CASE IN POINT
Judgment for the Defense

DIFFICULT RESECTION OF LIVER TUMOR

The case involved a 59-year-old man with tumors in his liver. He went in for a resection of a tumor in the caudate lobe of the liver (a small lobe located in the posterior section of liver). (Fig 1-1)

Fig 1-1 --- Click on Images to Enlarge
The surgical plan was to mobilize the liver to allow for safe control of vasculature and resect the tumor with clear margins of resection, which is the rim of tissue surrounding the tumor, to make sure that all tumor cells are removed. During the surgery, the right lobe of the liver was mobilized (Fig 1-2 sketches created by artist after meetings with the defendant; 1st step in the creation of a 3D animation).
Fig 1-2 --- Click on Images to Enlarge
Dissection was carried out between the two lobes. The surgeon then elevated the left lobe of the liver. Once he did this, he saw that there was a tear in the inferior vena cava (IVC) where the left/middle hepatic vein joins this vessel, and bleeding ensued (Fig 1-3).
Fig 1-3
The surgeon then completed the resection, by using a surgical stapler to transect the middle/left hepatic vein. and removed the tumor, caudate lobe and left lobe of the liver. The bleeding continued, and further attempts, such as compression with sponge stick and clamping high on the IVC and diaphragm, were initially unsuccessful (Fig 1-4).
Fig 1-4
The tear extended along the backside of the IVC above the diaphragm into the thoracic cavity. Although the surgical team was able to repair the tear, the patient had lost multiple units of blood and died subsequently in the ICU from multi-organ failure.

PLAINTIFF'S CLAIM:

The defendant's performance of the surgery was negligent by incorrect use of the surgical stapler so that the stapler itself cut into the IVC (Fig 2-1) and caused the major tear and bleed that lead to the patient's demise. The plaintiff also claimed that surgical exposure was inadequate, control of the vasculature was inadequate, the tumor directly abutted the confluence of the IVC and left hepatic vein such that a different surgical approach should have been utilized, a hanging maneuver should not have been performed, and the anesthesiologist response to intraoperative bleeding was inadequate.

Fig 2-1

DEFENSE'S ARGUMENT:

The tumor was in a location that did not directly abut the junction of the IVC and left hepatic vein (Fig 3-1), and thus the surgical approach chosen was appropriate. The extent of the incision used and the surgical retractors deployed provided excellent exposure for the operation. The hanging procedure was performed to allow for careful and safe dissection through the liver. The surgical stapler was used appropriately, and did not itself cause injury. Rather, retraction of the left liver to provide exposure was the cause of the tear in the IVC that extended posteriorly and above the diaphragm.
Fig 3-1

VISUAL STRATEGY:

Collaborating with the defendant and defense attorney, Illustrated Verdict created a visual strategy to help illustrate the anatomy and to show the complexity of the procedure that was performed by the defendant.

Based off sketches, an animation was created to help explain to the jury this complex surgical procedure as simply as possible. (Fig 4-1)

Fig 4-1 --- Click on Image to View Animation
Click here to view pdf of the storyboard.

 

A flexible 3d model of the vasculature and the tumor was printed based off the films from the patient. This was a tactile way for the defendant to demonstrate for the jury specific points of the operation, the appropriateness of use of the surgical stapler, and the mechanism by which the tear occurred (rather than the plaintiff's claim that inappropriate use of the stapler itself caused the tear). It also showed the precise location of the tumor relative to the vessels.

First 3D digital sketches of the anatomy were created by reading the films (Click on the images to view multiple pdf views):
(Fig 4-2, 4-3)

Fig 4-2 --- Click on Images to view multiple pdf views
Fig 4-3 --- Click on Images to view multiple pdf views

A flexible 3d model was then printed based off the sketches to help demonstrate the anatomy. (Fig 4-4)

Fig 4-4 --- Click on Image to View Video
 

This animation and 3D printed model helped the defense successfully convey to the jury the following key points:

  • The actual location of the tumor was in the caudate lobe relative to the IVC and left hepatic vein.
  • Surgical exposure for the operation was adequate and appropriate.
  • The hanging maneuver was performed correctly.
  • Traction on the left lobe of the liver resulted in the tear, and the precise location of the tear made its repair technically very difficult
  • The procedure was done correctly, but an unfortunate event caused the torn vessel and bleed that led to his death.
RESULT:
The jury found in favor of the defense. 

“We won the case! The animation was extremely compelling in my opinion (so compelling that the Plaintiff objected strenuously to its use), and the model was also incredibly helpful during my testimony. It was a pleasure to work with you. In my opinion, the product of your work was very important in our case, and indeed we were able to convince the jury. Thank you very much for your superb work.”

- Defendant Physician

 

About Us Case In Point Library