Bowel perforation following salpingectomy

June 1, 2014

A bowel injury during salpingectomy leads to septic shock and amputation. What went wrong?

 

MS. COLLINS is an attorney specializing in medical malpractice in Long Beach, California. She welcomes feedback on this column via e-mail to dawncfree@gmail.com.

Facts

A NEW YORK WOMAN underwent a salpingectomy in 2009 due to an ectopic pregnancy. She was age 29 at the time. The procedure was performed by a resident under the supervision of an attending gynecologist. The patient developed abdominal pain after the surgery but she was discharged after 2 days. She returned to the hospital the next day due to severe pain and was readmitted with a presumptive diagnosis of small bowel obstruction. Two days later she was in septic shock and had exploratory surgery, during which a perforation of the sigmoid colon was found. The woman underwent extensive treatment and developed complications and ultimately gangrene in her lower legs, requiring amputation of the lower portion of each leg.

The patient sued all those involved with her care and claimed the perforation occurred during the salpingectomy and should have been detected at that time. She also contended that the resident was not  properly experienced to perform that procedure. The patient also alleged she was suffering with a distended bowel at the time, which increased the likelihood of a perforation. She further claimed that her postoperative symptoms were not properly recognized and she was prematurely discharged; the exploratory surgery was not performed in a timely manner; and that the amputations could have been avoided with prompt diagnosis and treatment.

The surgeon and his practice reached a settlement during trial for $2.3 million. The other defendants argued that the colon perforation might not have occurred during the salpingectomy and could have developed after the procedure. They also claimed that sepsis was a known risk of the surgery about which the patient had been informed.

The verdict

A jury returned a verdict for the patient and assigned 40% liability to the hospital and the rest of the 60% to five other physicians, including the resident and attending who performed the salpingectomy. The award for damages was $62 million.

Claim that surgery for rectocele was unnecessary

Facts

IN 2006, A NEW JERSEY WOMAN went to a hospital at age 62 for an operation to correct a rectocele. The procedure was performed by a gynecologist, who was precepted by another gynecologist because this was his first surgery using mesh. Two days later, the patient exhibited symptoms of septic shock and was diagnosed with perforation of the rectum.

A diverting colostomy was performed, but the patient had continuing infections and ultimately required 14 operations with multiple complications, including bowel obstructions, hernias, and abscesses. The woman contended that scarring caused her to be unable to engage in sexual activity, which led to the end of her marriage.

In the lawsuit that followed, the woman claimed that the rectocele surgery should not have been performed and that she had no symptoms indicating that she even had a rectocele. She alleged lack of informed consent for the procedure.

The physicians claimed that the surgery was necessary and that the patient did have a rectocele with progressing symptoms. They also contended that the patient had been fully informed regarding the risks and benefits of the procedure and possible complications.

The verdict

A defense verdict was returned.

 

 

Negligent removal of vaginal packing alleged

Facts

A KENTUCKY WOMAN was 41 years old when she underwent a hysterectomy performed by her gynecologist in 2010. Eight hours after the operation, when a nurse removed the vaginal packing, some bleeding was noted and the incision was found to be disrupted. The patient was returned to the operating room for resuturing of a small area of the incision. The woman sued those involved with the initial operation and alleged negligence in aggressively removing too much packing too soon after the surgery.

The hospital claimed that bleeding is a known postoperative complication and that the second procedure was very minor and required just a few sutures.

The verdict

A defense verdict was returned.

Bowel perforation follows hysterectomy

Facts

IN 2008, A SOUTH CAROLINA WOMAN underwent a laparoscopic-assisted vaginal hysterectomy, which was performed by a gynecologist. The patient was discharged home the following day. Two days after discharge she went to an emergency department in acute distress. A bowel perforation was diagnosed and a second operation was performed to repair her colon. She made a full recovery following this surgery.

The woman sued, alleging negligence by her doctor in failing to properly examine and evaluate her after surgery. She also alleged negligence in the failure to explain the signs of a possible perforation to her before discharge.

The physician denied any negligence and maintained that the patient’s postsurgical course was normal when she was discharged and that a bowel perforation was a known complication of the procedure. He maintained that the patient had been informed of all of the signs and symptoms of a bowel perforation and had been instructed to call him or return to the hospital if she had any symptoms.

The verdict

A defense verdict was returned.

