Improper performance of a hysterectomy

by Sara Bergmanson, Digital and Social Media Specialist, and Jennifer Templin, Risk Management Representative 

Presentation  

A 58-year-old woman came to Ob-gyn A for treatment of postmenopausal vaginal bleeding and  dysmenorrhea. The patient’s history included obesity, gastric bypass surgery, and right-sided  salpingo-oophorectomy. Both surgeries occurred more than 10 years before coming to Ob-gyn  A.  

Physician action 

Ob-gyn A performed an ultrasound that indicated a thickened endometrial lining, which had a  normal biopsy, and a uterine fibroid around 2.5 centimeters in diameter. A repeat sonogram and  uterine cuttings were benign and consistent with polyps. Treatment with hormonal therapy was  unsuccessful.  

The patient and Ob-gyn A discussed the risks and benefits of a robotic-assisted total laparoscopic  hysterectomy, left salpingo-oophorectomy, and cystoscopy for dysmenorrhea and uterine  fibroids. They also discussed non-surgical management and non-treatment as alternatives. The  patient agreed to proceed with surgery, and it was scheduled for December 29. 

Upon performing the surgery, Ob-gyn A found dense adhesions in the abdomen making trocar  placement difficult and converted the procedure to an open laparotomy. Surgery was further  complicated by bleeding at the omentum from the failed trocar placement. Additionally, an  enterotomy of the small bowel was discovered and repaired. 

Before completing the surgery, Ob-gyn A inspected the abdomen, pelvis, and bowel. It was  documented that the bleeding stopped and the bowel repair was intact. No other injuries were  identified. 

At 7:45 p.m. that night, nurses notified Ob-gyn A that the patient was experiencing tachycardia  and an EKG was abnormal. At 5:15 a.m. on December 30, the nurses reported concerns about the  patient’s blood pressure to the on-call physician, Ob-gyn B. Ob-gyn B ordered a 1-liter bolus of  lactated Ringer’s.  

By 7:41 a.m. the patient had not improved, and Ob-gyn B contacted Ob-gyn A. At this time, a  phlebotomist came and drew labs according to sepsis protocols.  

While Ob-gyn A was waiting for lab results, the patient became more hypotensive, tachycardic,  and oliguric. Her white blood cell count increased to 16,000 and her creatinine level increased to 

2.5. Her estimated blood loss was documented as 1,500 cc leading to concerns of hypovolemic  shock. 

Intensivist A was consulted, and the patient was transferred to the ICU. Intensivist A suspected  septic shock and acute renal failure. Vasopressors were started, and radiology studies indicated a  possible bowel injury and free air. 

Records regarding the patient’s previous gastric bypass surgery were obtained, revealing she  suffered postoperative complications and had a prolonged recovery. (It is believed that this is the  cause for the adhesions found in the laparoscopic procedure.) 

Ob-gyn A, accompanied by a general surgeon, took the patient back to the OR on December 31.  Several other injuries to the patient’s small intestines were found including three perforations  within the duodenum, an injury to the Roux limb (jejunum), and three more enterotomies. A  large mesenteric defect causing ischemic injury to the transverse colon was also discovered.  Additionally, the patient’s gastrointestinal anatomy was significantly distorted, and a bariatric  surgeon was consulted. Bowel resections and enterotomy repairs were needed to restore her  intestinal tract.  

Due to severe amount of edema within the intestines, her abdominal wall could not be closed,  necessitating seven more returns to the OR for washouts and re-inspections. The patient became  septic and showed signs of respiratory and renal failure. It was felt her condition was terminal  and a DNR order was given by her spouse. She died after two weeks in the hospital.