Wednesday, April 1, 2020

Case Summary: The patient in this case underwent an abdominal hysterectomy with bilateral salpingectomy for refractory uterine bleeding. She had previously undergone an appropriate workup and conservative approach to her abnormal uterine bleeding. After failing all of these measures, including hormonal medications, a hysteroscopy, and dilation and curettage of the uterus, she underwent definitive surgical therapy with removal of her uterus and fallopian tubes by the defendant, Dr. M. The operative note states that there was endometriosis implants on the anterior lower segment of the uterus at the vesico-uterine reflection which were cauterized and that the bladder flap was dissected from the lower uterine segment with sharp and blunt dissection. A Foley catheter was utilized during the entire case, estimated blood loss was minimal and the operation lasted for a normal amount of time.

The patient was discharged home post-operatively, but presented to the ER for shortness of breath, right calf pain, nausea and abdominal pain just two days later. She was ruled out for a PE by a CT scan, but was believed to be in some degree of renal failure. Post-operative day #5, the patient was seen by Dr. M, as well as a nephrologist for her elevated creatinine. She had been having symptoms of abdominal bloating and difficulty having a bowel movement, despite different regimens given to the patient. Post-operative day #6, the patient had continued complaints of nausea, vomiting and constipation and abdominal distension, as well as difficulty urinating. A cystogram was ordered by another physician, which demonstrated a posterior bladder wall defect which is the area of dissection from the hysterectomy. The patient was placed on levaquin antibiotics and was scheduled for surgical repair the following day. The patient ended up developing allergic interstitial nephritis, subsequent acute renal failure and C. Diff. Fortunately, she did end up making a near, complete recovery.


Questions/Allegations: Did the defendant follow the applicable standard of care for an open hysterectomy? Was the bladder perforation appropriately diagnosed and treated? If not, did the undiagnosed bladder case further complicate and affect the length of the patient's recovery from the surgical procedure?


Expert Findings: AMFS’ expert (Obstetrics & Gynecology) reviewed this case matter and provided the following opinion: Based upon my review of the records, my education, experience and training, it is my opinion the Dr. M did not comply with the standard of care at all times with respect to his care of this patient. There is no documentation of the inherent risks of a surgical procedure discussed with the patient and the potential risk of injury to any of the surrounding organs. There is no mention of any evaluation or assessment of the bladder integrity during or immediately following the completion of the abdominal hysterectomy, either by inspection, administration of an intra-venous dye which concentrates in the bladder, or by direct visualization with cystoscopy. His post-operative progress notes do not mention her capabilities to void, or her urine output, or if this was even evaluated. Had such an evaluation taken place, it is likely that an intervention would have occurred sooner and most of the complications that the patient endured would have been avoided.