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
Diagnostic Laparoscopy
Resulting in Bowel Injury

http://www.illustratedverdict.com/projectreview/IV/IV_v1_2012web/1650m3_2580m1_small.jpg

A 46-year-old woman presented with pelvic pain. She was known to have dense adhesions in her abdomen and pelvis, discovered when undergoing a hysterectomy and a bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries along with uterus and cervix) about 7 years prior. The defendant recommended that she have a diagnostic laparoscopy to determine the cause of her pain, suspecting an ovarian remnant, notorious for causing pain. During the procedure, a large amount of adhesions and several loops of bowel were found adherent to the right pelvic side wall. After dissecting the bowel off of the side wall, the defendant uncovered what was believed to be an ovarian remnant near the infundibulopelvic ligament and sent a tissue sample to pathology for review.

The following day, the plaintiff presented to the emergency room with marked abdominal pain, distension and tachycardia. These symptoms raised concern for a possible bowel injury, so she was brought back to the operating room where a 1 cm defect was found in the terminal ileum approximately 6 inches from the ileocecal valve. Additionally, the pathology report from her procedure the day before reported the presumed “ovarian remnant” was actually a segment of small bowel wall with serosal fibrosis.

PLAINTIFF'S CLAIM:

The defendant was negligent in removing a piece of small bowel wall rather than an ovarian remnant. She was also at fault for not thoroughly examining the bowel at the time of the procedure to ensure it was not injured during dissection of the dense adhesions.

DEFENSE'S ARGUMENT:

The defendant followed standard of care by carefully examining the bowel during the procedure but the adhesions and fibrosis of the bowel serosa made it difficult to identify a defect in the bowel. The defense also argued that the size of the tissue sent to pathology, if taken directly from the terminal ileum, would have resulted in symptoms of a bowel perforation almost immediately following the procedure, and not a day later. They proposed the perforation likely stemmed from a small tear in the bowel wall, created by pulling on adhesions during the dissection, which opened up over time.


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VISUAL STRATEGY:

Collaborating with the defense attorney, IV created a visual strategy that helped experts explain that the defendant properly followed standard of care during the procedure by removing what was believed to be an ovarian remnant.

Several diagrams were used to help the jury understand the anatomy of the female pelvis and bowel.

Another diagram was developed to show the hysterectomy and bilateral oophorectomy the plaintiff had approximately 7 years prior.

Another diagram demonstrated the diagnostic laparoscopy performed by the defendant.

The final diagram illustrated how a small bowel injury to the outer serosal layer can progress to a full thickness defect in the bowel wall.

This series of illustrations helped the defense successfully convey to the jury the following key points:

  • The amount and location of adhesions in this case made it difficult to identify a defect in the bowel at the time of the procedure.
  • Illustrating the location of the removed tissue helped show it could have been mistaken for an ovarian remnant and also that the defendant did not take it directly from the bowel as the plaintiff claimed.
  • A bowel perforation can develop over time and not result only from an injury during surgery-an explanation more consistent with the timing of the plaintiff’s procedure and presentation of her symptoms.


RESULT:
The jury found in favor of the defense. 

"Defense verdict after 5 minutes of deliberation; your illustrations were very helpful. Thanks for handling on stat basis!"

- Attorney Ritchie E. Berger, Esq., Dinse, Knapp & McAndrew, P.C.,
Burlington, VT