Fatal postoperative bowel ischaemia following abdominal aortic aneurysm repair: Medico-legal implications of a rare complication

Ischaemic large bowel necrosis is a rare but severe complication following open abdominal aortic aneurysm (AAA) repair. Postoperative deaths from this condition often prompt medico-legal evaluation. We report a case of a 75-year-old hypertensive male who underwent elective open repair of an incidentally detected infrarenal AAA. On the fourth postoperative day, he developed progressive abdominal distension, oliguria and metabolic acidosis. Despite intensive management, including intravenous antibiotics, vasopressors, fluid resuscitation and haemodialysis, he deteriorated and died on the seventh postoperative day. Medico-legal autopsy revealed transmural necrosis and perforation of the rectum with generalised purulent peritonitis. The aortic graft was intact and appropriately positioned. Advanced atherosclerosis and chronic infrarenal dissection were present. The findings were consistent with Grade III ischaemic colitis, culminating in septic shock and multi-organ failure. This case highlights the importance of structured forensic evaluation in distinguishing recognised postoperative complications from potential negligence and emphasises the need for careful medico-legal evaluation.