IV Case in Point
Illustrated Verdict shares case examples from our archives to show how a visual strategy can support the defense effort. We hope that it is of value in your practice as you develop your defense strategies on behalf of health care providers. Please feel free to forward it to colleagues or clients.

About Us
IV is a leading provider of demonstrative evidence for the defense of medical malpractice claims. Our team of medical illustrators consults with defense teams to educate the lay jury audience about the complexities of medical care. We do this by developing a visual strategy with expert witnesses including high-quality case-specific medical illustrations, x-ray enhancements, and multimedia presentations. IV receives judgment for the defense in over 94% of the cases we participate in, as compared to the national average of 73%. Additionally, insurers who supply us with their trial list enjoy a win rate of up to 97%.
To learn more, e-mail us or call 617-530-1001.
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Case In Point Library
Click to view other editions:

Case In Point Library Page

Pregnancy and Delivery:
Fetal Assessment 2009v1
Shoulder Dystocia 2009v3
MVA Leads to Fetal Demise 2010v4
Fetal Descent Stalled 2010v5
Shoulder Dystocia / Erb's 2011v4
Fetal Tracings / Hypoxic Injury? 2013v1

Heart:
Coronary Artery Disease 2009v5
CAD / Recurrent MI 2010v1
Aortic Valve Replacement 2011v1

Lungs:
Stroke After Lung Surgery 2009v2
PE / Infection 2010v3
PE Following Roux En Y 2012v1
Intubation / Macklin Effect 2012v4
Lung Cancer vs. Infection 2015v3

Female Pelvis:
Hysterectomy / Fistula 2011v9
Hysterectomy / Ureter Injury 2010v2
Hysterectomy / Kinked Ureter 2010v8
Diag Lap / Bowel Injury 2012v3
Cervical Cancer 2013v3
Endometrial Cancer 2014v1

Male Pelvis:
Bladder Cancer 2013v2

Digestive System:
Gastric Bypass 2009v6
Recurrent Hiatal Hernia 2009v8
Right Colectomy / Leak 2010v7
Gastric Bypass / Volvulus 2011v2
Nissen Fundoplication 2011v3
Large Hiatal Hernia 2013v5
Necrotizing Enterocolitis 2013v7
Arrest during ERCP 2015v4
Diverticulitis Complications 2015v5

Abdomen:
Spleen Injury and Bleed 2009v4
Bleed Following Lithotripsy 2012v2
Lap Cholecystectomy 2012v5
Bowel Injury Lap Ovarian Cyst Removal 2013v6
LapChole - Hepatic Duct Injury2015v1

Orthopedic:
Partial Hip Replacement 2010v6

Vasculature:
tPA Infusion 2009v7
Vertebral A. Coil Embolization 2015v7

Head and Neck:
Bell's Palsy 2013v4
Tongue Cancer 2014v2
Chiari I - Vision Loss 2015v2

Judgment for the Defense
Complications in Surgery Following Gastric Bypass Procedure

http://www.illustratedverdict.com/projectreview/IV/IV_0509web/2202m3.jpg

PLAINTIFF'S CLAIM:
A gastric bypass patient claimed that mistakes made during her initial surgery caused painful complications and compelled her to undergo two additional surgeries. The third surgery, for removal of a severely inflamed gastrojejunostomy, left the patient in permanent need of a feeding tube (g-tube) into her stomach.

The plaintiff claimed that, after the initial surgery, the physicians should have seen evidence of a leak at the gastrojejunostomy site and performed a surgical revision immediately. The subsequent delay allowed an infection to form, which led to septic complications, unnecessary pain and the need for the g-tube.

DEFENSE'S ARGUMENT:
According to the defense, in January of 2002, the patient underwent a successful Roux-en-Y gastric bypass. However, she did not improve as expected following the surgery, and was brought in for an exploratory laparotomy five days later. A large amount of fluid was found in her abdomen. The surgical team irrigated extensively to clear the abdomen and identified no leak at either the gastrojejunostomy site or the jejunojejunostomy site. Therefore, they placed drains, closed the incision, and put her under close observation.

Five days later, the patient showed a worsening hemodynamic profile consistent with sepsis. The surgical team performed a revision surgery and discovered a significant leak at the gastrojejunostomy site. They decided to divide the stomach just prior to the gastrojejunostomy site and reduce the jejunal limb back down into the lower abdomen. The abdomen was irrigated and a g-tube was placed for feeding into the stomach.

The defense argued that the initial bypass surgery's operative report clearly explained the procedure and showed that all of the proper techniques were utilized to insure a successful bypass surgery before closing the patient. The complications did not arise from the initial surgery, but rather were common postoperative issues that had developed over time. This was also shown for the second surgery (the exploratory laparotomy). The gastrojejunostomy and jejunojejunostomy were specifically checked for leaks, and no leaks were discovered. Only after the second surgery did symptoms of the leak occur and as soon as they did, a revision was completed. The postoperative complications were recognized risks of the procedure, and the appropriate steps were taken for each complication when it presented.

VISUAL STRATEGY:
IV worked with the attorneys and experts to develop a visual strategy that would help explain to the jury in detail the procedures' accuracy and appropriateness.
We began by showing normal anatomy to orient the jury to the anatomical landmarks and surrounding structures.
We also showed a typical Roux-en-Y image with surrounding anatomy, to give the jury a better understanding of the procedure generally.

Illustrations of the initial surgery were created directly from the operative reports with the cooperation of the experts and defendants. We identified the gastrojejunostomy anastomosis and jejunojejunostomy locations, demonstrating that they were intact prior to completion.

We then illustrated the second surgery, the exploratory laparotomy described in the operative report. Lastly, we illustrated the third surgery and what was done to correct the leak found at the gastrojejunostomy site. From the complicated operative note, the illustrations explained to the jury how the stomach was divided just before the gastrojejunostomy site and the jejunal limb was reduced into the lower abdomen.

RESULT:
The jury was convinced that this patient's unfortunate outcome was the result of unavoidable, well-recognized, postoperative complications combined with preexisting conditions related to the Roux-en-Y bypass. After a quick deliberation, they found in favor of the defense. 

"We won!  The jury came back in less than two hours.  We all loved your work, so you're certain to hear from us again soon.  Thanks again."
-- Lynne Couch, Sulloway & Hollis, P.L.L.C., Concord NH