Case Summary
This case involves a 53-year-old female who presented to a urogynecologist with a chief complaint of uterine prolapse. She was diagnosed with symptomatic stage 2 uterine prolapse and underwent a laparoscopic-assisted vaginal hysterectomy with anterior repair and no noted complications. She was discharged to home on postoperative day one. On postoperative day two, the patient reported worsening pain and lethargy. On day three, the patient called the surgeon’s office reporting increased malaise and lethargy. She was told that the cause was likely gas related and was recommended to take GasX as a solution. On postoperative day four, she again called the office reporting a low-grade fever with chills and reiterated the previous and worsening complaints. She was not called into the office. On the fifth day after surgery, the patient reinstated her continued complaints along with abdominal distention. She was instructed to go to the emergency room. She suffered a syncopal event prior to arriving to the ER. Upon CT examination, the patient was found to have a fluid collection in the lower abdomen and was subsequently taken for surgery where a small bowel enterotomy with active sulcus leaking was discovered. The patient required resection of 30 cm of small bowel that necessitated a prolonged hospital stay.
Case Theory
Enterotomy is the surgical incision into an intestine. It may be purposeful or a complication of an abdominal surgery, such as exploratory laparotomies or hysterectomy. Intentional enterotomy is performed to remove an obstruction or foreign body from the intestine. Inadvertent enterotomy in abdominal surgery is widely underreported. Due to the limited field of vision, the incidence of enterotomy in laparoscopic surgery may be greater than that during an open procedure and may go unrecognized.
Injuries of the bowel during laparoscopic gynecological operations are well recognized. Due to the possible catastrophic complications resulting from bowel leak, the rapid diagnosis, and immediate repair of these injuries is critical. Mild injuries to the small and large bowel can be repaired by intestinal closure. Extensive injuries often require bowel repair and resection.
Side effects of bowel resection surgery include a temporary or permanent stoma, changes to bladder and bowel function or reduction of bowel and bladder function, including a lifetime risk of bowel obstruction due to scar tissue that may require future surgical intervention. Post-resection sexual function complications in females may include pain and discomfort. Nutrition may be also affected with noted differences in what a patient is able to tolerate post-surgery. In this case, the surgical error followed by the delay in recognition of the injury and inadequate nursing reporting of patient changes was below the standard of care and led to an unplanned bowel resection and a poor outcome for this patient.
Expert Witness Q&A
- How are bowel injuries recognized and prevented during laparoscopic surgery?
- What are some post-operative complaints that warrant evaluation by a physician?
- What is the long-term prognosis with bowel resection?
Expert Witness Involvement
Expert Specialty: Obstetrics and Gynecology. An Obstetric expert with experience in laparoscopic hysterectomy can opine on the risk of surgical injury in closed surgery and speak to the need for awareness of postoperative complications.