General Surgeon Causes Bladder Injury During Bowel Obstruction Procedure

This case involves a patient who was diagnosed with a sigmoid stricture and partial small bowel obstruction that was repaired by surgical means. Shortly after the original procedure, the patient underwent a sigmoid colectomy with Hartmann pouch placement, colostomy placement, and repair of a bladder injury which occurred during a previous surgery. Several months later, a general surgeon closed the colostomy and removed some bowel adhesions. During this procedure, the surgeon punctured the patient’s vaginal cuff with surgical staples, causing the formation of a colo-vaginal fistula, which resulted in the patient passing stool through her vagina. A decision was made to place an ileostomy to divert stool and allow healing prior to a redo of the anastomosis created by the staple wound. One month later, the patient underwent another procedure where the surgeon noted that the rings of the EEA stapler anastomosis could easily be visualized and that on the vaginal exam there was an opening at the distal posterior end of the vaginal cuff that was in communication with the rectum. The patient had to undergo several additional repair procedures and did not fully recover from the formation of the fistula.

Question(s) For Expert Witness

1. What is the standard of care in repairing or treating intestinal fistulas?

Expert Witness Response E-001161

The preferred procedure involves excision of the fistula tract, with segmental resection of involved bowel and anastomosis of the remaining bowel. If an unexpected abscess is encountered or the quality of the bowel wall is suboptimal, some surgeons may consider a primary anastomosis unsafe, instead choosing to perform a staged procedure, with exteriorization of the ends of the bowel during the first procedure. A staged repair may also be more appropriate in cases in which advanced malignancy or severe radiation changes are expected. If the procedure is performed for a malignancy, the involved segment of bowel is removed to negative margins.