Laparoscopic Lysis of Adhesions Leads to Missed Bowel Perforation: Case Study

David B. Troxel, MD, Medical Consultant to The Doctors Company

Analyses by The Doctors Company of closed malpractice claims repeatedly show that missed and delayed diagnoses of surgical complications lead to patient harm and prompt malpractice claims. Consider the following case example.

A 35-year-old G4, P3 woman with obesity presented to her 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.

The gynecologist 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 her gynecologist, who was concerned about possible bowel perforation. She developed a temperature of 103°F 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 the gynecologist 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 expert 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 the patient exhibited no evidence of injury immediately after surgery and that 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 gynecologist 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. The gynecologist wanted the case to be tried.

At trial, the 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 gynecologist 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 gynecologist 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.

Case Discussion

The overall rate of serious complications associated with laparoscopic surgery is low. Severe complications, however, such as bowel perforation and vascular injury, do occur. Typically, they result from anatomic distortion caused by adhesions in patients with a history of prior pelvic or abdominal surgery and with disorders such as endometriosis and pelvic inflammatory disease.

In these types of patients, it is important to discuss the risk of bowel perforation as well as the possibility of having to convert to open laparotomy, and to consider a nonlaparoscopic surgical procedure. This discussion and the patient’s understanding and consent should be documented in the medical record. While bowel preparation is no longer a standard practice prior to gynecologic surgery, it may be performed for patients who are at increased risk for surgical injury to the bowel.

Diagnosis of bowel perforation during the initial procedure is ideal. Long-term complications may be decreased if the injury is anticipated based on previous surgeries and current difficulties and steps are taken to make sure there is no perforation—including inspection of the bowel surface.

Claims associated with bowel perforation often result from a postoperative delay in diagnosing the perforation and/or the associated fecal 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.

For additional information, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

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