miércoles, 21 de enero de 2015

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web ► Bowel Injury After Laparoscopic Surgery Commentary by Krishna Moorthy, MD, MS

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

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Bowel Injury After Laparoscopic Surgery
Commentary by Krishna Moorthy, MD, MS

The Case

A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mesh placement. The patient had no significant past medical history and did not take any home medications. He was expected to stay a few hours after the surgery and then be released the same day.

The surgery went uneventfully, but after surgery, the patient continued to have high levels of pain at the surgical site. He was then admitted to the hospital for monitoring and pain control. As the team that performed the surgery had already left for the day, a resident physician who was unfamiliar with the patient provided overnight coverage. The night resident was called to the patient's bedside multiple times overnight by the charge nurse to address the patient's pain, and the resident ordered additional intravenous pain medication. When the primary surgical team arrived in the morning, they increased the patient's standing pain medication regimen and he was expected to be released that day or the next at the latest.

The patient remained in sustained pain and the surgical team was called to the bedside multiple times over the next 2 days. His physical examination was documented as unremarkable, and he was started on a patient-controlled analgesia (PCA) pump with hydromorphone. On postoperative day 2, the patient was weaned off the PCA and started on a clear liquid diet. However, the next day, he continued to have abdominal pain and became increasingly tachycardic with slight abdominal distention and a low-grade fever. A computed tomography scan of the abdomen was ordered, and the patient was found to have a bowel perforation. He was sent urgently back into the operating room in order to fix the perforation, and postoperatively required a lengthy stay in the intensive care unit due to septicemia. He did eventually recover and was discharged home.

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