On May 8, 2023, Patient, a 37-year-old female, underwent a Laparoscopic Assisted Vaginal Hysterectomy with Bilateral Salpingo-oophorectomy at X Hospital for abnormal uterine bleeding and fibroids.
During the initial trocar entry, an enterotomy (bowel perforation) was noted, requiring a general surgery consultation and laparoscopic repair. The surgery was further complicated by extensive intraperitoneal adhesive disease, necessitating adhesiolysis, and the case was converted to a Pfannenstiel incision.
In the immediate post-operative period, Patient experienced significant complications. Her hemoglobin dropped from 10.3 gm/dL on May 8 to 7.6 gm/dL on May 10, indicating worsening anemia 57. Additionally, she developed leukocytosis with a white blood cell count of 15.39 on May 9. These findings suggested a potential infection or other post-operative complication.
Following her discharge, Patient's condition continued to deteriorate. Patient repeatedly attempted to reach out to Doctor A about said issues. Dr. A did nothing with the Patient's concerns.
On May 18, Patient was diagnosed with mild superficial wound cellulitis and prescribed Bactrim. However, the infection persisted, and by May 23, purulent bloody drainage was noted from the incision site, leading to an extension of the Bactrim course to 14 days. Despite these measures, the infection continued to progress, and on June 1, Flagyl was added to her antibiotic regimen.
The severity of Patient's condition became evident when a wound culture from June 1 returned positive for ESBL-producing Klebsiella pneumoniae, a multi-drug resistant organism. This finding necessitated more aggressive treatment, and on June 5, Patient was urgently admitted to X Hospital for IV antibiotic administration. The Infectious Diseases consultation diagnosed deep surgical site infection with possible peritonitis, positive for ESBL Klebsiella pneumoniae.
The subsequent medical treatment was extensive and prolonged. Patient was started on IV Ertapenem, a powerful antibiotic, for a planned three-week course. To facilitate this treatment, a midline catheter was placed on June 8, which was later replaced on June 12. From June 12 to June 29, Patient received daily outpatient infusion therapy with Ertapenem 1g IV at the Y Hospital Infusion Center.
Throughout this period, Patient experienced significant discomfort and anxiety. She reported intense stomach pain and an overall feeling of sickness during the IV antibiotic infusions. She was also extremely anxious about administering IV antibiotics at home and requested an ambulatory infusion center.
The complications and subsequent treatments had a significant impact on Patient’s health and well-being. She experienced persistent anemia, requiring ongoing monitoring and treatment. The multi-drug resistant infection necessitated a prolonged course of powerful antibiotics, which likely contributed to her ongoing discomfort and anxiety.
Would you say that the Course of treatment for Patient shows potential areas of medical negligence, including, but not limited to:
• The initial surgical complication (enterotomy) and its management;
• The delayed diagnosis and inadequate treatment of the wound infection;
• The persistent and severe anemia that was not fully resolved; and
• The questionable cervical suture dehiscence.
Files:
Q: There is no mention in the initial submission about a cervical suture dehiscence. Can you elaborate on this?
A: —
Do you believe there might have been medical error?
This is a very long and involved case with multiple areas where a more aggressive course would’ve helped. First off, during the course of surgery the patient is noted to have multiple adhesions. Was there something in her medical history/surgical history, that would’ve suggested that an open procedure, rather than laparoscopy would’ve been more appropriate? Having an anatomy during initial insertion of a true car is not in itself medical negligence. Furthermore this was identified and repaired by a surgeon. Again, however, if she had a complicated surgical history beforehand, laparoscopy may not have been the best choice to proceed initially, but rather go right towards an open procedure. Given her postop history, combined with the complications beforehand, it does not seem that any antibiotics were used postoperatively. Furthermore, given her blood loss, were there any x-rays such as a CAT scan done to see whether or not she had intra-abdominal bleeding? The patient is discharged and said to try to contact her doctor ( Dr. A), who did not respond until later. Again, given the complications of this case, this in itself is negligence as the patient required immediate attention. When the diagnosis of cellulitis was made, was there any further attempt to try to drain the wound, obtain a culture at that time, or even perform an ultrasound to see if there are underlying abscesses. The patient then goes on to have drainage, which is apparently cultured as the diagnosis of Klebsiella is made on June 1. From that point forward, the patient needed to have aggressive antibiotic treatment. However, no further diagnosis intro abdominally was done to see whether or not the patient had possible complications from her anatomy such as fistula formation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
While, any surgery can have complications, it is the discovery and handling of these complications that will often lead to a successful outcome, or further injury and problems for the patient. Again, to make a long story short, this patient may have benefited by proceeding with an open procedure, rather than laparoscopy given the findings at the time of surgery. Also her medical/surgical history, which is unknown at this time, may have reinforced these decisions. Postoperatively, it does not appear the patient was started on antibiotics, which given the complications, would certainly have been recommended. Upon discharge, the patient tries to get in touch with her physician, but does not get treated until nine days later. Given the scope of the complications, actively, and postoperatively, this in itself is a dereliction of duty. Finally, upon discovery of the offending organism, intensive antibiotic care is administered. However, it does not appear that any other diagnostics, such as ultrasound, or x-rays, to search for other causes of the patient’s issues, such as an abscess, fistular formation, etc., which may need further surgical correction are present.
