Legally Speaking: Who perforated this bowel?

Sometimes, even the simplest cases take on a life of their own. When a patient suffers a postoperative complication, but she's had two surgeries by two specialists in a short period of time, the disagreement between those specialists as to how the complication occurred, and in which surgery it occurred, can turn a straightforward "risk of the procedure" case into a medical mystery.

The then 49-year-old patient presented to the defendant ob/gyn in February 2004, with a term-size fibroid uterus with intermenstrual bleeding, as well as elevated blood pressure (BP), and mild anemia. The plan was to do a D&C and cervical biopsy to be followed by a total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). The D&C was performed in March 2004 to rule out endometrial hyperplasia and any other abnormality beyond the fibroids as the cause of the patient's bleeding and it did so.

Although the chart indicated there was a dictated operative note, the only operative note was handwritten by defendant A. The preoperative diagnosis was fibroid uterus and menorrhagia and the postoperative diagnosis was the same, along with pelvic adhesions. TAH/BSO and lyses of adhesions were performed, and according to the anesthesia record, the surgery lasted approximately 2 hours and 30 minutes. The patient was transferred to the gyn floor and remained stable with complaints of abdominal pain.

Two days post-op, the patient's BP was found to be elevated. She was treated, and her BP came under control. She was started on clear fluids, which she tolerated and her abdomen was mildly tender. Overnight, however, she began vomiting, although her abdomen was soft and without distension. The following day she lost approximately 1½ L of fluids through vomiting, and her abdomen became distended with positive bowel sounds. An NG tube was passed and 1 L of bilious fluid was suctioned with some relief of symptoms. An abdominal x-ray on that date was consistent with postoperative ileus versus early partial bowel obstruction.

ON AUGUST 17, a repeat abdominal x-ray revealed dilated small bowel loops, the NG tube was replaced, and renal and surgical consults were requested. At the surgical consult on that date, the consulting surgeon opined that the patient was dehydrated with deficits secondary to increased NG tube output and vomiting, causing electrolyte disturbances and reduced renal function. The differential diagnosis was small bowel obstruction, and once the patient was hydrated with improvement in BUN and creatinine, the surgical consultant planned to take the patient back to the operating room for re-exploration. That evening, the renal consultant felt the renal insufficiency resulted from fluid loss and recommended replacement.

ON AUGUST 19, the patient underwent surgery by the surgical consultant, with a pre- and postoperative diagnosis of small bowel obstruction. According to the operative report, she underwent exploratory laparotomy, lyses of adhesions, repair of enterotomy, and repair of an umbilical hernia. The surgeon's operative note indicates that a "pinpoint" opening was found in an area of small bowel tucked into the left side of the abdomen. Although there was no specific area of transition (of the dilated bowel), these loops of bowel were obviously adhesed and adherent to the left upper abdomen.

Postoperatively, the patient remained in the PACU overnight, and was then transferred to the ICU where she remained for an additional 5 days. She continued to be followed by surgery, renal, gyn, and infectious disease. A peritoneal fluid culture came back positive for gram-negative bacteria and she was placed on antibiotics. Her renal status slowly improved, and the wound was noted by surgery to be approximately 10 inches long with areas of healing both closed and open. She was ultimately discharged home on August 31 and followed for wound care with the surgeon through December of that year, at which time she was fully healed and completely active.