**ALL OP NOTES ATTACHED BELOW**
Otherwise healthy 64-year-old gentleman has elective hiatal hernia repair and fundoplication for chronic acid reflux disease on May 3rd 2023. 3 weeks post-surgery, PC having increased lethargy and discomfort in his chest. June 3rd 2023, rapid deterioration in health with hematemesis and goes to a stand alone emergency room. Initial abdominal CT with contrast reveals herniation of most of the stomach into the lower chest. Modern dilation of the stomach and complete decompression of the distal intra-abdominal portion of the stomach with possibility of gastric outlet obstruction. He continues to decline and receives multiple units of blood. He is emergently transported to a larger facility with higher capabilities. The next day, he is taken for exploratory laparotomy. Was found to have ischemic stomach, hemoperitoneum, hard adhesions at the hiatus which made it inaccessible for evaluation. They evacuate the abdominal hematoma and do an open partial gastrectomy.
This procedure plus 7 days, PC went from stable to significant deterioration once again. CT abdomen and CT esophagram show distal esophageal perforation near the GE junction that extends into the left pleural cavity. He was emergently transported yet again to another facility with thoracic surgery.
He was emergently brought for a left thoracotomy repair of the esophageal perforation. During this procedure, it was found that one of the tie knot stitches had been placed through the pericardium causing dense adhesion between the pericardium, left ventricle and the fundoplication. This procedure had no complications as noted. PC eventually recovered approximately 3 weeks later. As of today, PC is a full health.
I have enclosed all three surgical notes for review. Our request is for review of the initial hernia repair and fundoplication. It appears this is where the poor-placed stitching would have happened. In addition, we would request that the surgeon who offers an opinion would be familiar and well-versed in the NIssen fundoplication and with this particular repair. Is there any issue with the second exploratory laparotomy? Was there timely and proper addressing of the PC’s symptoms and complications?
Original OP Note:
After the above procedure was described to the patient proper consent was obtained and placed in the chart. The patient was brought to the operating suite laid in supine position and general anesthesia was achieved. The anterior abdomen was prepped and draped in the usual sterile fashion, preoperative antibiotics were given, proper identification of the patient and the procedure was performed. An incision was made just above the umbilicus using an Optiview trocar the abdomen was entered under direct visualization insufflated to 15 mmHg and the patient tolerated this insufflation well. That time a laparoscopic was inserted revealed no injuries to the surrounding viscera from trocar placement. Next 2 5 mm trocars were placed just below the left costal margin in the midclavicular line and 1 in the anterior axillary line. Another 5 mm trocar was placed in the right midclavicular line just below the costal margin and a subsequent stab incision was made just below the xiphoid and Nathan some liver retractor was placed. At that time the gastrohepatic ligament was taken down with Harmonic scalpel as my partner retracted the stomach to the left. Dissection was carried up to the right crus which was identified and again with gentle retraction by my partner on the stomach to the right and the crus to the left the GE junction was identified in the mediastinum. Dissection was then carried to the anterior side of the GE junction and down down the left crus. Next attention was turned toward the short gastric vessels as my partner then retracted the omentum to the right and I retracted the stomach to the left to short gastric vessels were taken down dissecting into the lesser sac. This dissection was carried back up to the left crus which was then easily dissected free again pulling the GE junction down into the abdomen. An anatomical right to left dissection was then carried posterior to the GE junction revealing the left crus from the right side. Approximately 3-4 cm of intra-abdominal esophagus was obtained. Next as my partner retracted the GE junction to the anterior abdominal wall the posterior crus was then closed with an 0 Ethibond suture in figure-of-eight fashion with a TKA device used to secure the knot. Next the fundus of the stomach was brought posterior to the GE junction tethered in 3 separate locations at the 10 o'clock position with 0 Ethibond suture in a TKA device used to secure the knot. In mere image fashion the fundus of the stomach was then tacked at the 1 o'clock position with 0 Ethibond sutures to the GE junction for approximately 2 cm of length of a wrap. At that time the Nathan sent liver retractor was removed as the abdomen was allowed to deflate Valsalva maneuvers were performed.All wounds were irrigated and 0.5% Marcaine mixture 2% lidocaine was infused for postoperative analgesia. The skin of all incisions were then closed with a running 4-0 Vicryl in subcuticular fashion. Skin glue was placed and the procedure was terminated at the end of the procedure all sponge needle instrument counts were appropriate. The patient went to the postanesthesia care unit stable extubate condition.
