Please see photos attached and the operative notes below Case description.
PC is a 70 year old female who went to the ER on 5/25/23 for abdominal pain for one week. CT of the abdomen showed sigmoid diverticulitis with contained perforation and 6.2 cm perisigmoid abscess. Seen by general surgery and they did a Hartmann’s procedure 5/26/23. Post procedure day one, PC was having peritonitis with intra-abdominal fluid collection and abscess. CT showed two encapsulated fluid collections in the pelvis. Original surgeon did IR guided drainage on the abscess on 6/4. However, still continued to have several episodes of fecal matter draining from the wound and the lower JP drain as well as right lower abd wall celliulitis. Was still being tee’d up to be discharged and the family wasn't happy with the original surgeon, they asked for original surgeon be removed from caser asked for a second opinion. Second surgeon did an I&D of the abdominal abscess without any complication (6/9/23). PC had very slow recovery, however did eventually recover with IV antibiotics and was eventually discharged.
While seeing PC post op in late June, the nurse practitioner noticed that there was significant green discharge from her surgical site/wound. PC was found to have a large ventral pelvic wound with high volume enterocutaneous small bowel fistula track to the skin and had to be admitted (see dated photos) 2nd surgeon saw PC and elected conservative treatment of fistula, to put her on TPN for 12 weeks.
This was his note when he saw the surgical site on 6/26/23 “I had a lengthy discussion with the patient regarding the findings. I recommend she go back to the hospital for admission. We can then get this fistula on control. Patient does not appear ill to me and I am hoping that we can get this under control, continue wound care and plan good nutrition and get this fistula to heal spontaneously with time. I explained this to the patient. I explained that she may need to be on IV nutrition versus oral nutrition depending on the output of the fistula. She voiced understanding. She will head to the emergency room now for admission”
However, after 2 weeks it was obvious that that plan was not going to work because PC still continued to have foul content leaking from abdomen. August 30th 2023, 2nd surgeon did small bowel section and reverse the colostomy and begin the process of repairing the fistula. PC was eventually discharged from the hospital however had significant complications and extended hospitalization from the first surgery.
Concern for first surgery being substandard. Also, is this wound consistent with the post surgical healing process? Is this a post-surgical failure by rehab?
Looking for general surgeon who is familiar with Hartmann's and performs regularly.
Thank you in advance for your opinions.
Please see attached photos and operative notes:
Original OP note:
The patient was taken to the operating room and placed in a supine position. General
endotracheal anesthesia was induced. The patient was placed in a lithotomy position. All bony prominences were padded and the patient was secured time-out was completed verifying correct patient, site, procedure, ASA class, the patient's allergies, administration of preoperative antibiotics, the fire risk, and any special equipment needed. A lubricated cystourethroscope was passed through the urethra and the bladder was entered. The right ureteral orifice was identified and cannulated with an open 5 French catheter. 3 cc of ICG followed by 1 cc flush normal saline was placed. The catheter was removed and the left ureteral orifice was identified and cannulated. 3 cc of ICG followed by 1 cc flush of saline was placed. The catheter remained indwelling. It was removed at the end of the case. The cystourethral scope was removed and a Foley catheter was placed. A lower midline laparotomy incision was made and extended to above the umbilicus. The skin and subtenons tissue were dissected down to level the fascia and the fascia was carefully entered and the Bookwalter retractor was placed. There is significant malodorous pus on entry to the abdominal cavity. The mid pelvis contained a thickened and acutely inflamed loop of sigmoid colon felt very hard and was surrounded by an abscess cavity that had been walled off internally by the small bowel and omentum. The left ovary was adhered to
the base of the sigmoid mesentery. The uterus was in situ and appeared to have walled off a portion of the pericolonic abscess. The antimesenteric edge of the loop sigmoid colon was gangrenous. The sigmoid colon was resected. This was done by passing a contour green load stapler just distal to the point of perforation after clearing off the sigmoid
mesentery around it. Bilateral ureters were palpated and free of the stapler prior to firing the stapler. The proximal colon was transected after control of the mesentery and once again palpation of the bilateral ureters with a GIA 80 mm stapler.
