A Complication Involving Laparoscopic Lysis of Adhesions
A 35-year-old G4, P3 obese woman presented to our insured gynecologist with complaints of pelvic pain, dyspareunia, and urinary frequency with urgency. Three years earlier, he had performed laparoscopic lysis of pelvic and intra-abdominal adhesions. Two years prior to that procedure, another physician had performed a hysterectomy for endometriosis with lysis of adhesions.
Our insured suspected that the patient’s current symptoms were again due to adhesions. He reviewed her treatment options and recommended laparoscopic lysis of probable adhesions. At surgery, he found extensive pelvic adhesions and performed sharp and blunt dissection and hydrodissection in an attempt to dissect the intestine off the apex of the vagina. The loops of bowel were densely adherent to each other, and he terminated the procedure due to the anatomic distortion. The patient left the OR in stable condition and was discharged the following day.
One day later, she presented to the ER with nausea and vomiting. She was admitted by our insured, who was concerned about possible bowel perforation. She developed a temperature of 103 with tachypnea and tachycardia and became lethargic and unresponsive. Septic shock from a perforated viscus was suspected, and she was transferred to the ICU and placed on broad-spectrum antibiotics.
Plain films of the abdomen revealed free air, and she was explored by a general surgeon who found a 1 cm perforation of the sigmoid colon with stool leaking from it. A sigmoid colectomy and colostomy were performed. The small bowel appeared intact. She returned to the ICU and was continued on multiple antibiotics. She developed respiratory distress syndrome and was placed on a ventilator and heavily sedated. She then developed ventilator-dependent pneumonia with empyema. Following a complicated hospitalization, she was discharged six weeks later.
Plaintiff’s Expert Opinion
The plaintiff’s expert opined that our insured had breached the standard of care by not counseling the patient on the very high risk of bowel perforation. The opinion stated that this surgery should have been avoided except as a last resort and that a preoperative bowel preparation should have been seriously considered.
Defense Expert Opinions
A board certified ob/gyn felt there was no breach in the standard of care. He stated that bowel injury is an accepted and known complication in this type of surgery. He noted the history of pain due to adhesions and felt the insured appropriately ruled out other causes of pain, specifically urinary tract infection, pelvic mass, and prolapse. It was reasonable for the insured to believe that surgery would again alleviate the patient’s pain, because it had done so when he performed the same procedure three years earlier. He did not believe the standard of care required pre-op bowel preparation. He noted that the patient exhibited no evidence of injury immediately after surgery, and when she returned to the ER, she was admitted and appropriately treated.
Another board certified ob/gyn was not supportive, commenting that the patient was high-risk because of obesity and the prior history of surgery with dense and plentiful adhesions. Because bowel perforation is a known complication of the procedure, he believed the insured should have ordered a pre-op bowel preparation.
Should This Case Be Tried?
The plaintiff alleged negligent performance of surgery, failure to order a bowel prep, and mismanagement of postoperative care. Our insured gynecologist wanted the case to be tried.
At trial, our defense expert opined that the laparoscopic procedure was appropriate and properly performed, adding that bowel perforation is a known risk and is not indicative of negligence. The plaintiff’s expert was critical because the insured had previously operated on this patient for adhesions and should have considered performing an open procedure. He added that a preoperative bowel preparation should have been done.
The insured testified that the patient had pain relief from the previous laparoscopic procedure, and he expected that she would again have relief of her symptoms. Additionally, he had informed the patient of the risks of laparoscopic surgery, and this informed consent was well documented in the office medical record. The jury awarded a plaintiff verdict but made no award for damages.
Laparoscopic surgery is associated with higher risk of complications in patients who have had prior surgery or who have intra-abdominal diseases such as endometriosis or pelvic inflammatory disease. These complications are a consequence of intra-abdominal or pelvic adhesions and anatomic distortion. In these patients, a non-laparoscopic surgical procedure should be considered, and it is particularly important to discuss (and to document in the medical record) the risk of bowel perforation or vascular injury and the possibility of having to convert to open laparotomy if the surgery is to be done laparoscopically.
Two issues frequently arise in claims resulting from the complications of bowel perforation (typically fecal peritonitis) following laparoscopic surgery:
- Delay in diagnosis of bowel perforation and/or peritonitis. In general, patients gradually feel better with each passing hour after surgery. If pain continues or worsens, particularly if there is fever or tachycardia, perforation should be suspected and a general surgical consult obtained. The presence of free air on an upright abdominal film is of limited diagnostic value, because approximately 40 percent of patients have more than 2 cm of free air at 24 hours post-laparoscopy. However, this volume should gradually decrease, so increasing free intra-abdominal air is a concern and should suggest a perforated viscus until proven otherwise.
- The value of preoperative bowel preparation. Gynecology experts often disagree on the routine use of pre-op bowel preps, and there is little consensus in the gynecologic literature. While it is an accepted practice to order some form of pre-op bowel preparation prior to surgery when there is increased risk of bowel perforation, there is little evidence to support use of aggressive bowel preparation (oral solutions and enemas). One meta-analysis in the colorectal surgical literature showed little or no advantage resulting from use of aggressive bowel preparation, and other studies suggest that aggressive preps may actually increase the risk of spillage through a perforation due to the large volume of fluid colonic content produced.