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
Lap Chole - Common Hepatic Injury

A 79 year old man with a history of ventricular tachycardia, and pulmonary and renal issues, presented to the defendant’s partner and was diagnosed with carcinoma of the sigmoid colon. At that time, the defendant assisted in the resection of the plaintiff’s colon. The plaintiff returned to the same physician some time later and was diagnosed with acalculous cholecystitis (inflammation of the gallbladder without the presence of gallstones).

Based on the plaintiff’s history, the defendant performed a laparoscopic removal of the plaintiff's gallbladder to rule out carcinoma. During the dissection to the gallbladder, the defendant encountered multiple adhesions. The gallbladder itself was very inflamed, small, and contracted with further adhesions. After the surgery, the defendant and partner were able to rule out cancer of the gallbladder.

A few days post op, the plaintiff went to an ER complaining of nausea and vomiting. He ended up having an ERCP (endoscopic retrograde cholangiopancreatography), where it was discovered that at least one of the clips had occluded his hepatic duct. He had a roux-en-Y hepaticojejunostomy to repair the damage to his bile system.

 

PLAINTIFF'S CLAIM:

The defendant should have elected to move to an open procedure, rather than continuing the laparoscopy, to avoid duct injury, both because of the plaintiff's history and the defendant's awareness of extensive adhesions.

 

DEFENSE'S ARGUMENT:

The defendant chose to do the procedure laparoscopically due to the plaintiff's pre-existing conditions. The plaintiff had pulmonary issues, as well as diabetes (which causes delay in healing larger incision, resulting in a higher risk of complications). IV had worked with the defense on the first trial, which was declared a mistrial because the plaintiff had films that were not shown to the defense until after the trial.

After seeing the films, the defendant had a clearer picture of what happened during the surgery. Originally, she believed that the clips on the cystic duct might have overlaid onto the common hepatic duct, causing the injury. After reviewing the newly discovered films, she was able to determine that the injury was much higher on the common hepatic duct, next to the clips placed on one of the cystic arteries. The anatomy was also different; the common cystic and hepatic ducts were much thinner than she was previously aware. When the second trial came around, we worked directly with the defendant to revise the illustrations.




VISUAL STRATEGY:

Collaborating with the defense attorney and defendant, Illustrated Verdict created a visual strategy to help illustrate the patient's anatomy and show how the complication could have occurred under those circumstances. The following illustrations were used in the second trial:

 

The initial illustration demonstrated the normal anatomy of the gallbladder, ducts, and arteries vs. what the defendant described as the patient’s aberrant anatomy.

 

The next exhibit showed the medial dissection and critical view technique used to help free the gallbladder from a bed of adhesions.

 

Another illustration demonstrated lateral dissection, as well as infundibular technique.

 

The fourth diagram illustrated in detail the dissection of the gallbladder. as well as where the clips were placed on the cystic duct and cystic arteries. The final illustration on this board shows how the defendant believed the injury to the duct occurred. She believed that the common hepatic duct may have become kinked by the clips that were placed on the superior cystic artery.

 

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

  • The variation in the anatomy of the patient’s gallbladder was significant. Both the gallbladder and ducts were very small.
  • The patient’s anatomy was complicated by multiple adhesions, but the physician felt she gained enough access in her dissection.
  • Damage to the duct may, unfortunately, have been caused by the clip, but this was a known risk of the procedure, and the defendant properly preformed the dissection using the correct techniques to adequately expose the anatomy.

 

RESULT:
The jury found in favor of the defense. 

“Unanimous Defense verdict last Friday after two and a half hours; I doubt the jury could have ever understood what was being talked about if we hadn't had your illustrations! Thank you so much; they were fabulous!!”

- Attorney Howard Krisher, Bieser, Greer, Landis, Dayton, OH