Colorectal Surgery Expert Witness Advises on Proctectomy Resulting in Erectile Dysfunction

A Wyoming-based colorectal surgery expert witness advises on a case involving a 35-year-old male patient who was diagnosed with Crohn’s disease. His past medical history included perianal disease requiring several incisions and the drainage of several fistulas. In October of 2011, prior to a protocolonectomy, which was performed in April of 2012, he developed a stricture of the upper rectum/sigmoid. He was brought into the operating room for an attempted resection at that time. However there was apparently a great deal of inflammation and his rectum had thickened to the point that one of the treating surgeons felt that it was unsafe to perform an anastamosis so instead he performed a Hartman procedure. Following the Hartman procedure the patient became chronically anemic and required blood transfusions. The surgeon recommended a total protocolonectomy to the patient with the express promise that following the surgery his life would be “completely normal,” except for his colostomy bag, and that he would be able to return to work.

It is alleged that there was no discussion concerning potential complications of the procedure in general or sexual dysfunction in particular. The surgery appears to have been divided into colectomy and proctectomy and was performed by two separate teams each consisting of a resident and an attending surgeon. The colectomy was performed through the previous midline abdominal incision which was extended inferiorly for the procedure. During the procedure, some of the patient’s omentum had been found to be stuck on the right side of his abdomen and several loops of bowel were found to be matted together medial to his previous colostomy. The patient’s colostomy is reported to have been very adherent. It was transected at the abdominal wall within the peritoneal cavity and the external portion was removed separately by dividing it off of the rectus muscle. At that point, the rectum was mobilized circumferentially within the peritoneal cavity before using a bovie cautery and a ligature device. The patient’s pelvis was found to be very narrow and the rectum was found to be thickened, leaving little working room and making the dissection difficult. The report indicates that the dissection was performed laterally and anteriorly “as best we could.” The prior colectomy site was closed and a new opening about the size of a nickel was created in the skin in a circular fashion. The end of the ileum was removed through an opening large enough to allow the passage of two fingers. The operative report for the proctectomy indicates that it was performed perineally in an intersphincteric plane. The operative report indicates that the rectal dissection was connected with the abdominal part of the dissection and that the dissection was carried out 360 degrees around the rectum. Because the rectum was very thickened, it could not be taken out from the perineal side and was removed through the abdominal part of the dissection. Hemostasis was achieved with electocautery and a suture tie. Since the procedure, the plaintiff has suffered complete erectile dysfunction, which no amount of sex therapy or medical attention has been able to remedy thus far.

Question(s) For Expert Witness

1). Could there have been any alternative medical or surgical treatments other than the performance of a total protocolonectomy?

2). Could you look at the medical records to determine if erectile dysfunction is the result of poor surgical technique?

Expert Witness Response E-006363

As the Chief of Colorectal Surgery at my institution, I routinely perform this procedure, around 200 times per year. Although erectile dysfunction is a known complication of the surgery and is well documented in the literature, my rate of instances is extremely low compared to my peers I have an instance rate of 7% compared to an average of 40-50%. It is imperative that the risk of this complication occurring be discussed at length and in detail with the patient prior to taking him to the OR. I have previously served as an expert in a similar case where a patient suffered erectile dysfunction following pelvic surgery. I would need to review the medical records, including the endoscopy and pathology reports before I could opine as to whether or not an alternative procedure would have been more appropriate for this patient. That said, it'd be my pleasure to review this matter on behalf of the plaintiff.