Fatal ileal perforation following umbilical granuloma excision: A medico-legal case analysis

Abstract

Umbilical granuloma (UG) is a benign and common umbilical anomaly in neonates and infants, typically managed conservatively with salt application or silver nitrate. While rarely requiring surgical intervention, complications arising from invasive treatments are significantly underreported. We present a rare, but fatal case, of bowel perforation following electrocautery excision of a UG in an 11-month-old male infant. The child had a persistent pinkish umbilical lesion unresponsive to conservative treatment. Ultrasonography ruled out underlying vitellointestinal anomalies, and surgical excision was performed under short general anesthaesia. The procedure was uneventful, and the infant was discharged within a few hours postoperatively. Within 24 hours, the child exhibited signs of abdominal distress and was declared dead upon arrival at the emergency department. A medico-legal autopsy revealed haemoperitoneum and a perforation on the antimesenteric border of the ileum. Histopathology demonstrated transmural necrosis at the perforation margins. No other organ pathology or toxicologic cause was identified. The cause of death was certified as haemorrhagic shock secondary to bowel perforation. This case emphasises the need for caution even with routine paediatric procedures, particularly when involving thermal instruments. It underscores the anatomical vulnerability of infants, the critical need for intraoperative precision, extended postoperative observation and protocol-based care. From a legal standpoint, this case raises questions about informed consent, standard of care and institutional liability. The findings highlight the need for national paediatric surgical safety guidelines, especially regarding electrocautery use in superficial procedures and demonstrate the vital role of forensic pathology in uncovering preventable iatrogenic deaths.