The pelvis and left lower quadrant were re-inspected and found to be hemostatic and without evidence of abscess/purulence. 1 flat 10 mm JP drains were then placed through the right lower abdominal wall . 2-0 nylon suture was used to secure the drain to the skin.
Attention was then turned to creating the end colostomy. The site for this colostomy had been previously marked, and a circular incision was made approximately the size of a nickel. A small amount of subcutaneous fat was removed with this skin incision. The fascia was then opened vertically and a muscle splitting technique was used to gain access into the abdomen. This colostomy site easily accommodated 2 fingers. The descending colon staple line was
grasped and delivered through the colostomy site. There was difficulty in delivering the colon through this site due to the amount of inflammation in the colonic mesentery and the large epiploica.to the table. The perineum was prepped and draped in the surgical fashion. A All packs were removed from the abdominal cavity prior to closure. The omentum was brought down to the pelvis and left lower quadrant. The midline abdominal fascia was closed using 0-looped PDS suture from either end. The subcutaneous tissue was irrigated with saline solution, and the skin was closed with a skin stapler. The lower midline incision was isolated from the left side of the abdomen during maturation of the stoma. The colostomy was matured in standard Brooked fashion using 2-0 vicryl sutures. An ostomy appliance was placed around the new end colostomy. A- pressure incisional dressing was placed to the midline incision. The patient tolerated the procedure well without complications. Estimated blood loss was 100 mL. I was present and scrubbed for the entire duration of the operation. The patient was extubated in the operating room and brought to the recovery room in stable condition.
I&D Op Note: Patient was taken the operating room, placed in the supine position and
identified by the surgical and anesthesia staff. The abdomen was prepped and draped in usual sterile fashion. Was performed. Patient had a open lower portion of wound with partial fascial dehiscence however to the right of this the subcutaneous tissue had a tunnel with unroofed abscess spanning approximately 10 to 15 cm right lateral in the subcutaneous fat there were 2 draining sinuses. I widely open this area full-thickness to the level of the fascia exposing abscess and necrotic fat. This was irrigated until clear. Debridement was performed of any necrotic tissue. The wounds were then packed with normal saline wet-to-dry Curlex. Sterile dressing was applied. Patient tolerated the procedure well.
Files:
No questions yet!
Do you believe there might have been medical error?
Sounds like the colon was not properly sealed at the original surgery. That is a known complication of the surgery however I think the error is not taking the patient back on POD 1 when she had peritonitis and fluid collection on CT.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the patient is taken back on POD 1 most likely she would have avoided the multiple complications and problems.
What makes you a good expert for this case?
I am an OK expert. I’ve done 100s of colon and small bowel surgeries including hartmanns procedures and have also had my own patients have colonic leak and have had to manage them as well.
How often do you encounter cases similar to this one in your practice?
I have seen and managed about 10-12 really bad colonic leaks that have led to multiple complications including hernia and wound dehiscence like this one.
Do you believe there might have been medical error?
This is a known complication of sigmoid colectomy particularly given that she had a contained perforation prior to her first surgery.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
the reason for the fistula are multiple, it could be a complication of her her perforation with a pre-existing fistula that declared itself after surgery, or it could have occurred at the time of the drain placement. hard to tell
What makes you a good expert for this case?
As an acute care surgeon , I perform this operation about 20/year. these are challenging cases
How often do you encounter cases similar to this one in your practice?
2-3/year, Though this is rare, this complication is well known
Do you believe there might have been medical error?
This is a common complication of complicated diverticulitis. The patient had an abscess from the perforation, and the developemtn of an intra abdominal abscess or abdominal wall abscess does not breath the standard of care. The op note read correctly. patient also appears obese. probably had other risk factors that can lead to this issue.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Common complication from a Hartmanns procedure, especially with perforation and abscess. The surgery was done correctly. The develpement of an abscess after colectomy is not a breach in the SOC
What makes you a good expert for this case?
This is the type of surgery I do monthly. Very common complication from perforated diverticulitis with abscess
How often do you encounter cases similar to this one in your practice?
very often. I have performed hundreds of these types of operations. High risk for abscess and infection especially after a perforation
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