Description of Event or Problem · 1
THE PT UNDERWENT LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS SURGERY FOR MORBID OBESITY. DURING THE PORTION OF THE PROCEDURE IN WHICH THE SURGEON CREATED THE REVISED STOMACH POUCH, ENDOGIA 60 X 3.5MM STAPLER (US SURGICAL) WAS USED TO SEPARATE THE STOMACH WITH A SERIES OF FIRINGS USING GORE SEAM GUARDS TO REINFORCE THE SUTURE LINE. AFTER COMPLETION OF A PORTION OF THE FIRING, THE SURGEON NOTED OPEN MUCOSA IN THE NEWLY CREATED STOMACH POUCH, INDICATING THAT THE STAPLER HAD INADEQUATELY FIRED STAPLES INTO THE TISSUE IN ORDER TO SECURE THE INCISION LINE. THE SURGEON NOTED THAT THE STAPLES, WHICH ORDINARILY HAVE A SIDEWAYS "B" SHAPE, INDICATING CLOSURE, WERE IN AN INVERTED "U" SHAPE, INDICATING THAT THEY HAD NOT CLOSED. AS A RESULT, THE SURGEON CONVERTED TO AN OPEN LAPAROTOMY PROCEDURE IN ORDER TO REPAIR THE AREA, USING A COMBINATION OF STAPLES AND OVERSEWING. AFTER THIS WAS COMPLETED, THE SUTURE LINE WAS DETERMINED TO BE SOUND, AND THE REMAINDER OF THE CASE PROCEEDED WITHOUT COMPLICATION. THE US SURGICAL REP WAS CALLED TO THE OPERATING ROOM TO INSPECT THE STAPLE GUN AND THE STAPLES. THE REP TESTED THE DEVICE AND STATED THAT THE DEVICE FIRED PROPERLY. ON POST OPERATIVE DAY #2, THE PT DEVELOPED A FEVER TO 102 DEGREES. A SEPTIC WORKUP WAS INITIATED, INCLUDING CHEST X-RAY. THE PT DID NOT REPORT ANY OTHER COMPLAINTS. THEY REMAINED NPO WITH A NASOGASTRIC TUBE IN PLACE. THEY REQUESTED TO GET OUT OF BED TO A CHAIR. THEY WERE ASSESSED BY THE STAFF NURSE. THEY DID NOT REPORT ANY COMPLAINTS AND APPEARED COMFORTABLE. THEY REQUESTED ASSISTANCE TO RETURN TO BED. UPON RETURN TO BED, A STAFF NURSE NOTED SEROUS FLUID ON THEIR ABDOMINAL DRESSING. THIS INFO WAS REPORTED TO THE PT'S NURSE WHO IMMEDIATELY ASSESSED THE SITUATION AND THEN PAGED THE SURGICAL RESIDENT TO EVALUATE. THE NURSE RETURNED TO THE PT'S ROOM IN ORDER TO OBTAIN A CULTURE SAMPLE OF THE DRAINAGE, AS WELL AS TO REINFORCE THE DRESSING. AT THAT TIME, THE PT WAS NOTED TO BE UNRESPONSIVE AND WAS NOT BREATHING. A CODE WAS CALLED AND RESUSCITATION EFFORTS WERE IMMEDIATELY INITIATED BUT WERE UNSUCCESSFUL. PRELIMINARY AUTOPSY RESULTS REVEALED THAT THE STAPLE LINE IN THE DEFUNCTIONALIZED STOMACH, HAD FAILURE, HOWEVER, A SPECIFIC CAUSE OF DEATH HAS YET TO BE DETERMINED. THE GORE SEAM GUARDS ADD APPROX .5MM IN THICKNESS TO THE MUCOSA. ONE HYPOTHESIS WAS THAT THE STOMACH MUCOSA MAY HAVE BEEN UNUSUALLY THICK AND THAT THE COMBINATION OF THE SEAM GUARD AND THICK MUCOSA MAY HAVE OVERWHELMED THE STAPLER (STAPLE SIZE WAS 3.5MM) ALTHOUGH THE STAPLE GUN DID FIRE AND DID NOT EMIT A CLICKING NOISE THAT WOULD INDICATE THAT THE GUN HAD NOT FIRED OR MISFIRED. THE DEVICE WAS DISCARDED AT THE TIME OF THE PROCEDURE. IT WAS NOT THOUGHT TO BE DEFECTIVE BY NURSING STAFF AND MFR REP AVAILABLE WITH THIS CASE.