HospitalInspections.org

Based on interview and record review, the facility failed to complete a detailed operative report for a surgical procedure for one patient (#6) of four patients reviewed for surgical services resulting in incomplete documentation. Findings include:

On 5/15/23 at 1314 during initial chart review, it was identified that Patient #6 (Pt #6) had a surgical procedure done on 8/5/22.
On 5/16/23 at 0839 during interview with Nursing Administrator, staff QQ, Chief Medical Officer, staff Z, and Chair Department of Surgery, staff XX, the process of dictating complete post-procedural report and reasonable expectations were discussed. Staff XX indicated that the surgeon's report needs to include performed procedure in detail. When asked if his expectations are to include in report information about laterality, if procedure was performed on both sides, implants used, and staff who performed the procedure, he said "yes". During interview, it was confirmed that Pt #6 had a Repair Left Inguinal Hernia Laparoscopy with mesh, Repair of Recurrent Incarcerated Right Inguinal hernia converted to open, Right orchiectomy procedure on 8/5/22. Procedure was performed by attending general surgeon, staff CC, with assistance of second year surgical resident, staff DD, and fifth year surgical resident, staff FF. Surgery start time was recorded at 1301 and end at 1514. Post-operative surgeon dictation/report was identified and reviewed with staff Z. Staff Z confirmed that report did not appear to be complete.

Pt #6's peri-operative electronic medical record review on 5/16/23 at 1030 revealed the following operative report signed and dated by physician CC on 08/05/22 at 1301:
"Preoperative diagnosis: Recurrent right inguinal hernia with bowel in the scrotal sac.
Postoperative diagnosis: Left inguinal hernia and recurrent incarcerated right inguinal hernia.
Procedure:
1. Laparoscopic repair of left inguinal hernia.
2. Open repair of recurrent incarcerated right inguinal hernia with simple right orchiectomy.
Anesthesia: General.
Surgeon: Dr. (name, staff CC)
Estimated blood loss: About 500 mL (milliliter).
74-year-old male known to me from history of hernia repair with recurrence, was going down to scrotal sac affecting his mobility. Patient was evaluated by me in the office in the presence of his daughter. He was given the option to proceed with laparoscopic (minimally invasive surgical technique used in the abdominal and pelvic areas) extraperitoneal (located or taking place outside the peritoneal cavity) repair, possible open. Risks and benefits of procedure, including bleeding, infection, recurrence, need for further operation, possible convert to open, possible operation may not resolve his symptoms were discussed in detail with him and his daughter. They understood all these risks and benefits and elected to proceed with surgery. Informed consent was obtained. Patient brought to operating room, placed in supine position. After induction of anesthesia, Foley catheter (a sterile tube that is inserted into a bladder to drain urine) was placed. An attempt to reduce the hernia was not successful. After, we put the patient in Trendelenburg position (patient on their back on the surgical table, and their head is angled down). Subsequently, abdomen was then prepped and draped in standard fashion. Peritoneal cavity was accessed in left upper quadrant using Veress needle (a spring-loaded needle used to create pneumoperitoneum for laparoscopic surgery), creating pressure of 15 mmHg. Subsequently, 5 mm trocar inserted in the left upper quadrant, 1 in the left lower quadrant, 1 in the epigastric area (upper abdomen, just below the ribs and above the belly button). It appeared this patient has hernia on the left side, which we planned to repair after we reduce the hernia on the right side. Attempt to reduce the hernia on the right side using graspers was not successful. At this time, we proceeded with making an incision from umbilicus. Incision taken through subcutaneous tissue and fascia and muscle laterally and the peritoneal space was dissected and with the balloon, subsequently trocar was placed filling the preperitoneal space to a pressure of 15 mmHg and we placed another two 5 mm trocars. We were able to reduce the hernia sac, which was all large, measuring about 3 cm in diameter, but overall was direct and subsequently dissected lateral epigastric vessels and placing a large piece of mesh in this area. Looking at this recurrence and all was in the deep ring away from the mesh, it looks the mesh had retracted medially. The plan was to go ahead and open another incision just on the top of the rectus sheath, dissecting lateral in the area and hoping we can place a piece of mesh in the area without opening the patient. When we did that, we were able to dissect, however we could not reduce the hernia and we were moving between intraperitoneal and extraperitoneal trying to reduce, it was not successful. At this time, decision was taken to proceed to open, where incision was made and taken through subcutaneous tissue to the fascia. External oblique aponeurosis (a thin but strong membranous structure, the fibers of which are directed downward and medially) was incised. This patient has a lot of bowel (sic) down in the scrotal sac and separating the hernia sac and the spermatic cord, kind of pushed a Penrose (a soft, flexible latex tube) around it and tried to reduce it, it was not successful. Subsequently, I pulled the testicle out of the scrotum. Taking into consideration the large size of the hernia and the large opening and the deep ring and the patient's age, the decision was to go ahead and proceed with orchiectomy (surgical removal of one or both testicles) at the same time since there is colon and small bowel in this area and we need to push it back and I want to give him better repair, where the testicle was separated from the scrotal sac using electrocautery and tie ligation and subsequently, the testicle was ligated at the deep ring using 0 Vicryl tie. Freeing up the hernia from all its adhesions, I pushed it back in the preperitoneal cavity. On re-inspection of the scrotal sac, there was no active bleeding. We then proceeded with approximating the hernia by approximating the shelving edge of the inguinal ligament to the conjoined tendon in interrupted fashion and other layers were approximated, the external oblique aponeurosis in the running fashion. At this time, we saw some bleeding coming in from the opening that we had in the rectus sheath lateral to the midline and we extended the incision. It appeared this patient had a bleeding from the epigastric vessels, where some bleeding was evacuated, ligated the vessels and placing the camera again and there was hematoma resolved. We went ahead and closed the skin in the bottom and the subcutaneous tissue. Looking again, there was no evidence of bleeding. We closed the anterior sheath of the rectus using 0 Vicryl on fascia. The skin was approximated with staples. At the end of procedure, sponge and needle count correct. Patient tolerated procedure well and went in good condition to recovery room. Electronically signed by (staff CC), MD at 08/07/22 0822".

Further review of the intra-operative records for Pt #6 indicated that staff DD, resident was assisting in this case, with the start time 1259 (no end time recorded) and one more resident was assisting, staff FF, with start time 1259 (no end time). It was not noted in surgeon's report what specific surgical tasks residents performed during procedure. Also, record revealed that CapSure Permanent Fixation System was used to secure the mesh on the left side, (a soft tissue mesh anchor, non-bioabsorbable and considered to be an implant). Information about this type of the implant was not included in the surgeon's report. Hemostatic powder Surgicel was used in the left abdominal area, per nursing documentation, to control the bleeding. Information about this type of the implant was not included in the surgeon's report. No record of multiple incisions for ports (during laparoscopy) closure and dressing were found.

On 5/17/23 at 1000 during interview with attending general surgeon, staff CC, and residents, staff DD and FF, details of the surgical procedure were discussed as well as sequence of the procedure. Staff CC acknowledged that documentation on the operative report could be more detailed and need to address minimal required information (name of assistants, description of their performed significant surgical tasks, exact laterality when describing bilateral procedure, and devises implanted).