1. PEDIATRIC SURGERY Poornima Vanguri Jessica Potter Alex Starks

2. Cases (~4 weeks) PGY-1 PGY-2 PGY-3 PGY-4 PGY-5 Total 6 20 NA 42 NA 68

3. MR NumberAge/SexAttendingResident/FellowDiagnosisDeath Y/NOperationComplicationABAction Name DxNoList ProcedureList ComplicationEJ1 18mo/MLange/SharmaEspino/GuptaHepatoblastoma NO 3/23 - Right hepatectomy, 4/1 - Roux-en-y Hepaticojejunostomy 4/17 - BacteremiaPD2 Removal of port-a-cath 11y/FLangeVanguri/LewRelapsed Neuroblastoma No 4/7/15 - Left neck deep cervical lymph node biopsy 4/15 - Neck hematomaPD1 Observation, platelet transfusion 16y/MOiticica/LanningVanguri/LewSigmoid Volvulus No 4/29/15 - Laparoscopic sigmoidectomy5/4/15 - Sigmoid leak requiring re- exploration and central line placement with pneumothorax, 5/9 - Intraabdominal abscess/sepsis ET3 Multiple re-explorations, transfer to ICU, IR drainage 15y/FHaynesRosatiUlcerative Colitis No 4/24/15 - Laparoscopic subtotal colectomy5/15/15 - Readmission, intraabdominal abscess, parastomal abscess ET2 Re-exploration, drainage of abscess 18y/MHaynes/LangeVanguriUlcerative coltis No 5/22/15 - Laparoscopic completion proctectomy, ileoanal anastomosis 5/30/15 - wound infection at ileostomy site PD1 Opened and packed wound 17y/MBagwellVanguriSpontaneous pneumothorax No 5/26/15 - Left VATS, blebectomy, mechanical pleurodesis 6/15/15 - Readmission, recurrent left pneumothorax PD1 New pigtail, operative intervention Assessment: A Error in Technique (ET) Error in Judgement (EJ) Error in Diagnosis (ED) Systems Error(SE) Patient Disease (PD) Assessment B 1. - Error unavoidable or minimal effect on patient outcome 2. - Preventable Error 3. - Error with significant deleterious effect on patient outcome

4. Complication Date: 4/29/15 Procedure: Laparoscopic Sigmoidectomy Patient: Faculty/Residents: Oiticica/Lanning/Vanguri/Lew Complication: Anastomotic leak Assessment: Error in technique, Preventable Error, Error with significant deleterious effect on patient outcome

5. Case 16 year old boy presented for elective Laparoscopic sigmoidectomy PMH: Constipation Sigmoid volvulus – that had been reduced (by sigmoidoscopy) once at OSH Learning disability – (minimally communicative) PSH: none

6. Procedure 4/29/15 Findings: Colon appeared torsed at time of surgery, was reduced Sigmoidectomy performed laparoscopically with ligasure and Endo GIA purple loads, sigmoid extracted through umbilical incision, freed colon to the splenic flexure for anastomosis No leak noted when rectal stump tested Anastomosis with 33 EEA stapler, no leak appreciated on leak test Appeared to be without tension or contamination

7. Post-operative course Diet was advanced but minimal return of bowel function Serial abdominal exams demonstrated tenderness but without obvious peritoneal signs but exam limited by patient’s ability to communicate Remained afebrile, with normal heart rate, WBC 3 Imaging demonstrated free air which was “possibly due to operative intervention”

8. Imaging Acute Series

11. As there was question due to the large amount of free air but minimal symptoms, gentle gastrograffin enema performed “Fecal material extending across the anastomosis. Although no contrast extravasation was definitively identified at the anastomosis, there was only minimal retrograde contrast passage through this area.” Due to failure to progress, unreliable clinical exam and persistent free air, decision was made to re-explore

13. Re-exploration 5/4/15 Findings: Diffuse fecal peritonitis Dehisced staple line Procedure: Oiticica/Lanning/Vanguri Oversewed dehisced staple line, diverted with end descending colostomy, closed fascia Monitored in PICU, started on TPN, broad spectrum abx Fevers, negative cultures, +ostomy output on POD3 Obtained CT due to persistent fevers – multiple fluid collections

14. CT  OR 5/9/15 Haynes/Vanguri Findings: Multiple purulent fluid collections that were drained and irrigated, dehiscence of oversewed staple line, ostomy intact Procedure: washout, resected dehisced portion of Hartmann’s pouch, ABthera placement Washed out on 5/11/15 (Lange/Wheeler) Edematous bowel, no obvious leak noted, ABthera replaced OR 5/13/15 (Oiticica/Vanguri) Washed out and closed fascia, no evidence of pus or leak

15. Post-op Course Remained in ICU, on TPN, on abx Continued to spike temps, cultures were overall negative except for intra-abdominal cultures Repeat CT on 5/16/15 Bilateral fluid collections – drained by IR Slow return of bowel function and improvement in diet Discharged on 6/12/15

16. Analysis of Complication CLAVIEN DINDO CLASSIFICATION Grade III: Requiring surgical, endoscopic or radiological intervention Grade III-b: intervention under general anesthesia Grade IV: Life-threatening complication (including CNS complications)‡ requiring IC/ICU-management

17. Root Cause Analysis - Fishbone Diagram Pre-op Intra-op 1. Torsed Bowel 1. Creation of ostomy at initial procedure? 2. Unprepped bowel 2. Use of double staple technique – compromise vascular supply or increased tension? 1. Re-operated sooner 1. Leak 2. Resection vs. 2. Intraabdominal sepsis Oversewing leak 3. ICU care, prolonged hospital stay Post -op Outcome

18. Teaching Point: Factors for Creating an Anastomosis Tension-free Adequate blood supply Avoid contamination Pre-operatively consider nutrition status, other medical conditions

19. Teaching Point – Signs of Anastomotic Leak Tachycardia Fever Abdominal pain Drainage from wound Nausea Hypotension Decreased Urine Output

21. Sigmoid Volvulus

22. Cecal Volvulus

27. CT

28. CT 5/8/15

34. CT 5/16