The patient presented to the defendant hospital gyn clinic on May 6, 2015. She reported continuous bilateral pelvic pain in the right and left quadrants somewhat relieved by oral contraceptives, but said she was taking ibuprofen “around the clock.” She was examined by Dr. A, counseled regarding treatment options, given a referral for magnetic resonance imaging (MRI) and told to follow up in 3 weeks to
discuss whether surgery was indicated. In a Progress Note, Dr. A indicated that she discussed the causes of pelvic pain with the patient, advising her she likely had endometriosis for which an MRI could determine the extent of the disease and surgical planning.
An MRI done on May 21, 2015 revealed bilateral endometriomas. A left hematosalpinx/hemosalpinx or pelvic endometrial implant also was noted posterior to the uterus.
The patient was seen by Dr. A to discuss the results of her MRI. She reported she was still taking ibuprofen “around the clock,” and was requesting surgery as both she and her family felt the pain was directly affecting the quality of her life. Dr. A documented that she discussed the surgical approach, risks, benefits and alternatives with the patient and her family.
The patient presented for surgery on June 16, 2015. Dr. A’s Preoperative Note listed the indications for surgery as a history of dysmenorrhea, pelvic pain, bilateral cysts, and suspected endometriosis. The patient and Dr. A executed a Surgical Consent authorizing the performance of a hysteroscopy, dilation and curettage, laparoscopic bilateral ovarian cystectomy, possible salpingectomy, treatment of endometriosis, and possible cystoscopy. Hysteroscopy revealed a normal uterine cavity with some discoloration in the endometrium and possibly adenomyosis. Both ovaries were adherent to pelvic sidewall and the posterior cul de sac, peritoneum, and on the uterus. A 3-cm uterine mass was noted on the posterior superficial myometrium of the uterus, and the rectum was pulled to the mass. Endometrial curettings were obtained from the posterior uterine wall and sent to pathology.
The laparoscopic portion of the procedure was performed via umbilical incision. Two right ovarian cysts were incised, enucleated, and removed. Hemostasis was secured. The left ovary was mobilized from the pelvic side wall with hydrodissection; a left ovarian chocolate cyst was incised, enucleated, and removed. Hemostasis was secure. Adhesions from the posterior uterus to the rectosigmoid colon were taken down with hydro dissection and blunt dissection. The posterior uterine mass, which was about 3 cm, was grasped using the laparoscopic shears; the serosa was electro-dissected and the mass removed using a specimen bag. Peritoneal lesions were excised from the right uterosacral ligaments and posterior cul-de-sac using traction and hydrodissection. Chromotubation with methylene blue was performed and spillage noted from the left fallopian tube. No spillage was noted on the right side.
At the conclusion of the procedure, Dr. A. noted: “...air was pushed into the rectum with a syringe. The pelvis was then filled with irrigation fluid and no air leak was identified upon filling the colon with air. Evicel was placed over the operative sites and peritoneal dissection sites with excellent hemostasis noted. Ancillary ports were removed with decreased pneumoperitoneum and there was no bleeding.”
On admission to the Postoperative Acute Care Unit (PACU) at 4:20 PM the patient’s vital signs were stable. Surgical incision was well-approximated with scant serosanguinous drainage.
At 5:00 PM, an RN noted the patient’s complaints of abdominal pain/discomfort at 6/10 intensity. Fentanyl 25 mcg intravenous (IV) push was given. By 5:15 PM the patient reported only partial relief from fentanyl and complained of 6/10 abdominal pain. At 5:30 PM her vital signs were blood pressure (BP) 119/77, pulse 105, and an additional dose of fentanyl (25 mcg IV push) was given. By 5:45 PM relief was obtained, with the patient’s pain at 2/10. At 6:00 PM the patient complained of continuous nausea. Palpation of her abdomen revealed all quadrants as soft and non-tender. No drainage from the incision was noted. Promethazine 6.25 mg IV was administered. By 6:30 PM the patient reported relief of symptoms.
At 7:00 PM the patient denied any pain or discomfort; her abdomen was soft and non-tender and there was no drainage from the incision. At 7:30 PM she was out of bed to the bathroom. At 8:00 PM the patient again complained of abdominal pain at 6/10 intensity. Her vital signs were 121/62, pulse 74, temperature 97.7°F. She was medicated with fentanyl 25 mcg and oxycodone 5 mg orally. By 8:15 PM the patient reported partial relief, and by 8:45 PM, confirmed relief of pain (with a rating of 2/10 at rest and activity) at which time she voided 400 mL. At that time, her vital signs were 110/65, pulse 88. At discharge, she was instructed to notify her physician about persistent vaginal bleeding, nausea or vomiting; inability to urinate or a fever greater than 100.4°F; and to follow up in the clinic on July 8. The patient left the hospital at approximately 9:00 PM accompanied by family.