Exploratory Lap Op Note:
Patient is taken to the OR hemorrhagic shock on multiple
pressors and metabolic acidosis. Patient is prepped and draped and a surgical
time-out performed. Generous midline incision is made with a 10 blade. Blood
was pouring out from the abdomen. After evacuation of the hematoma with
suction and multiple lap sponges Bookwalter retractors were placed. Small
bowel was run from the ligament Treitz to the terminal ileum. The small bowel
was fine. The right and left colon were evaluated with no evidence of bleeding.
Attention was then paid to the area of the fundoplication. Initial inspection
showed bright red blood in this area verses dark blood in the other areas of the
abdomen. This is probably the area of bleeding. Several short gastrics
appeared to have been avulsed. This is ligated using EnSeal energy device.
Further inspection of the stomach showed that the greater curvature was
ischemic. There are multiple serosal tears. Small gastrotomy was made to
examine the contents. There appeared to be no active bleeding in the stomach
surface. Patient was actively in hypotensive shock on multiple pressors and
coagulopathic. Further dissection was carried to the hiatus. Here there was
hardened scar tissue which did not appear to be amenable to lysis of adhesions.
There were dense adhesions chest which could not be pulled through to the
bottom. Total gastrectomy was not a viable option as the GE junction was not
clearly accessible in the scar tissue. In addition ongoing hypertension on
multiple pressors with acidemia and coagulopathy not allow for extensive lysis of
adhesions. The spleen was seen and appeared normal without evidence of any
avulsion or tears. Liver was also intact without any tears or injuries. Once the of
ulcer short gastrics and the additional short gastrics were ligated the up. The
stomach on the greater curvature appeared to be ischemic. Small gastrotomy on
the greater curvature was used to evaluate the pylorus and it was patent and
there was no evidence of gastric outlet obstruction as evidence on earlier
imaging. A 48 French bougie was introduced. This was used to tubularize the
viable portions of the stomach on the lesser curvature. Babcocks were used to
grasp the area of ischemic stomach on the greater curvature. Multiple fires of the
GIA 75 blue load and afire of the 45 mm echelon blue load was used to resect
the partial stomach on the greater curvature. The 48 French bougie was used to
ensure patency of the tubularize the stomach. April line was then reinforced with
a running 3-0 Vicryl. The area of the hiatus was hemostatic however Arista and
Surgicel was applied in this area to augment hemostasis. 19. Blake drain was
taken through the left side of the abdomen placed in the area of the staple line.
The drain was secured with the 2-0 silk. The abdomen was irrigated with
Aricept. Fascial layer was closed running 1. Looped PDS from superior to
inferior inferior superior and tied in the middle. The wound was irrigated with
Aricept and then the skin was closed with skin staples. Generous amount of
local anesthesia was injected throughout the incision and the drain site.
Dressings were applied. All surgical counts were correct. Surgical debrief was
Performed.
Thoracotomy Esoph perforation repair OP Note:
He was positioned right lateral decubitus. The left chest was prepped with
Betadine solution. Sterile drapes were placed. A left posterolateral thoracotomy
was performed. Soft tissue interstitial edema was evident by clear water running
down the drapes confirming severe septic shock. The latissimus dorsi muscle was
severed with electrocoagulation. The serratus anterior was detached at its
insertion point from the chest wall. The left chest was entered through the 7th
intercostal space.
There was approximately 2 L of empyema fluid which was drained in the cannister.
The lung was completely encased by a dense fibrotic, yellow, white fibrous cap.
