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
Laparoscopic Hysterectomy Leads to
Ureter and Bowel Injury

http://www.illustratedverdict.com/projectreview/IV/IV_v2_2010web/2624m7changed_small.jpg

PLAINTIFF'S CLAIM:
Negligence during a laparoscopic hysterectomy caused unnecessary post-op surgeries. The alleged negligence included perforating the bowel at the level of the proximal ileum and transecting the right ureter at the ureterovesical junction.  The plaintiff claimed these injuries should have been noticed in the initial surgery and corrected immediately. Instead, the patient was sent home and the injuries were not discovered until an open laparotomy days later, causing the patient unnecessary pain and suffering.

DEFENSE'S ARGUMENT:
On the bowel injury, the defense believed the injury might have occurred during the subsequent laparotomy.   The perforation of the bowel occurred away from the area of dissection during the laparoscopic hysterectomy.   During the second surgery, the urologist, who did not do the first surgery, performed blunt dissection of extensive adhesions in the area of the proximal ileum, the area of injury.

On the ureteral injury, the defense position was that the injury to the ureter (at the ureterovesical junction) was the result of a thermal injury during ligation of the cervical vessels. This is a recognized risk of the procedure, associated with cauterization of the cervical vessels.  The area of injury, at the ureterovesical junction, is beneath tissue and therefore not visible to the surgeon during the procedure.  A slight thermal injury could have occurred while cauterizing the vessels without being detectable by the surgeon at that time. These injuries typically worsen over time and in this case, the patient presented a few days post operatively with symptoms. The surgeon performed the surgery accurately and appropriately as described in the record, and the resulting injury was a recognized risk that had been discussed with the patient beforehand.

VISUAL STRATEGY:
IV worked with the attorneys and experts to develop a visual strategy that would help explain to the jury in detail how the plaintiff’s laparoscopic hysterectomy was done appropriately. The primary focus was on the ureteral injury because the defendants believed the bowel injury resulted from a subsequent surgery. 

We began by showing normal anatomy of the female pelvis to orient the jury on the location of the ureter, the uterus, and the surrounding structures.

We also illustrated the normal anatomy of the uterus with vasculature to orient the jury on the location of the ureter in relation to the vessels.

We also created a deep dissection of the pelvis with part of the peritoneum removed to show exactly where the ureter lies in relation to the deep uterine vessels following dissection.

We created a board of the laparoscopic view which helped show the close proximity of the ureter (indicated as a dotted line) to the uterine vessels and how it wasn’t visible to the surgeon. This was used to explain how an undetectable injury could have occurred.

We illustrated the surgical positioning (Trendelenburg position) that the patient was placed in during the insertion of the trocars into the abdomen.  This illustrated the location of the pelvic and abdominal organs during the insertion.  This board showed that while the patient was in the Trendelenburg position, the intestine was back in the abdominal cavity superior to the surgical site and remained that way during the whole procedure.

Finally, we showed a normal anatomy board of the abdomen to help the experts explain the location of the surgical field in relationship to the bowel.

We utilized web meeting software throughout the process to communicate directly with experts and counsel and fine tune the exhibits.

This combination of illustrations helped the defense successfully explain that:

  1. The ureter sustained a thermal injury that worsened over time, causing the symptoms to present days later. The ureter is close in proximity to the uterine vessels, and a thermal injury might not be apparent to the surgeon. The surgery was performed appropriately and within the standard of care.
  2. The position of the patient, the area of the surgical site, and the careful steps taken during the laparoscopic hysterectomy made it unlikely that the bowel injury could have been caused by our client.


RESULT:
The jury found in favor of the defense.

Attorney Donna Zito emailed to share her verdict and give thanks:
“Thank you very much for your extraordinary efforts to help me translate my ever evolving ideas for illustrations into reality.  The illustrations made a big difference, and allowed us to receive the defendants' verdict that my client so deserved.”
-- Attorney Donna Zito, O'Brien, Tanski & Young, LLP, Hartford, CT