 

 

Claim of misdiagnosis of ectopic pregnancy

Facts

A 36-YEAR-OLD CALIFORNIA WOMAN went to the emergency department (ED) of a hospital in 2010 with complaints of lower abdominal pain with prior vaginal spotting. Her pregnancy test was positive. An ultrasound (U/S) showed milk thickening of the endometrium and a 1.5-cm right ovarian cyst. The patient returned to the hospital 5 days later and another U/S was performed, which revealed a 4-mm round fluid collection in the fundus of the uterus. Her beta-hCG level had risen appropriately. She was told to follow up in 2 days to have her hormone level rechecked.

A little over a month later the woman went to a physician’s office to be examined. The obstetrician performed an U/S, found the uterus empty, diagnosed a double-ring structure in the adnexa as an ectopic pregnancy, and recommended an immediate injection of methotrexate to terminate the ectopic pregnancy and prevent rupture of the fallopian tube. The injection was given by the nurse and the patient’s blood was drawn to check hormone level, which had risen appropriately. The patient returned a week later and was seen by a different physician; another U/S showed an empty uterus, but her beta-hCG level had increased.

The first obstetrician learned of the results and called the patient to tell her that she needed immediate laparoscopic surgery and a D&C to remove the ectopic pregnancy. The patient went to an ED at another hospital 3 days later, where U/S showed a 12-mm gestational sac in the uterus, a yolk sac, and a small embryo with no cardiac activity. She then underwent a D&C.

The woman sued the obstetricians and their group, claiming that fetal demise was caused by the methotrexate injection and the physicians were negligent in misdiagnosing her viable pregnancy, leading to the loss of the pregnancy. The matter ultimately proceeded to trial against the doctor who recommended the methotrexate only, and it was alleged that he had misread the U/S and had failed to wait for the patient’s hormone reading before ordering the injection.

The obstetrician denied any negligence and maintained that the patient had undergone two U/S that were unable to confirm an intrauterine pregnancy and that the hormone levels were such that an U/S should have shown a pregnancy if everything were normal. He also contended that the patient’s complaints of vaginal bleeding and right-lower-quadrant abdominal pain prior to being seen had led other physicians to also suspect an ectopic pregnancy. He additionally maintained that the pregnancy was most likely not viable in any event.

The verdict

A defense verdict was returned.

Ureter injury during hysterectomy

Facts

A NEW YORK WOMAN was age 43 when her gynecologist performed a hysterectomy for fibroids in 2008. Two days later she was diagnosed with left ureter obstruction, which caused damage to the bladder and necessitated extensive treatment.

In her lawsuit against those involved with the hysterectomy, the woman claimed that the ureteral injury was due to a clamp used during the operation. She also claimed that the ureters were not properly protected because the arteries were clamped and sutured before the ureters had been identified, according to the operative report. The patient’s expert maintained that the ureters should be identified before the arteries are sutured and clamped.

The gynecologist claimed that the injury is a known risk of the procedure and that the proper sequence was used during the operation, although an assisting physician might have erroneously documented the sequence of events. The defense attorney also claimed that the operation was complicated by the patient’s fibroids, which distorted the anatomy. Additionally, he maintained that the damage to the ureter could have been caused by a kink in the ureter or during the procedures performed by a subsequently treating urologist.

The verdict

A $526,088 verdict was returned.

 

 

Excessive cauterization blamed for fistula

Facts

AN ILLINOIS WOMAN underwent a supracervical hysterectomy with bilateral salpingo-oophorectomy performed by her gynecologist in 2007. The patient, age 52, filed a malpractice case and claimed that the physician used electrocauterization excessively during the procedure, leading to a vaginal-peritoneal fistula. She developed an abscess, prolonged infection, pain, and had two additional operations a few months later. The woman also claimed that Seprafilm, an adhesion barrier, was used improperly, preventing the fistula from healing. She also argued that she would not have had her ovaries removed if she had known the consequence of doing so would include hot flashes and painful sexual intercourse.

The gynecologist claimed that the operation was properly performed and that there was no evidence that excessive electrocautery was used. She maintained that the patient’s consent was obtained to remove her ovaries and the Seprafilm was properly used and did not cause any injury.

The verdict

A defense verdict was returned.

Claim of delayed diagnosis of cervical cancer

Facts

A GYNECOLOGIST PERFORMED a pelvic exam and Pap smear on a 50-year-old New York woman in 2005. The pathology report revealed dysplasia of the epithelial cells of the endocervical canal. Another test revealed that the patient had subtypes of human papillomavirus (HPV).