There were multiple intra fissure, posterior mediastinum, and superior aspect of
the chest abscesses. Two Toufier retractors and a Baulfor retractor were placed in
the chest to allow for exposure and inspection of the chest cavity. With
combination of blunt and sharp dissection the left lung was freed superiorly
posteriorly and anteriorly. The inferior pulmonary ligament was taken down with
electrocoagulation and the posterior mediastinal pleura was opened with
electrocoagulation from the hiatus all the way to the aortic arch.. There were
dense adhesions at the hiatus. Esophagus was dissected off the descending
thoracic aorta. There was murky fluid in the area. The proximal and mid
esophagus were then encircled with a 1/2 inch Penrose drain which allowed for
retraction of the proximal and mid esophagus. Dissection of the crus was
performed using electrocoagulation to the level of the Toupet repair. Dense and
mature adhesions were found at the level of the hiatus as well as the chronic
inflammatory changes. A 360° dissection of the hiatus was done. Attention was
paid to protect descending thoracic aorta posteriorly and the pericardium
anteriorly during dissection. Once that was accomplished, the repair was brought
into the chest and mobilized. Several stitches with tie-knot were encountered at
this location. Of noticed, 1of the stitches/tie-knot had been placed through the
pericardium. Dense adhesion was found between pericardium, left ventricle and
the fundoplication. Diligent dissection was carried out so to protect the
pericardium and the left ventricle and isolate as well as mobilize the
fundoplication off of it. The chest was then filled with 2 L of normal saline
solution. Insufflation ofthe esophagus with O2 through the nasogastric tube
allow was to identified a 1cm hole in the tip of the Toupet gastric
fundoplication. Once the Toupet fundoplication was completely undone, it was
amputated by firing a 45 mm green stapler. Once again, air leak test was carried
performed. There was no leakage. The suture line was reinforced with 2-0 silk
sutures.
Intra operative EGD was performed at this time of the operation. The scope was
advanced through the upper esophageal sphincter without any difficulty. It was
navigated through the proximal and mid esophagus which mucosa appears to be
normal. The scope was then advanced into the gastric conduit with aid of digital
palpation. There was no signs of bleeding, ulcerations, or tumors. With digital
palpation were able to feel the scope. Once again a insufflation test was carried
out. There was no signs of leak. The gastroscope was then removed. A
nasogastric tube was advanced into the gastric conduit with palpation and
measured 55 cm from the incisors.
Next, a complete pleurectomy decortication of the visceral pleura was carried out
removing a large amount of fibrothorax. The left lower lobe appears to be
consolidated with signs of intraparenchymal hemorrhage. The chest was once
again irrigated with 3 L of normal saline solution and suction. Three chest tubes
and a Blake 24 French which was placed into the right hemithorax were placed.
Hemostasis appears to be adequate.
All the sponges, needles, instruments counts were correct.
The chest was then closed with 4 pericostal 2. Vicryl sutures. The muscle was
reapproximated with 0 Vicryl sutures. Subcutaneous tissue was closed with 2-0
The patient was then transferred to the CV ICU in critical but stable conditions
Files:
No questions yet!
Do you believe there might have been medical error?
The esophageal perforation likely happened during the second operation, the exploratory laparotomy/take back. It is not clear from this operative note when the wrap was taken down in order to perform the partial gastrectomy due to ischemia. It would be surprising for the greater curvature of the stomach to become ischemic, unless during the first operation, they came across the left gastric artery. It would be important to look at any CT scans to ensure that the left gastric artery is patent, and was not accidentally sacrificed during their dissection up towards the hiatus. It’s unclear from any of the operative notes when a stitch was placed in the pericardium. This is obviously concerning and raises questions about the technical experience and expertise in performing this operation. It would also be important to know the timing of the second operation. If there was a delay in diagnosis that could’ve significantly contributed to this patients complications.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Several observations mentioned in the operative note are inconsistent, and don’t paint a clear picture of the events necessary to perform, said procedures.
What makes you a good expert for this case?
