PLEASE POST AN OPINION ONLY IF YOU ROUTINELY PERFORM ROBOTIC BARIATRIC SURGERY
On 02-06-23 62 year old male patient undergoes robotically assisted laparoscopic Roux-n-Y gastric bypass, EGD for surgical weight loss. His pre-op height is 175.2 cm and weight is 126.7kg. Anesthesia starts at 09:20 and ends at 12:25.
He is in PACU at approximately 12:30 with BP 122/60, HR 82, RR 24. He initially complained of nausea and then complained pain was worse. RN placed abdominal binder and gave Phenergan and Toradol. He was given a second does of Phenergan.
Just as he was to receive a dose of fentanyl (around 14:15 in recovery) he has decrease in blood pressure (64/45), and at 14:55 had profound drop in hemoglobin (7.5) and at 14:39 drop in hematocrit (22.6) requiring return to the operating room. At 15:05 Code Blue was called and patient was intubated. Anesthesia attempted central line with ultrasound but placed it in left carotid instead of IJ.
The Op Note indicates surgeon was able to find a bleeding arterial vessel located on the lesser curve far from the area where the surgery site was located. He stated "In fact, this is nowhere near the previous Roux-n-Y gastric bypass dissection or anastomosis but rather on the lesser curve near the antrum." The patient become very coagulopathic so they packed the abdomen and waited for FFP. INR was 2.4 or 2.5. He received FFP and multiple units of packed red blood cells. Patient was left intubated and taken to ICU.
The next day patient was ultimately transferred to another hospital for vascular surgery evaluation and removal of CVC and left common carotid artery repair. Neurology work-up and 02-09-23 MRI revealed left watershed distribution infarcts/ischemic strokes. He is subsequently discharged 02-20-23 home with home health and home PT/OT.
Files:
Q: Did the nursing staff contact the surgeon during the post-op period or was the patient being managed by the Anesthesiologist?
A: Initially anesthesia came for assessment and placed patient on NRB. He was receiving neosynephrine with continuous fluids and labs were drawn with bladder scan at 13:30. Surgeon was then notified via phone and text to assess in PACU.
Q: Did the surgeon discuss the case with a Interventional radiologist for a possible embolization of the gastric artery?
A: Do not see any evidence of this in the records we have.
Q: I understand the patient was unstable after a few hours, but was any bedside assessment completed by the Surgeon?
A: Pt having issues with BP in PACU and at 13:25 anesthesia ordered Stat CBC, Chem, Albumin, EKG, and H&H. Surgeon then orders arterial blood gas, CT angio thorax, and CT A&P around 14:37. Do not see any documented bedside assessments by surgeon.
Q: Why is toradol being given post bypass at all? I would avoid using as much as possible post bypass. Additionally, paper in Annals of Surgery recommended not using toradol post GI anastomosis takes place. Here there were 2 GI anastomoses.
A: —
Do you believe there might have been medical error?
Post operative bleeding is a known complication after any bariatric surgery. Post operative pain is common in most patients post operatively. The location in this case is unusual as it was not in the immediate operative field. This may have occurred from a traction injury. The patient was still in the PACU when the blood pressure dropped precipitously. Appropriately, he brought back to the OR. The patient was in the PACU for longer that usual. I wonder if his clinical presentation was changing over a longer period of time such as gradual tachycardia or gradual decrease in systolic blood pressure. During emergency line placement in patients with a low blood pressure(code blue), an inadvertent placement of a central line can occur. What is important is that the inadvertent placement in the carotid artery was recognized.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The inadvertent placement of the central line into the left carotid artery did result in left water shed infarction/ ischemic stroke. This is a known complication that occurs when the carotid artery is instrumented and a central line is place into the artery. However, with little to know blood pressure and hypovolemia this can occur. It was important that it was recognized and subsequently the patient was referred to vascular surgery to remove and repair the injury.
What makes you a good expert for this case?
I am a general and bariatric surgeon. as well as a director of an MBSAQIP center. 85% of my practice is bariatric surgery. I have done over 4,500 bariatric procedures. I have been doing all of my procedures robotically since May 2020. I am presently and have been in the past a Vice Chairman of surgery in my present and past institution. I have been doing medicolegal work since 2011. The majority of which involved bariatric procedures.
How often do you encounter cases similar to this one in your practice?
I have done over 850 gastric bypass procedures. I have been doing them robotically since 2020.
Do you believe there might have been medical error?
There likely was an injury to the gastric vessel in question during dissection of the stomach or manipulation of tissue for positioning of organs for anastomosis, etc.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, attention wasn't paid to the tissue being manipulated or dissected which resulted to the injury to this gastric vessel.
What makes you a good expert for this case?
Experienced, fellowship-trained, regionally recognized robotic bariatric surgeon with more than 700 robotic cases performed (and more than 2000 bariatric cases overall). Vice-president of my state's chapter of ASMBS (our national bariatric surgery society). Previously employed as an academic surgeon with significant research & education experience in the field of bariatric surgery. Expertise in medico-legal case review, deposition, and expert-witness statement preparation.
How often do you encounter cases similar to this one in your practice?
Rarely, usually less than 1-2 per year (as a transfer from another hospital for my assistance with management of these cases).
Do you believe there might have been medical error?
I believe there is an injury that was initiated, if not overly caused by the surgeon during the initial operation. There is no reason a bleeding vessel on the lesser curvature should cause such a massive bleed unless it was a significant vessel, i.e. GDA, or right gastric or r. Gastroepiploic or splenic artery which Wouldn’t be injured unless the surgeon did it.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The initial injury to the yet unnamed artery leading to the profound hypotension and cardiovascular shock, necessitated urgent, central line placement in a depleted vasculature.
What makes you a good expert for this case?
Because I perform robotic gastric bypasses every week, and have been doing it in roughly the same way for the last 11 years.
How often do you encounter cases similar to this one in your practice?
I have never encountered a severe arterial injury in a gastric bypass case that I have ever done
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