What makes you a good expert for this case?
I’ve been in practice privately for 34 years. I have performed dozens upon dozens of hysterectomies, both open, vaginal, and laparoscopically. The hospitals where I worked, had residents which I personally trained and instructed and also assisted with their own clinic cases as well. Presently, I have engaged in numerous expert opinions and reports for a different law firms. I have written expert reports as well as performed depositions.
How often do you encounter cases similar to this one in your practice?
In our own practice, these may occur once a year since we use direct view entry upon laparoscopy, which assist greatly in avoiding these, as well as being very judicious as to which patients are good candidates for laparoscopic versus open type of procedures. While assisting the residents with their cases, they might see one or two of these every six months. Furthermore, postoperative infections of various types occur very frequently with our own and the resident service cases and so I am well-versed in postoperative infection and care of the patient
Do you believe there might have been medical error?
Based on the information provided, there appears to have been a potential medical error, primarily in the postoperative management rather than necessarily in the occurrence of the bowel injury itself. An enterotomy during laparoscopic entry can be a recognized complication, especially in the setting of dense adhesions, and is not by itself proof of negligence. However, once that complication occurred, the patient became high risk for serious postoperative infection and other intra-abdominal complications. The more concerning issue is the apparent delay in recognizing and appropriately escalating treatment for the postoperative infection. The patient had warning signs including worsening anemia, leukocytosis, persistent pain, repeated complaints, wound cellulitis, ongoing purulent drainage, and ultimately a deep surgical site infection with ESBL Klebsiella requiring hospital admission and prolonged IV antibiotics. If the treating physician failed to timely evaluate the patient’s complaints, perform appropriate reassessment, obtain imaging or cultures sooner, or escalate to hospital-based care earlier, that may represent a deviation from the standard of care. The postoperative hemoglobin drop was also significant and may not have been adequately investigated. Overall, the case raises substantial concern for delayed diagnosis and delayed treatment of serious postoperative complications.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the information provided, it is likely that the suspected medical error contributed to the patient’s injury. The most plausible causation issue is not the initial bowel injury alone, which may have been a recognized surgical complication, but the apparent delay in identifying and aggressively managing the postoperative infection and other warning signs. The patient went on to develop a deep surgical site infection with ESBL-producing Klebsiella pneumoniae, required hospital admission, placement of vascular access, and a prolonged course of IV Ertapenem. If the patient’s repeated postoperative complaints, purulent wound drainage, persistent pain, leukocytosis, and other concerning findings had been addressed earlier with timely reassessment, culture, imaging, drainage if indicated, and escalation to hospital-based care, it is likely that the severity and duration of the infection-related injury could have been reduced. At a minimum, the delay appears likely to have contributed to prolonged pain, prolonged treatment, greater emotional distress, and a more extensive recovery.
What makes you a good expert for this case?
I am a board-certified OB/GYN with 28 years of clinical experience, including the performance and management of gynecologic surgery and postoperative complications. In addition to my direct clinical work, I have served on a peer review committee, where I evaluated physician decision-making, complications, and adherence to standards of care. That combination of long-standing clinical experience and formal peer review work makes me well qualified to assess the surgical and postoperative issues presented in this case.
How often do you encounter cases similar to this one in your practice?
In a 28-year OB/GYN practice, I have encountered similar cases on multiple occasions, including patients undergoing hysterectomy and other pelvic surgery with extensive adhesive disease, bowel injury risk, and postoperative infectious or wound complications. Bowel injury itself is uncommon, but it is a recognized complication in gynecologic surgery, and I have had experience both managing such complications clinically and evaluating them through peer review.
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