Her physician recommended a colposcopy, which was performed 2 months after the initial exam. A biopsy revealed a precancerous lesion. The physician recommended cryosurgery, which was performed 2 months later. A followup test did not reveal subtypes of HPV, but the report did show cervical dysplasia. Six months later, an additional cryosurgery was performed, and another follow-up test again did not reveal HPV, but it was detected 6 months later. Surgery revealed severe squamous epithelial dysplasia. The patient went to another physician, who subsequently diagnosed stage III squamous cell carcinoma of the cervix. The patient then underwent a laparotomy, hysterectomy, removal of the upper portion of the vagina, and a salpingo-oophorectomy, approximately 1 year and 8 months after the 2005 examination. The procedures eradicated her cancer.

The woman sued the original gynecologist and claimed that he failed to properly address the dysplasia found in 2005. The patient claimed that her dysplasia was in areas that could not be reached by cryosurgery and that conization should have been performed, which would have completely eradicated the precancerous tissue.

The physician argued that cryosurgery was appropriate, all follow up was properly managed, and that cancer is a rare result of dysplasia.

The verdict

A defense verdict was returned.

 

 

Injury to bowel during abdominal hysterectomy

Facts

A WOMAN IN HER LATE 40s underwent a total abdominal hysterectomy and bilateral pelvic and para-aortic lymphadenectomy in 2008 due to a diagnosis of cervical cancer. The operation was performed by a gynecologic oncologist at a Pennsylvania medical center. Four days later the patient was diagnosed with a perforation of the small bowel and had contamination of the peritoneal cavity and sepsis. She underwent emergency surgery with resection of 12.5 cm of her small bowel. The incision was left open and she required multiple debridement procedures.

She has significant asymmetrical bulging and other disfigurement of her torso, and underwent several procedures for hernias during the following 2 years. The patient claims she is at risk of future hernias and that plastic surgery has been recommended to remedy her disfigurement.

In the lawsuit that followed, the patient claimed the bowel perforation occurred during the operation as a result of electrocautery use. She maintained that the defendants should have recognized the bowel injury earlier, and that it should have been detected during surgery. This would have avoided many of her subsequent injuries and complications.

The defense claimed that the bowel injury was a known complication of this operation and that it was recognized and appropriately treated. They contended that it was not necessary to run the bowel at the conclusion of the operation.

The verdict

A defense verdict was returned.

Thermal burn blamed for bowel perforation

Facts

A 55-YEAR-OLD ILLINOIS WOMAN underwent an operative hysteroscopy, dilation and curettage, and endometrial ablation in 2007, performed by her gynecologist. The procedure was done to address complaints of heavy and irregular bleeding. The patient returned to the hospital 2 days later with severe abdominal pain. She was diagnosed with a perforated rectosigmoid colon and underwent surgery the next day to repair the colon. A Hartmann’s procedure and colostomy were performed.

The operative report for the repair described a hole in the uterus that appeared burned. The pathology report found that the cause of the colon perforation was acute perforated diverticulitis. The patient underwent another surgery several months later to reverse the colostomy and three subsequent operations were required to repair incisional hernias.

The woman sued the gynecologist and hospital, claiming that they improperly seated the array device, utilized the device with a contraindicated uterine measurement after miscalculating the size of her uterus, and caused a thermal injury to the uterus and colon. The patient claimed that the colon perforation was not due to diverticulitis, but instead, was caused by an indirect thermal injury.

The physician and medical center claimed that the uterus and colon were not burned and endometrial scarring observed by the surgeon performing the colon repair can mimic the appearance of a burn. They also claimed that the cause of the bowel perforation was diverticulitis.

The verdict

The hospital settled for $162,500 shortly before trial and a jury returned a defense verdict for the physician.

 

 

Fistula develops after colon injury during ovarian cyst surgery

Facts

A 55-YEAR-OLD WOMAN underwent ovarian cyst surgery at a New Jersey medical center in 2007. Two days later she underwent another operation to repair a tear in her colon. A fistula then developed between her colon and bladder, necessitating a third surgery. After the third surgery, the woman suffered a cardiac arrest and sustained brain damage due to lack of oxygen. She was resuscitated but remains in a vegetative state.

A lawsuit was filed on woman’s behalf, claiming that the bowel injury was not recognized and treated in a timely manner and that a temporary colostomy should have been performed that would have avoided the fistula and eliminated the need for the third operation. In addition, she maintained that the antihypertensive given after the third surgery precipitated the cardiac arrest.

The verdict

A $2.725 million settlement was reached with two doctors, the medical center, and a nurse.