Sep 05 2017
An unnecessary diagnostic laparoscopy was performed on a 44-year-old woman for complaints of a 2-3 week history of pelvic pain and pressure, thought to be caused by a relatively small, resolving left ovarian cyst. The woman, who was a CNA (certified nursing assistant) at NorthShore University HealthSystem, was at high risk for surgery due to her medical history, which included pelvic and abdominal adhesive disease from multiple prior pelvic surgical procedures. The laparoscopic procedure resulted in bowel perforation that was not diagnosed at the time of laparoscopy and resulted in the emergent re-admission of the woman 2 days later. The bowel perforation ultimately led to peritonitis, severe sepsis, respiratory failure and the woman’s death, while still in the hospital. The surgeon failed to perform an appropriate physical examination of the woman prior to surgery, which would have likely been negative and would have been an additional indication not to perform surgery, exposing the patient to an unnecessary risk of harm. Once the procedure began, the surgeon observed dense adhesive disease upon entry, which should have been a clear indication to either discontinue the surgery or convert to an open procedure, to minimize the risk of injury to the abdominal organs or tissues. Additionally, it was alleged, the surgeon failed to appropriately examine the bowel, prior to ending the procedure, to be certain injury to the bowel had not occurred during the dissection and biopsy of the abdominal cyst. The patient, a wife of 17 years and mother to a teenage daughter, was unable to recover from the massive infection and passed away approximately 6 weeks following the initial laparoscopy.