Robot Assisted Surgery Leads to Sepsis

This surgical technology case takes place in Michigan and involves an elderly female patient with a past medical history of bilateral salpingo-oopherectomy, rectocele and cystocele repair with a recurrence of pelvic organ prolapse. To treat these conditions, the patient underwent a bladder suspension and hysterectomy with vaginal prolapse repair. The surgery was performed with the assistance of the DaVinci robot. Intra-operatively, the OB/GYN noted an incisional hernia from a previous surgery and undertook an elective procedure to repair it. He did not gain informed consent from the patient’s husband to do so, and the patient was not informed pre-operatively that there was a potential for this procedure to be performed.

During the hernia repair, the OB/GYN included the bowel in the hernia repair and perforated the patient’s bowel, however he did not recognize this in the OR and the patient was closed. The patient subsequently became septic, which was also not recognized by the treating OB/GYN. He cosigned orders that the patient be discharged despite her lack of urine output, hypoactive bowel sounds, and worsening abdominal distention and pain. The patient was not discharged and was subsequently diagnosed with sepsis, peritonitis and intra-abdominal compartment syndrome.