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%.
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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

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

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

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

Partial Hip Replacement 2010v6

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
Recurrent Hiatal Hernia


Plaintiff alleged that there was a ten-day delay in diagnosing a recurrent hiatal hernia after she underwent an operation performed by the defendant. A hiatal hernia occurs when a portion of the stomach protrudes through a defect in the diaphragm upward into the chest.  The plaintiff claimed that failure to identify and treat her hernia in a timely manner resulted in extensive damage. 

The plaintiff had a history of hiatal hernias, and had two prior surgical repairs before pursuing a third procedure with the defendant.  On initial review, the defendant diagnosed the patient with a complex hiatal hernia and performed a laparoscopic paraesophageal hernia repair (to reduce the hernia) along with a revision of a prior Nissen fundoplication (in which the fundus of the stomach is wrapped 360 degrees around the esophagus).  Postoperatively, the plaintiff claimed that the defendant did not follow the standard of care, failing to identify that her hiatal hernia had reoccurred. 

The defense claimed that the plaintiff was prone to hiatal hernias and that the defendant closely monitored her after surgery.  He spoke with the plaintiff several times when she experienced episodes of postoperative nausea, but noted that she had gone as long as a week without symptoms. The defendant attributed the nausea to bloating from gas, a common condition following this type of surgery.  He also indicated that patients are more likely to have a protracted recovery following repeat procedures to repair hiatal hernias.  

Weeks after the third operation, the plaintiff had a 24-hour period when her nausea did not abate and was accompanied at times by shortness of breath.  The defendant ordered a chest x-ray and the recurrent hiatal hernia was discovered.

The defense argued that the plaintiff did not initially present with symptoms of a complex Type IV hernia, in which the stomach, the colon, and other abdominal contents are pushed up into the chest.  When the severe symptoms appeared, she was managed appropriately and according to the standard of care.  She had a diagnostic x-ray and subsequently underwent a successful corrective surgery. 

IV worked with the attorneys to create a visual strategy to illustrate the plaintiff’s history of hiatal hernias.  The attorney’s goal was to have the jury visualize a hiatal hernia and develop a detailed understanding of the surgeries to repair it.  We used operative reports to tell the plaintiff’s complex history:

A Normal Anatomy Board was used to orient the jury.

A Large Hiatal Hernia Board was created to illustrate the mechanics of a hiatal hernia, showing how the stomach can move up through a weakness in the diaphragm.

Reduction of a Hiatal Hernia and Nissen Fundoplication Board and a Detail of Nissen Fundoplication Board were used to give a basic overview of the procedures performed on the plaintiff over the preceding two-year period. 

We then illustrated Pre-Op and Post-Op Images of The Plaintiff’s First and Second Surgeries to show her postoperative history of reoccurrence. 

We created a board of the Pre-Op and Post-Op Images of The Plaintiff’s Third Surgery performed by the defendant.

Lastly, we illustrated the Type IV Hiatal Hernia that subsequently occurred and was treated by the defendant.

This combination of illustrations helped the defense successfully explain that:

  • The defendant was aware of the plaintiff’s prior history of recurrent hiatal hernias postoperatively;
  • The defendant closely monitored the plaintiff’s symptoms postoperatively; and
  • Once the defendant believed the plaintiff’s symptoms warranted further investigation, he took the appropriate steps to discover and correct the hernia.

The jury found in favor of the defense. 

" We won a defense verdict and the IV boards were very helpful to us; thanks as always."
-- Attorney Christopher D. Nyhan, Esq., Preti, Flaherty, Beliveau, and Pachios, Portland ME