CASE IN POINT
Judgment for the Defense

EMERGENT ECTOPIC PREGNANCY LAPAROSCOPY VESSEL INJURY

Fig 1-1 --- Click on Images to Enlarge

A woman in her mid-20s who was approximately 5 weeks pregnant presented urgently to the hospital with complaints of sharp, constant pain in the right lower quadrant of her abdomen. A pelvic ultrasound revealed a large amount of free fluid within her pelvis, as well as a mass in the right adnexa. She was quickly diagnosed with a right-sided ruptured ectopic pregnancy (Fig 1-1) and was taken to surgery for what was intended to be an urgent laparoscopic right salpingectomy.

Fig 1-2

Two port incisions were made and trocars were placed, based on anatomic landmarks. During the procedure, visualization was poor due to the extent of bleeding, resulting in inadvertent injury to the right infundibulopelvic (IP) ligament (Fig 1-2), which compromised the blood supply to the ovary. This required the surgeons to convert the procedure to a right salpingo-oophorectomy. The surgeons removed the right ovary through the left port incision, which they needed widen. They then attempted to evacuate all the blood from the rupture, but left behind approximately 1000 mL that could not be evacuated due to clotting. They also noted violin string adhesions on the anterior surface of the liver to the abdominal wall. The patient's abdomen was inspected, and hemostasis was confirmed prior to closure. She was discharged later that same day.

Fig 1-3

A few hours after discharge, the patient returned to the ER with increasing left-sided abdominal pain and a distended abdomen. A laparoscopic exploration (Fig 1-3) found a 1500 mL hemoperitoneum, so the procedure was converted to an open laparotomy to explore and determine the source of the bleed. A midline incision was made, revealing oozing in the area of the left inferior epigastric vessel. Sutures were placed inferior and superior to the left port site to prevent further bleeding. It was concluded that this left inferior epigastric vessel injury occurred at the time of trocar placement during the previous surgery.


PLAINTIFF'S CLAIM:

Fig 2-1

Surgeons are required to perform a translucency exam to identify the epigastric vein prior to trocar placement to prevent injury, which the defendants failed to do. The defendants were negligent in their placement of the left-side trocar: they failed to note that they had injured the epigastric vessel, they failed to repair it, and they failed to establish hemostasis prior to closure of the laparoscopic procedure. These failures led the defendants to close despite the presence of blood in the abdomen (Fig 2-1), and in turn the plaintiff was discharged while she continued to bleed into her abdomen, creating the need for an emergent laparotomy and additional blood transfusions. The defendants also failed to appropriately evaluate the plaintiff's left-sided abdominal pain following the removal of her ectopic pregnancy. The plaintiff went on to experience additional pain and suffering that physicians have been unable to treat, including ongoing abdominal pain and numbness on the left side of her body in the area where the laparotomy was performed, which she was informed was most likely the result of surgical adhesions. The laparotomy also left the plaintiff with a large, prominent, somewhat raised scar.

 

DEFENSE'S ARGUMENT:

Fig 3-1

The defendants appropriately used anatomic landmarks (specifically measuring 2 cm from the iliac crest) and direct visualization to place the trocars. The inferior epigastric vessel runs beneath the rectus muscle (Fig 3-1), which cannot be visualized by transillumination- therefore, the use of transillumination would not have done anything to prevent this injury. The two complications that occurred- the injury of the right IP ligament and the injury to the left inferior epigastric vessel- were both known risks that were properly explained to the plaintiff prior to the procedure. When the defendants recognized that the IP ligament had been cauterized and transected, they appropriately converted the procedure to a salpingo-oophorectomy. The left inferior epigastric vessel was not bleeding at the time of closure, or at any time prior to the plaintiff's discharge, and the abdomen was properly inspected and noted to be hemostatic prior to the conclusion of the procedure. The inferior epigastric vessel in this case did not bleed initially due to tamponade and clotting, but likely spasmed and developed an active bleed shortly after discharge.

Fig 3-2

Adhesions are common following surgery, but typically do not cause chronic abdominal pain. Also, the violin string adhesions observed during the original surgery were suggestive of prior significant pelvic inflammatory disease (PID) (Fig 3-2), which could have been a cause of her ongoing pain. It was recommended that she be evaluated by a gastroenterologist to reach a diagnosis and determine the cause of her abdominal pain, but she did not follow through. Her complaints of chronic abdominal pain and numbness were most likely related to a medical condition, such as pre-existing PID or gastroesophageal reflux disease (GERD), and were unrelated to her surgeries.

VISUAL STRATEGY:

Collaborating with the defense attorneys, who also received input from their clients, Illustrated Verdict created a visual strategy to help explain the plaintiff's condition and the steps taken in her care, supporting the view that the defendants' actions were within the standard of care.

The initial diagram illustrated the vasculature of the abdomen, including the epigastric vessels, to help orient the jury and show how the inferior epigastric vessel runs beneath the rectus muscle. (Fig 4-1)
 
Fig 4-1

   
The second diagram illustrated the close-up anatomy of the fallopian tubes and blood supply to the ovaries, including the IP ligament. (Fig 4-2)
 
Fig 4-2
   
The next illustration showed an example of a ruptured ectopic pregnancy. (Fig 4-3)
 
Fig 4-3

   
Another diagram showed the plaintiff's violin string adhesions between the abdominal wall and the liver that the defendants noted during her first surgery. (Fig 4-4)
 
Fig 4-4
   
The fifth and sixth diagrams showed the process of inserting the trocars using anatomic landmarks (2 cm from the iliac crest) under direct visualization (with the camera trained directly at the insertion site) (Fig 4-5), and the location of the trocars once in place in the patient. (Fig 4-6)
 
Fig 4-5
 
Fig 4-6

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

  • The defendants worked within the standard of care, acting urgently in the emergent and potentially life-threatening situation of a ruptured ectopic pregnancy, and utilizing appropriate surgical technique throughout the case.
  • When the defendants discovered that the IP ligament had been injured, they made the appropriate intra-operative decision to convert the procedure to a salpingo-oophorectomy.
  • The surgery performed by the defendants was successful in removing the ectopic pregnancy and achieving hemostasis.
RESULT:
The jury found in favor of the defense. 

“I just wanted to let you know that we received a defense verdict in our case yesterday. We appreciate all of your work on the Boards. They were used frequently at trial and were very helpful.”

- Attorney Michael Barkley, Adler, Cohen, Harvey, Wakeman and Guekguezian, LLP, Boston, MA

 

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