Bowel Perforated During Vaginal Mesh Procedure

This case involves a female patient that underwent surgery to excise a sacrocolpopexy mesh that eroded into her vaginal wall. Postoperatively, the patient was afebrile and vitals were noted to be normal. The following day, the patient began to suffer from abdominal distention, anuria, abdominal pain, and tachycardia. A CT scan revealed extravasation of contrast in the pelvis from an intraluminal source. An exploratory laparotomy was performed and the operative findings indicate that there were several loops of proximal small bowel with gross perforation in the pelvis around the area of mesh removal. Two large perforations were identified, one of which was almost a complete transection through the bowel with a suture present in the bowel wall. Approximately eight to ten centimeters of bowel was removed and sent to pathology for review. The patient was also noted to have had an arrhythmia during her hospitalization. This occurred between post-op days seven and eight. A chest X-ray revealed that her bi-lateral pleural effusions and cardiac enzymes were slightly elevated. An echocardiogram revealed a small pericardial effusion with an ejection fraction between 30% and 35%, severe tricuspid regurgitation, and severe pulmonary hypertension.

Question(s) For Expert Witness

1. What are the accepted perioperative complications of this procedure?

Expert Witness Response E-000733

Immediate perioperative complications include bowel obstruction, peritonitis, urine leak from failed intraoperative recognition of a cystotomy, and infection from a perforated bowel. Although most of these complications occur rarely, they must be included in the differential when symptoms occur. Delayed bleeding is a rare complication but should be entertained in a patient who is hemodynamically unstable. This patient's bowel obstruction should have been noticed sooner and it would have significantly altered the outcome.