I’m an academic surgeon at a tertiary referral center who is fellowship trained in complex surgery,, robotics, and laparoscopy.
How often do you encounter cases similar to this one in your practice?
I take care of gastro intestinal and foregut pathology frequently as part of my duties, ass an assistant, professor of surgery at Ohio State University.
Do you believe there might have been medical error?
Having an esophageal perforation is a known complication but have a stitch in the pericardium is unusual
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Given the deterioration after the initial operation, the gastric necrosis and the damage to the pericardium, this was caused by the hiatal hernia repair without which it would not have happened
What makes you a good expert for this case?
I am an acute care surgeon/Trauma with experience in gastric resection
How often do you encounter cases similar to this one in your practice?
Rarely, have a pericardial injury from a funduplication is rare
Do you believe there might have been medical error?
No suture should be through the pericardium during fundoplication.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Suture into the pericardium most likely was full thickness through the stomach causing gastric leak, which caused the dense adhesions between the left ventricle, pericardium and fundoplication. Also the stomach was anchored to the pericardium so it was probably "too tight" of a wrap. The stomach should only be wrapped and sutured to itself and to the esophagus, and not the diaphragm or pericardium
What makes you a good expert for this case?
I'm not the best expert for this case, I have done probably 20-30 of these but this is not a regular case that I do anymore.
How often do you encounter cases similar to this one in your practice?
I don't do these anymore.....I have not worked clinically for 3 years now. I was doing about 2-3 per year before that and had done probably 15-20 in residency.
Do you believe there might have been medical error?
The first operation did not follow the standard dissection. The surgeon did not mention removing or dividing the hernia sac from the pericardium. It is next to impossible to reduce a paraesophageal/hiatal hernia without completing either. A bougie as not utilized to assist in forming the fundoplication. This surgery involves being in the chest and adjacent to the pericardium. Nor was an upper GI completed to ensure no leak and good position of the wrap. Either the initial surgeon did not complete the correct procedure OR did not document the entire case. The sutures found at the third procedure were the same type of suture placed at the initial operation. The second procedure utilized a different type of closure system.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
An ischemic/perforated stomach 3 weeks after the initial surgery is a rare event especially in a 50 year old patient. I suspect the operation failed early in the post-operative course and cause a traction injury to the remaining short gastric vessels. The initial surgery and associated operative note do not discuss entering the chest which as stated is impossible for this type of surgery.
What makes you a good expert for this case?
I have completed 100s of the laparoscopic nissen fundoplication and repair of the hernia defect. I have never heard of such a complication. The appropriate steps of the surgery were not performed. In all of my cases, I had one perforation from the bougie placed by the Anesthesiologist and thank god the patient did well after a stent. The case raises questions about the initial surgeons skill, understanding of anatomy and ability. I am a general surgery board examiner and the surgeon would have "failed" this question on an oral board exam.
How often do you encounter cases similar to this one in your practice?
I encounter paraesophageal hernias weekly because of the high utilization of CT scans. However, not all are symptomatic, nor do all need surgery. It is a very advanced surgery and patient selection is essential.
Do you believe there might have been medical error?
I would need evaluation of imaging- but basic imaging should have demonstrated a significant issue going on in the chest. In addition, it makes no sense the short gastrics would be actively hemorrhaging- this would either be due to trauma during first case or that the bleeding had nothing to do with the short gastrics and was rather due to hemorrhaging from the hole in the heart. Finally, very unclear how there was a stitch in the left ventricle (shouldn't be anywhere near the usual anatomy for fundoplication). Finally there was acute failure of the hiatal repair- why is this? again seems as though multiple inappropriate stitches placed
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
errors during the first surgery would have never led to mulitple repeat surgeries also question second surgery and why such a delay in chest findings
What makes you a good expert for this case?
I am a foregut surgeon- specializing in hiatal hernia/antireflux/bariatric surgery
How often do you encounter cases similar to this one in your practice?
I have never heard of this happening before during this kind of case.
Want to open a case or submit response?
Comments are accepted only from Surgery (General Surgery) experts.