An otherwise healthy adult patient presented to the
emergency department (ED) with left lower quadrant
pain, which had gradually increased over a two-day
period, and mild nausea. The patient’s temperature
was 100 degrees, and the physical exam was negative except for lower abdominal rebound tenderness
and guarding. Lab assessment was normal except for
a white blood cell (WBC) count of 14,000 with a left
shift. An abdominal and pelvic computed tomography
scan revealed sigmoid diverticulitis. The patient was
admitted, responded to antibiotics, and discharged five
A month later, a colonoscopy revealed only diverticular disease. During the next six months, two more
attacks occurred that were somewhat milder but that
required outpatient antibiotics; a laparoscopic anterior
resection was performed.
When the stapled anastomosis was checked intraoperatively with transrectal air, some air bubbles
were noted. However, ongoing attempts to identify
additional bubbles revealed none. It was decided to
accept the anastomosis as intact without further
The patient did well initially. However, on the
fourth postoperative day, the patient complained of
mild lower abdominal pain. The patient’s temperature was normal and tenderness was compatible with
postoperative expectations. The WBC count was stable
at 9,000. Because the surgeon was looking forward to
beginning a long weekend off and the patient was
eager to go home, a hasty generic handoff between
the primary surgeon and call partner included plans
for discharge on afternoon rounds.
That evening the call partner was busy and late for
rounds. The patient wanted to go home. Finally, at the
request of the patient, the surgeon was called. Happy
to have one less patient to see, the call partner authorized discharge by verbal order.
The next evening, the patient presented in the ED
with moderately severe generalized abdominal pain
that had increased throughout the day. The abdo-
men was moderately tender with mild rebound in all
quadrants but worse in the left lower quadrant. Blood
pressure was 140/80, pulse was 96, and temperature was
99 degrees; the WBC count was 12,000. A transrectal
Gastrografin study revealed extravasation of contrast
into the left lower quadrant, and a computed tomogra-
phy scan showed a large amount of free air throughout
the abdomen. The patient was admitted and treated
with antibiotics and intravenous fluids.
On rounds the next morning, the findings were
unchanged, but later that evening, pain increased, blood
pressure dropped to 90/60, and the pulse increased to
140. Oxygen saturation was 92 percent on room air.
The surgeon was called, a fluid bolus and pressors
were given, and the patient was taken to the operat-
ing room. A Hartmann’s procedure was performed
for a leaked anastomosis. In the operative note, the
possibility that the circular stapling device may have
misfired was mentioned.
Multi-organ system failure ensued. Three months
later, after several more procedures for intra-abdominal
abscesses, the patient was released from rehab with
a granulating abdominal wound, loss of mental
capacities, amputation of several digits, a healing tra-
cheostomy site, and a colostomy.
This case involved a leaked anastomosis—a known,
albeit infrequent, complication of anterior resection
even in the hands of experienced, skillful surgeons.
Having documented favorable prior experience with
laparoscopy and the double-stapling technique, the
primary surgeon’s technical skills and scope of prac-
tice were validated.
Although brought into question, systems failure
related to a failed stapling device was never proven.
Systems-related problems beyond our control often
are sought to explain failures and avoid personal
An intraoperative cognitive error may have
occurred: Was it a false hypothesis error to conclude
that the air bubbles were trapped air, and should the
procedure have been converted to open? In any case,
the team was diligent, making ongoing efforts to dem-
onstrate additional bubbles, which failed and led to an
informed but possibly incorrect decision to complete
the procedure laparoscopically. Failing to think is unac-
ceptable; failing to think accurately is human.
The clearly preventable errors that followed were
caused by behavioral and cognitive deficiencies. Diligent professional behavior required that the call partner