Page 23 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

CASE STUDY

continued
documentation was added to the medical record to
reflect that the pertinent risks or injuries were shared. Nor

did the documentation confirm that the patient had an

opportunity to ask questions.

The patient underwent a laparoscopic colon resection on

April 27, which included the removal of a 5cm malignant
sigmoid tumor. Pathology identified a T3N1 lesion with

one of 32 lymph nodes as positive. The post-op course
was uneventful and by May 1, the patient was eating and

voiding without difficulty and vital signs were stable. He
was discharged on May 2.

On May 6, which was post-op day nine, the patient
presented to the ER with chest and LLQ pain. His

bloodwork showed a slightly elevated white blood cell

count, but his creatinine was stable. Clear yellow fluid was
leaking from the trocar site in the right-upper quadrant
of his abdomen. The abdomen was noted to be non-

tender and the patient was hungry and said he felt better,

so he was discharged. On May 8, the patient saw his
primary care physician and was found to have moderate
abdominal tenderness, but his abdomen was not

distended so he was told to see the surgeon. No notes are

available regarding that visit, but the patient did see the
surgeon on May 22, and the notes from that visit indicated
that the patient had no complaints and no drainage from

his wounds.

On June 5, he felt a “pulling” sensation in the right lower
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