Intestinal injury after operative hysteroscopy

Intestinal injury after operative hysteroscopy

The case

A 48-year-old gravida 2, paragraph 2 presented to her physician complaining of menorrhagia and increased cramping during the previous 18 months. Initial progress notes document that the patient tried various oral contraceptives over the next 5 years without improvement. An endometrial biopsy revealed fragments of quiescent endometrial glands and stroma in a hemorrhagic background. Laboratory evaluation showed normal thyroid-stimulating hormone (TSH) and decreased hemoglobin and hematocrit, by 8.9 g/dL and 26.4%, respectively.

The doctor recommended endometrial ablation and tubal ligation. There was reasonable written informed consent, although no discussion of hormonal intrauterine systems (IUSs) was documented in her chart.

The patient underwent a laparoscopic application of a Filshie clip. A hysteroscopy and dilation before ablation had revealed a small polyp, and subsequent pathology revealed a benign, weakly proliferative to atrophic endometrium. Initial attempts to perform endometrial ablation with a bipolar electrosurgical global ablation device revealed a narrow endometrial fundus width (2.5 cm). The device was removed and reinserted, subsequently failing the uterine integrity test, suggesting uterine perforation. The procedure was discontinued with no apparent complications.

Two months later, a physician at an ambulatory surgery center performed a hysteroscopic electrosurgical endometrial resection and ablation with monopolar electrosurgery, using sorbitol for distension. The procedure lasted 50 minutes and the doctor documented a fluid deficit of 2000-2500 ml. Nursing notes reflect the use of 5,000 mL of sorbitol with a deficit of 2,800 mL. A sodium level of 131 mEq/L was obtained at the end of the procedure. Furosemide was administered in the operating room. In recovery, the patient initially had normal breathing, oxygen saturation, blood pressure, and pulse. But about 2.5 hours later, she was short of breath and experiencing bloating and abdominal pain, which she rated as 10 out of 10. She was therefore transferred to the hospital affiliated with the center with a diagnosis of electrolyte imbalance after hysteroscopy. One and a half hours after transfer, computed tomography (CT) revealed free air throughout the patient’s abdomen and within her pelvis and a surgical defect in the right anterior uterine wall. She was given morphine and meperidine, but the pain did not subside and she was admitted for observation.

Early the next morning, the nurses tried to get the patient to her feet, at which point she became dizzy and nauseated. The patient went back to bed and the symptoms slowly subsided. However, she complained of increasing pain. Evaluating the patient that morning, the physician documented that the abdominal distention had improved and that the bowel sounds continued to decrease but were improving. The patient’s pain was documented as 6 out of 10. The doctor’s notes stated: “Computed tomography (CT) scan of the abdomen and pelvis shows free fluid in the abdomen, with no evidence of blood or other abnormalities.” Evaluation at this time was still endometrial ablation complicated by fluid shift and pain. The plan was to increase her diet and discharge her in the afternoon.

At 4:40 pm on postoperative day 1, the pathologist notified the surgeon that endometrial ablation showed smooth muscle fragments consistent with benign leiomyomas, with probable identification of small bowel mucosa and muscle wall. Two hours later, the gynecologist documented that the patient had a painful abdomen, without rebound or defense. Progress notes documented pathology results and a plan to see a general surgeon and proceed to surgery.

That night, the surgeon performed an exploratory laparotomy, evacuated peritonitis, and performed a partial small bowel resection, primary anastomosis with a stapling device, and an incidental appendectomy. The pathological study revealed a 1 cm perforation of the small intestine and an appendix with periappendicitis. Cultures obtained during surgery included a large growth of Klebsiellamoderate growth of Haemophilusand slight growth Streptococcus. Broad-spectrum antibiotic therapy had been started before surgery and continued postoperatively. The patient improved dramatically and was discharged 3 days after exploratory laparotomy.

Approximately 3 months after the original surgical procedures, the patient presented to another hospital with acute abdominal pain. A CT scan revealed fluid in the abdomen and a probable small bowel obstruction. The patient underwent an exploratory laparotomy, which found an acute small bowel obstruction secondary to a confined perforation and peranastomotic abscess. The patient then underwent a partial small bowel resection and right hemicolectomy. She recovered uneventfully and was discharged 6 days after this procedure.

