A patient’s primary care physician (PCP) referred her to a general surgeon for a right upper quadrant mass after suspecting a hernia.  In his written referral to the general surgeon, the PCP stated that the patient’s present illness was “Abdominal pain in RUQ from hernia…Refer to surgeon to evaluate RUQ mass/pain.”

In October 2008, the general surgeon examined the patient and noted that the patient presented with “a painful bulge in the R lateral abdominal wall,” she was 75 years old, 5’4” tall, 240 pounds, and suffered from hypertension.  The pre-operative note also indicated that the patient would not accept a blood transfusion.  This is significant considering that the patient’s pre-operative laboratory report showed a low platelet count of 84,000.

Although the patient had been experiencing significant pain and her PCP had suspected and noted the likelihood of a hernia, the general surgeon believed the abdominal mass to be a lipoma.  The general surgeon did not obtain any pre-operative image studies.  Instead, the general surgeon scheduled the patient for surgery at an outpatient, ambulatory surgery center, where he works.  The general surgeon did not take into account that complex hernia repairs that require bowel repair or resection are not appropriate for same day surgical procedures and outpatient centers are not equipped for such procedures.  At a minimum, without a preoperative image study, the general surgeon should have scheduled the patient for surgery at the hospital so that whatever issue was encountered could be properly addressed.

In November 2008, the general surgeon attempted surgery on the patient at the ambulatory surgery center.  The general surgeon used the subcostal approach and discovered that in fact, the patient had a hernia and not the lipoma he had anticipated.  A hernia was stuck to the undersurface of the abdominal area where the general surgeon found dense adhesions.

The surgery had to be stopped 25 minutes after its start because the surgery center lacked the instrumentation and equipment for hernia surgery.  As a result of the more difficult and involved surgery required, the conscious sedation started by the anesthesiologist was insufficient to control the patient’s discomfort, and a laryngeal mask airway was needed and provided.  The patient was immediately transferred by ambulance to the hospital.

The surgery center’s anesthesiologist’s report stated that the patient had a “likely bowel perforation.” If the anesthesiologist’s note is correct, the requisite delay in repairing the perforation could potentially expose the patient to an increased risk of wound infection.  A bowel perforation requires emergent repair, and any delay poses serious consequences.

The general surgeon denied perforating the patient’s bowel during the surgery at the surgery center but his own hospital admission report states that the patient had “a probable perforation of the hepatic flexure.”  The hospital’s report also contains a contradicting note where the general surgeon states that the patient had begun outpatient surgery to remove a right-sided abdominal mass which “ended up perforating bowel.”  This hospital’s report further acknowledged that the patient was admitted for “bowel resection as this could not be done at the surgery center.”

At the hospital, the general surgeon undertook the more extensive surgery which confirmed that the bowel was perforated.  The general surgeon performed this second surgery with a subcostal retroperitoneal approach despite his recognition of dense adhesions and presumed bowel injury, as well as the earlier difficulty in exposing the large hernia in the morbidly obese patient.

The general surgeon’s discharge summary states that the patient had experienced purulent drainage from her incision.  However, the general surgeon did not document his evaluation of the patient’s wound prior to discharging the patient from the hospital, nor did the general surgeon document the patient’s complaint of pain.  The general surgeon discharged the patient to a rehabilitation center.

Within 24 hours of discharge, the patient immediately returned to the hospital by ambulance with a grossly infected wound.  The patient appeared septic, experienced constant, intense pain, with fever, chills and brown, bilious-colored material draining from her surgical incision.

A CT scan showed draining fecal matter in her right abdomen.  The patient stated that her abdominal pain and wound drainage began three days prior to discharge from the hospital.  The scan also revealed the patient had a significant intra-abdominal process that likely festered for some time.  This fact raises the possibility that the drainage in the abdominal wound was the continuum of a process that was occurring intra-abdominally.

The patient returned for a third surgery.  The general surgeon again performed the surgery, this time using a midline incision.  The general surgeon described the surgery as mildly bloody.  During this surgery, in a purulent area in the right side of the abdomen, the general surgeon identified a perforation in the patient’s colon which was leaking air.  The general surgeon resected the patient’s colon and broke down some hard adhesions.  Because of the extensive peritonitis that had developed, the patient had to have a colostomy.  The patient’s health rapidly declined following the third surgery.

The patient died less than thirty days after the general surgeon’s initial surgery.  The general surgeon prepared the death certificate, and he failed to accurately reflect that the patient died of multi-organ system failure as a consequence of a bowel perforation that occurred from his abdominal surgery to repair a hernia.  There was no mention for reason of organ failure and the only pathology mentioned were various organ system failures that occurred just before death.  A death certificate should accurately reflect the course of events leading up to a patient’s demise.  The general surgeon neglected to properly document the actual cause of the patient’s death.

The Commission stipulated the general surgeon reimburse costs to the Commission, arrange for the manager of the Quality Review Committee at all facilities where he provides patient care to submit quarterly reports addressing whether any surgical cases involving the general surgeon were discussed at the Quality Review Committee meetings,  and write and submit a paper of at least 1500 words, with annotated bibliography, discussing the Communication and Resolution Program (CRP) principles and the importance of integrating these principles into practice.

State: Washington

Date: January 2017

Specialty: General Surgery

Symptom: Abdominal Pain

Diagnosis: Post-operative/Operative Complication, Sepsis, Procedural Site Infection

Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Lack of proper documentation, Procedural error

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF