Delayed diagnosis of an incarcerated Spigelian leads to small bowel necrosis

    bowelThis case takes place in Hawaii and involves a thirty-nine year-old female patient who was married with four children. The patient and her husband had decided that their family was complete and the patient decided to undergo an elective tubal ligation as a method of birth control after using Yasmin and an IUD for several years. The procedure was performed by the patient’s gynecologist. Within a few hours of the procedure the patient experienced a severe episode of nausea and projectile vomiting. Three days following the surgery the patient was seen by the treating gynecologist who suspected that there was a hematoma in the lower quadrant of the abdomen. The patient was sent back to the hospital where she was admitted for a suspected small bowel obstruction. After being closely followed and treated conservatively with nasogastric tube decompression and slow advancement of a liquid diet, the decision was made to discharge the patient after she had a bowel movement. No scans or confirmatory tests were performed upon discharge. The patient was discharged after a 10 day hospital stay despite the fact that she was still experiencing episodes of vomiting and reported feeling systemically unwell at the time of discharge. Two weeks following discharge from hospital the patient presented to the emergency room complaining of abdominal pain. The patient was admitted and later underwent an abdominal CT scan to investigate the cause of the abdominal pain. The CT scan revealed the presence of hernia. The patient was sent for surgery immediately which identified an incarcerated left Spigelian hernia along with 23 centimeter of necrotic bowel that had to be resected due to strangulation.

    Question(s) For Expert Witness

    • Should the patient have been discharged without diagnostic testing to confirm that the obstruction had passed or to rule out a hernia? Assuming a CT (or some other test) was performed prior to the patient being discharged and the hernia was detected and repaired on that date, could that have prevented the adhesions and damage to the patient's small bowel?

    Expert Witness Response E-006830

    Usually in this sort of scenario, we would perform an imaging study to confirm that the small bowel obstruction or hematoma has resolved before discharge. With the assumption that a CT (or some other test) was performed and the hernia was detected and adequately repaired in a timely manner, that could have prevented the adhesions and extensive damage to the patient’s small bowel that occurred when the hernia was finally diagnosed. Additionally, two weeks of incarcerated hernia definitively had a negative impact on the patient’s condition.

    This expert is board certified and trained at top medical centers in the United States. He currently practices at one of the largest medical centers in the United States. He has been published in peer-reviewed journals and is highly respected in his field. He is familiar with minimally invasive gynecologic surgery, including the da Vinci system.

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