Two separate obstetrician/gynecologists reviewed the case and both had difficulty defending the case. It was not clear why the defendant performed the TAH.
On February 11, a 47-year-old patient with a history of irregular and heavy periods lasting 6 to 7 days presented to her gynecologist's office. Physical exam indicated a 14 week-size uterus, with a deviation to the left. A large pelvic mass was appreciated.
On March 7, the patient underwent a transvaginal ultrasound (TVS). The radiology report showed a thin-walled, sonolucent left ovarian cyst, with internal echoes believed to represent a hemorrhagic corpus luteum. The right ovary appeared normal, and the endometrium was well defined.
The patient underwent another U/S on April 6, which revealed what was believed to be a simple left ovarian cyst that measured 6.227.727.1 cm. Three fibroids within the uterus were now noted, with mean sizes of 19 mm, 21 mm, and 11 mm, respectively. An April 7th note by the gynecologist reflected a "prolonged discussion" with the patient and her husband about the procedure type, anesthesia, recovery, and incision. According to her office notes, the couple agreed with the plan and declined a second opinion.
On April 13, surgery was performed in the hospital. The resident's dictated operative report indicated that a total abdominal hysterectomy (TAH) and LSO were performed without complication. The intraoperative findings were a smooth-walled left ovarian cyst measuring 82827 cm and a 32322-cm myoma in the left cornu of the uterus. Both tubes and the right ovary were normal. The pathology report described the uterine specimen as also containing a right fallopian tube and right ovary but made no mention of the myoma. Further adding to the confusion, the operating room nurse's note indicated that a pathology specimen consisting of the uterus and right tube and ovary were being sent to the path lab, but also suggested that the pathology specimen consisted of the uterus and left adnexa.
The pathology report indicated that two specimens were submitted. Part "A" consisted of the uterus, cervix, and right tube and ovary, and Part "B" consisted of the left tube and ovary. The pathologist noted that the right fallopian tube measured 6 cm and was 0.5 cm in diameter, with some focal atrophy. The right ovary carried no pathologic diagnosis, and was described as a portion of white ovarian tissue, measuring 0.920.520.5 cm. The left fallopian tube was described as 5 cm and 0.6 cm in diameter, with a simple, cystic lesion measuring 82626 cm with tubo-ovarian adhesion. A pelvic wash was negative for malignant cells.
The patient had two follow-up visits with the gynecologist before going to see a new physician. A subsequent pelvic exam and U/S revealed the presence of a normal right ovary. The second gynecologist noted that the patient's estrogen levels were normal and documented: "Patient states only LSO was to be done unless cancer was found-patient also agreed to a myomectomy if one was present."