Fatal biliary peritonitis due to postinsertion migration of a Robinson drain tip, with erosion into the liver...

Iatrogenic injury due to incorrectly sited drains and tubes is a rare but recognized complication and can occur at many different sites. Migration of correctly sited drains and tubes is rarer still. A handful of rare cases involving longstanding ventriculoperitoneal and lumboperitoneal shunts migrating and causing perforation of the bowel exist, often complicated by central nervous system sepsis. We present a previously unreported complication of a Robinson drain, one of 2 abdominal drains inserted under direct vision during a subtotal gastrectomy for carcinoma, in a frail 78-year-old woman. Twenty-four days postoperatively, after a period of predictably slow but steady recovery, bile-stained fluid was noted in the drain. Unfortunately, the patient rapidly deteriorated and died. Autopsy revealed multiorgan failure due to peritonitis. Both drains were noted to be correctly and firmly sutured to the skin. The tip of the right-sided Robinson drain was found to have migrated, eroding into the liver parenchyma, resulting in biliary peritonitis. The left-sided Robinson drain was correctly sited in the peritoneal cavity. We present the postmortem findings and a review of the literature.