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Repair of incisional hernia performed as a day procedure (07HDC00329)

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(07HDC00329, 20 November 2007)

General surgeon ~ Surgical day unit ~ Incisional hernia ~ Day procedure ~ Standard of care ~ Information ~ Rights 4(1), 6(1)

A woman complained about the care provided by a general surgeon to her husband following the repair of a ventral hernia with a hernia patch. The man was discharged home at noon, several hours postoperatively. At 4.30pm he developed severe abdominal pain. He was reviewed shortly afterwards by the surgeon, who prescribed intravenous analgesics and injected subcutaneous analgesia into the wound. The man remained relatively pain free throughout the evening.

In the early hours of the following day, the man experienced further abdominal pain. The surgeon returned to see him shortly afterwards and increased the flow from his anaesthetic pump. At 4am, the man's wife informed the surgeon that brownish fluid was leaking from her husband's wound. The surgeon assumed that the leak was an overflow of subcutaneous analgesia, and decided not to review the man until later that morning.

From approximately 6am, the man began vomiting, and the surgeon was contacted. As the man was not in pain at that time, the surgeon proceeded to attend a personal appointment. He arrived at the man's home at approximately 10.15am, and observed "very dark material" oozing from the wound. As this was indicative of a small bowel fistula, the man was transferred to hospital for corrective surgery.

It was held that it was not appropriate for the man to have been operated on as an outpatient despite his past medical history and presentation. Having discharged the man home several hours following surgery, the surgeon was responsible for ensuring that any subsequent complications were appropriately managed. The surgeon did not provide an appropriate standard of care and breached Right 4(1).

It was also held that the man was not given the opportunity to evaluate the pros and cons of day surgery as opposed to inpatient surgery for his hernia operation. The surgeon did not provide adequate information prior to performing the surgery, and breached Right 6(1).

This case highlights the need for surgeons to adequately review patients' medical and surgical history when deciding whether to perform a particular procedure as a day case or as an inpatient. In instances of previous significant complications, patients should be offered the alternative of having surgery in hospital. Where a procedure is performed as a day case, it is important for surgeons to attend to subsequent complications promptly, including transferring patients to hospital for review.

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