Colostomy take-down, 2 surgeons working together. Stapler gets put in vagina and is anastamosed to the colon.

[wamcp]

How does this occur?

Expert Witness Case #38

If you’re a fan of medical literature, you’re probably familiar with Oliver Sacks’ book The Man Who Mistook His Wife for a Hat. I wouldn’t compare myself to Sacks, but I will borrow his naming convention and adapt it for today’s case: The Surgeon Who Mistook A Vagina for a Rectal Stump

expertwitness.substack.com

Mrs. L was a 66-year-old woman who presented to the ED with abdominal pain.

Workup revealed perforated diverticulitis.

She was admitted and had a diverting colostomy.

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18 months later she had a take-down of her colostomy.

The general surgeon who did the initial surgery and a fellowship-trained colorectal surgeon operated together.

Allegedly, they mistakenly formed a complete anastamosis between her vagina and colon.

The patient hired an attorney and a lawsuit was filed.

Both the general surgeon and colorectal surgeon are named Dr. M.

The lawsuit is ongoing with a trial scheduled for October 2022.

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[LucidSplash]

Have you ever been involved in one of these cases? All kinds of scar tissue in the pelvis and using an EEA stapler. Admittedly this is bad. Sounds like someone put the EEA into the vagina instead of the rectum which is... bad. Importantly they didn’t recognize the error immediately and fix it. A pretty serious error. If they had recognized it and fixed immediately probably not malpractice. But I guess that is for a jury to decide. I can see not realizing it from the inside but not realizing that you inserted the EEA into the wrong orifice is pretty bad. Maybe a trainee did that part and they didn’t verify?

A warning to everyone that no one is above a serious error. Trust but verify.

 

[Dr.LeoSpaceman]

How does this occur?

Get @SLUser11 in here.

People joke about this, but that's because it happens. I know of it happening to two otherwise skilled, careful CR surgeons. However in both of those cases it was a low rectal stump in a reoperative pelvis (with prior hysterectomy), and both times it was noted intraoperatively.

To answer the question of "how", it's all speculation. But my guess is that they didn't adequately dissect the rectal stump from the cervix/vaginal vault anteriorly. Because of that when the stapler went into to the vagina it "looked" like it was in the rectum, and my guess is that the spike from the EEA came out of the rectal stump making it appear like they were in the right spot. The fact that the uterus was still in makes it seem even worse.

As the expert notes, though, it could have also been that the stapler was in the rectum and they incorporated a piece of the vaginal wall. That too could result from inadequate dissection to define the rectal stump and the vagina.

What really kicks this up a notch is that they apparently did flex sig and didn't realize what happened.

 

[LucidSplash]

Get @SLUser11 in here.

People joke about this, but that's because it happens. I know of it happening to two otherwise skilled, careful CR surgeons. However in both of those cases it was a low rectal stump in a reoperative pelvis (with prior hysterectomy), and both times it was noted intraoperatively.

To answer the question of "how", it's all speculation. But my guess is that they didn't adequately dissect the rectal stump from the cervix/vaginal vault anteriorly. Because of that when the stapler went into to the vagina it "looked" like it was in the rectum, and my guess is that the spike from the EEA came out of the rectal stump making it appear like they were in the right spot. The fact that the uterus was still in makes it seem even worse.

As the expert notes, though, it could have also been that the stapler was in the rectum and they incorporated a piece of the vaginal wall. That too could result from inadequate dissection to define the rectal stump and the vagina.

What really kicks this up a notch is that they apparently did flex sig and didn't realize what happened.

BMI could have played a role too. We have all had those patients where finding the correct orifice is a little bit guesswork/rule out.

 

[dpmd]

Have seen other people put it in the wrong hole but it gets figured out before the stapler is deployed. When I do these I put a finger partially in vagina and then find the rectum. You would be surprised how hard it is to differentiate the two in some people, especially the fat ones not optimally positioned on the table. So I work downwards from the Foley and thus far have escaped an error.

 

[DoctwoB]

Have seen other people put it in the wrong hole but it gets figured out before the stapler is deployed. When I do these I put a finger partially in vagina and then find the rectum. You would be surprised how hard it is to differentiate the two in some people, especially the fat ones not optimally positioned on the table. So I work downwards from the Foley and thus far have escaped an error.

Haha, we do the opposite for “difficult” female foleys. Usually due to habitus, poor exposure, and not trying enough to facilitate exposure. Finger in the vagina, when foley goes anterior must be in urethra.

 

[mestielest]

These things happen, unfortunately. Once I forgot a sponge, for instance.

 

[deleted50541]

Horrifying. I did a fair number of these cases in residency with several very skilled CR surgeons. They usually tagged the rectal stump with Prolenes at the first operation, so they at least had some idea where it was, anticipating a scarred mess in the pelvis at the re-do. The Prolenes definitely helped, but still not a cake walk. If they hadn't done the original surgery though, then who knows what we'd find.

As a resident, I definitely put the EEA stapler at least once in the vagina of a larger woman, but I realized my error immediately.

 

[anonperson]

How does this occur?

Expert Witness Case #38

If you’re a fan of medical literature, you’re probably familiar with Oliver Sacks’ book The Man Who Mistook His Wife for a Hat. I wouldn’t compare myself to Sacks, but I will borrow his naming convention and adapt it for today’s case: The Surgeon Who Mistook A Vagina for a Rectal Stump

expertwitness.substack.com

Mrs. L was a 66-year-old woman who presented to the ED with abdominal pain.

Workup revealed perforated diverticulitis.

She was admitted and had a diverting colostomy.

---

18 months later she had a take-down of her colostomy.

The general surgeon who did the initial surgery and a fellowship-trained colorectal surgeon operated together.

Allegedly, they mistakenly formed a complete anastamosis between her vagina and colon.

The patient hired an attorney and a lawsuit was filed.

Both the general surgeon and colorectal surgeon are named Dr. M.

The lawsuit is ongoing with a trial scheduled for October 2022.

I'm sure the pelvis was a complete mess.

It is interesting that they made this mistake even when she had a uterus in place. But in a 66 year old post menopausal woman, the uterus will be fairly small and potentially easy to miss.

Bad case and I can't imagine this is going to end well for the surgeons.

This is a good reminder to always be cognizant and aware of the procedure at hand. It can be easy to get into a zone for certain procedures where you are almost working with muscle memory and not really thinking things through.

Stop and double check your work.

 

[Dr. Salah Salih]

I think the complication can occure by any surgeon to keep in mind that no one above the complications.
One of the criteria of good surgeon is the early detection of the complication & how to deal with it.
Finally "It's wise to check twice"