I have reviewed the medical records in this case and as requested, providing my opinion regarding the medical care given to Mrs. Annita S. I am certified by the Division of Gynecologic Oncology of the American Board of Obstetrics and Gynecology and in active clinical practice in the state of **.
Medical records from ** medical center, including H&P and operative report of Dr. H and consultation by **, M.D. and operative report by **, M.D.
This patient is a 54-year-old woman with a 20 cm uterine fibroid that increased in size by ultrasound exam on 2/21/2013 compared to one done a year before. An MRI on 2/27/2013 indicated central necrosis of the fibroid. The patient had hysterectomy and removal of ovaries and tubes on 4/5/2013. The operative report stated that a vertical incision was made and the fascia was incised and “ the fascia was separated from the underlying muscle”. A blood loss of 1700 cc was noted, but there was no indication as to how this occurred. “Surgical was placed on the incision “ , but this location is unclear. Indigo carmine was given and the mid ureters inspected, but no reason for doing this was given. The patient received 2 units of blood during the procedure and 2 more units postoperatively and 2 units later for a total of 6 units. She was discharged on 4/8/13 and the last Hgb was 8.5.
She returned to the hospital on 2/10/13 with incisional bleeding and anemia and received another unit of blood. CT scan indicated a 11cm x 6 cm x 6 cm abdominal wall hematoma and pelvic fluid collection. Her incision was opened, 14 cm in length and 10 cm deep with an evacuation of old blood and clots. It was irrigated and packed. On 4/13/13 evisceration of the bowel occurred and Dr. Powell did an exploratory laparotomy and abdominal wall closure with # 1 Prolene and Smead – Jones technique.
The operative report stated that a vertical incision was made and the fascia was incised and “ the fascia was separated from the underlying muscle”. This is not done with a vertical incision, only with a transverse incision. This can provoke abdominal wall bleeding and is a departure from the standard of care.
This patient had massive blood loss during hysterectomy, but the operative report is notable in making no mention of how this occurred. Surgical was placed, but the location of the persistent bleeding is unclear. The ureters were visualized and indigo carmine given, but why this was done was not stated. It is a departure from the standard of care to fail to document details of significant operative complications as occurred here.
There were no progress note records describing the patient’s incision or clinical condition to determine if she was discharged prematurely on 4/8/13.
The abdominal wall hematoma and subsequent evisceration and exploratory laparotomy were a result of the extensive bleeding and fascial dissection of the operation on 4/5/13.
Dr. H departed from standard of care by:
- Dissecting the fascia from the muscle in a vertical incision
- Having massive blood loss during operation with no documentation describing how this happened.
- Surgical placement indicates persistent bleeding, but the location was not identified in the op report.
- Indigo carmine infusion and visualization of the ureters is often done with difficult dissections, but no details of any such problems were stated in the op report.
- The abdominal wall hematoma and subsequent evisceration and exploratory laparotomy were a result of the extensive bleeding and fascial dissection of the operation on 4/5/13.
I reserve the right to amend my opinions subject to additional information