe antibiotic except during original surgery(prophylaxis). He ordered flat and erect view xrays of her abdomen on POD#2 which showed Subcutaneous emphysema in right upper quadrant and a few loops of air containing bowel with no signs of bowel obstruction. Nurses notes indicated patient was belching loudly and excessively on POD#1. Surgical report indicated surgeon used Veress needle in the left upper quadrant to create Pneumoperitoneum and 5 mm trocar was introduced. Patient continued to decline and emergency surgery performed on POD#4 after CT Scan finally ordered which showed fluid in the periotoneal cavity and periotinis. Surgeon went back in and admitted in following report he "nicked" the bowel and missed it due to omental fat covering it. Questions: If 69 year old female with abnormal EKG and no pain from hernia was a surgical candidate? (pre-op report by surgeon indicated it was needed to prevent strangulated bowel) but in discharge report referred to surgery as elective. Was it below the standard of care for surgeon to have "missed" a 2.5 cm (almost 1 inch) perforation to small intestine if he ran the bowel or flooded cavity and looked for air bubbles? Shouldn't he have recognized infection on POD # 2 from vitals and nurses notes, and ordered CT Scan? Shouldn't he have ordered CBC, Urinalysis and Chem. tests on POD #2 and #3 which he did not? Patient could not get up due to pain and refused PT. If CT Scan was performed on morning of POD#4 and report dictated at noon, shouldn't surgeon have instructed radiologist for immediate input? Emergency surgery was not performed until approx. 9 p.m. that evening and patient had widespread peritonitis and sepsis. Thanks for your help!

Optional Information:
Female , Age: 69

Already Tried:
Transferred to another hospital ICU for further surgeries; lost most of small intestine; tracheotomy; colostomy and incision still open and healing
Customer (name blocked for privacy)
Status: Closed   Value: $100   
Answer
February 06, 2006 4:00 p.m. (19 minutes and 23 seconds later)
ACCEPTED Check Mark

Hernia repair is performed electively or emergently based on the patient status at the time. It is necessary to perform 'electively' to prevent strangulation which makes it emergent and can make the patient at higher risk for complication. She is a candidate for the surgery if she has not had stroke or mi in past 6 months (abnormal ekg) or unstable rhythm on ekg. The standard of care issue you raise - if he checked for perforation and missed it he is not negligent. He simply missed it . If he did not DOCUMENT that he checked for perforation, even if he always does it, then he did not check for perforation under the law. The law states that if it is not documented then it did not happen(even if you know you did it but forgot to write it down.) Reason for fever on post op day 1 - the first thing that comes to mind is infection - but commonly pt's with dehydration, breathing issue, slow movement of colon will also present with fever. It all depends on the doctor's interaction with the patient at the time - as to what he would have been thinking. I wouldn't necessarily say you had delay in diagnosis of the post op infection, because it takes some time to manifest itself before it can be discovered. As for the ct report - a few hours most likely did not change the outcome of the widespread peritonitis and sepsis. The only point of contention I see is if the first surgical report does not state he checked for perforation - you may have a case. Otherwise the rest of the issues were par for the course and would have transpired similarly over similar time frames for the most part.

__________________
DrStephanie
PictureS. Sarisky DO.  -- Doctor -- 98% Positive Feedback on 505 Health Accepts
board certified family physician 12 yrs
Reply to S. Sarisky DO.
Sent February 06, 2006 5:06 p.m. (1 hour and 5 minutes later)

According to the nurses' notes she had active bowel sounds on the day following surgery. She was having bowel movements on POD 2&3. If she had an infection on POD1 based on lab results and she was screaming in pain and when she was awake saying her stomach was paralyzed and she thought she was going to die, shouldn't the doctor have done more than stop by to visit her once a day while she was asleep? He never prescribed antibiotics until the day of the emergency surgery and did not order a CT scan which would have shown a bowel perforation as opposed to an xray.
Customer (name blocked for privacy)

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