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Wrong site surgery


A 72-year-old woman was referred by her primary care physician to a gastroenterologist for evaluation of right lower quadrant abdominal pain.

Physician action

The gastroenterologist performed a colonoscopy that revealed a 3 mm sessile polyp in the sigmoid colon and a 25 mm pedunculated polyp in the recto-sigmoid colon. Both polyps were removed. The pathology report noted that the specimen labeled “sigmoid colon polyp” demonstrated villous adenoma with focal areas of high-grade dysplasia.

Two weeks later, the gastroenterologist performed a flexible sigmoidoscopy and partially resected a 30 mm polyp in the sigmoid colon with a hot snare. This polyp, labeled as “rectum hot snare,” was biopsied and interpreted as invasive well/moderately differentiated adenocarcinoma arising from a pre-existing villous adenoma.

During an office visit a month later, the gastroenterologist handwrote that the patient’s chief complaint was “rectal CA” with a further handwritten note stating “F/U Rectal CA.” However, his handwritten impression was “colon cancer.” The patient was told that she had sigmoid colon cancer, and a referral was made to a general surgeon.

The next day, the general surgeon saw the patient and noted a history of a mass in the sigmoid colon and that she was referred to him for a colon resection. The records sent from the gastroenterologist included the colonoscopy report, a handwritten impression of colon cancer, and the pathologist’s report from the sigmoidoscopy. The surgeon diagnosed the patient’s condition as sigmoid colon cancer. He planned a laparoscopic sigmoid resection, after cardiac clearance and CT scan. 

Four days later, the patient underwent an abdominal CT scan that revealed “nonspecific irregular wall thickening in the right lateral aspect of the rectum, adherent stool versus infiltrating mass.”

Three days later, the patient was admitted for a sigmoid colon resection. During the surgery, the surgeon noted there was nothing in the sigmoid colon specimen. He then performed a rigid protoscopy and found the tumor in the rectum. He tried to perform a rectal resection but was unable to take it as low as he needed. Believing the patient needed an abdominoperineal resection, he placed a colostomy and deferred further surgery until he could talk with the patient. The surgeon also believed she would benefit from chemo-radiation therapy, which would allow him to preserve her sphincter complex.

The pathology report showed the sigmoid colon segment was negative for dysplasia, malignancy, or metastatic disease. The rectum segment was also negative for metastatic disease.  The patient developed a wound infection that was treated and then underwent chemotherapy and radiation therapy.

Four months later, the patient was admitted for surgery, and the surgeon was able to further resect her rectum. The surgeon then performed a diverting ileostomy.

The rectum specimen revealed a poorly differentiated, high-grade adenocarcinoma with therapy effect.

Five months later, the surgeon took down the patient’s ileostomy and repaired the incisional hernia. A second incisional hernia repair was performed nine months later.


A lawsuit was filed against the gastroenterologist. The allegations included:

  • failure to properly work up the patient for her condition before recommending colon surgery;
  • failure to properly perform and interpret colonoscopy procedures; and
  • improperly informing the patient and surgeon that the patient had sigmoid colon cancer.

A lawsuit was also filed against the surgeon. The allegations included:

  • failure to properly interpret the pathology report stating cancer from a rectum biopsy;
  • failure to properly prepare for surgery, including failure to determine cancer location; and
  • failure to properly perform surgery.

Legal Implications

The plaintiff’s experts testified that the gastroenterologist breached the standard of care by mistakenly citing the location of the tumor in the colon when referring the patient to the surgeon. Plaintiff experts also testified that the surgeon breached the standard of care by failing to confirm the location of the mass and diagnose rectal cancer prior to the first surgery.

Defense consultants agreed that the weakness of the gastroenterologist’s documentation included varying descriptions of the location of the tumor. The documentation was also described as inaccurate and inconsistent.

Defense consultants were critical of the surgeon for not confirming the location of the mass prior to surgery. There were indications that the tumor was in the rectum/rectosigmoid colon, rather than more proximal in the colon/sigmoid colon region. However, the surgeon either ignored or failed to notice such indicators as the specimen from the flexible sigmoidoscopy being labeled as “rectum hot snare” or the gastroenterologist’s handwritten note of the patient’s chief complaint as being “rectal cancer.”  

The surgeon testified that the CT scan was performed without bowel prep, thus he believed the thickening to be retained stool. He also stated that if he had been given a diagnosis of rectal cancer, he would have performed a rectal exam.


Due to the documentation/communication issues, the case was settled on behalf of both physicians.

Risk management considerations

When working up a potential colonic malignancy, it is imperative that all physicians involved clearly document the location of the tumor. This is particularly important when dealing with rectum versus rectosigmoid versus sigmoid colon cancers.

Inadequate communication between the physicians was a key element in this case. Failure to properly communicate can result in conflicting care, ignored recommendations, and delays in addressing medical conditions.  It is beneficial for every referring physician to speak directly with the consulting physician to discuss the patient’s history and the expectations for the consultation and to record this in writing.

Adequate and clear documentation can prevent confusion and potentially avoid adverse outcomes. A clear and consistent medical record makes it easier to defend a physician’s actions in the event of a claim. The Texas Medical Board requires that a physician document any communication made or received by the physician regarding a patient, about which the physician makes a medical decision. (1) Documenting all physician-to-patient and physician-to-physician conversations helps assure the medical record is complete and accurate. 


1. Texas Administrative Code, Title 22, Part 9. Chapter 165. Medical Records. Sections 165.1-165.6. Available at: Accessed September 16, 2015.