However, she continued to complain of persistent menorrhagia, chronic abdominal and pelvic pain, and fecal incontinence. She was no longer able to work and she was separated from her husband.

accusations

The patient sued the doctor for negligence during the performance of the endometrial ablation that subsequently required multiple operations and hospitalizations and resulted in loss of income, loss of consortium, and significant pain and suffering. She sued the original surgeon general for negligent handling of the initial bowel injury, claiming that a primary anastomosis without concomitant bypass was below the standard of care. She also sued the hospital for improperly granting privileges to the gynecologist and sued both the radiologist and the pathologist for improperly communicating abnormal findings to the gynecologist.

Proof

After the discovery, the radiologist was dismissed from the lawsuit because the communication of the critical findings to the gynecologist, the documentation of the method of communication (telephone), and the time of communication were clearly indicated in the CT report. The pathologist was also terminated because the telephone communication of abnormal results had been clearly documented in the pathology interpretation and report.

The surgeon general was also terminated when, in deposition, the plaintiff’s expert admitted that primary anastomosis without bypass is within the standard of care and is an acceptable alternative surgical approach. The defense expert testified that subsequent anastomotic leak is a recognized complication of the anastomosis, which had been adequately managed when discovered 3 months after the primary anastomosis.

The hospital decided to settle the lawsuit before trial because its medical staffing office was unable to produce documentation about the gynecologist’s training or experience in performing endometrial ablations, either with hysteroscopic or bipolar electrosurgical devices, or about the gynecologist’s privilege to perform endometrial ablations.

At trial, the plaintiff expert testified that the management with the global electrosurgical ablation device in the initial procedure, when a perforation was suspected, had been adequate. However, the expert expressed criticism on 3 issues. First, there was no documentation to show that the option of a levonorgestrel intrauterine system (IUS) had been discussed or offered, even though an IUS is as effective as endometrial ablation in controlling abnormal uterine bleeding and can be inserted in the office without anesthesia or surgical risk. Second, fluid management in the second procedure was below the standard of care. There were discrepancies in documented fluid deficit, which ranged from 2,000 to 2,800 mL. Regardless, the deficit put the patient at risk for fluid overload and hyponatremia. Having noted that his electrolytes were normal, the gynecologist should have entertained the idea that fluid had been lost through a uterine perforation. Third, although the transfer and hospital admission were appropriate, the gynecologist did not adequately respond to and document the free air identified on the CT scan, more concerning for an intestinal perforation. The gynecologist did not acknowledge the finding of free air and did not express concern about bowel perforation. Broad-spectrum antibiotics had to be given immediately and the patient referred to a general surgeon for immediate exploration. Delay in treatment resulted in an increased risk of infection, subsequent rupture of the anastomosis, a plugged abscess, and small bowel obstruction. Multiple bowel resections led to bowel incontinence and persistent pain for the patient.

The defense expert testified that endometrial ablation is an accepted treatment for heavy menstrual bleeding. Perforation is a recognized complication of both global ablation devices and hysteroscopic electrosurgical endometrial ablation. Although there was a significant fluid deficit during the hysteroscopic procedure, the patient did not present any symptoms of fluid overload and there were no objective findings in this regard. The delay in performing the exploratory laparotomy was not significant and, when the anatomopathological result was notified, the gynecologist immediately obtained a consultation for general surgery and the patient underwent an exploratory laparotomy, with adequate surgical management. Also, at that time, the surgeon became the main doctor attending the patient.

Result

After 6 hours of deliberation, the jury returned the plaintiff’s verdict, awarding $1.5 million. The jury’s post-verdict poll revealed that 2 facts had weighed heavily in his decision:

  • the inability of the gynecologist to provide documentation of training in performing hysteroscopy or global endometrial ablation procedures, and
  • the gynecologist’s failure to recognize free air shown on CT and the associated risk of bowel perforation.

learning points

Informed consent is the process of counseling patients about treatment and management options. The informed consent document simply commemorates the discussion. Each state and jurisdiction has its own requirements for documenting such discussions, with some only requiring that R/B/A (Risks, Benefits, and Alternatives) be analyzed. However, it is recommended that the informed consent document a discussion of the planned procedure or treatment, alternatives to such treatment, including doing nothing, and substantial complications related to the planned procedure or treatment. Electronic records allow the development of intelligent sentences that include these elements, minimizing the time required for the complete documentation of these discussions. In this case, no discussion of the option of a levonorgestrel IUS, which has treatment outcomes similar to endometrial ablation without the surgical risks, was documented.

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