CASE IN POINT

LAP CHOLE WITH BOWEL INJURY

A woman presented at the ED with complaints of nausea and vomiting. The attending determined, after an ultrasound, that she might need to have her gallbladder removed and that there were signs of chronic issues. The attending recommended her symptoms be watched (Fig 1-1).

Fig 1-1 --- Click on Images to Enlarge
A few days later, she was taken in for a laparoscopic cholecystectomy, lysis of abdominal pelvic omental adhesions, and umbilical hernia repair. The surgeon also ran the bowel (examined of every inch), and no abnormalities were found
(Fig 1-2).
Fig 1-2
Overnight, post-op she developed severe abdominal pain. The following day her condition continued to worsen, so she was brought in for exploratory surgery. The defendant found two perforations in the small bowel at one and two feet from the ligament of Treitz. Two areas of serosal tear were also noted. They were all repaired, and she was sent to recovery (Fig 1-3).
Fig 1-3
The rest of her hospital course was difficult, with infection and necrotizing fasciitis. After more surgeries and further recovery, she was discharged. She continues to have problems, leading to more hospitalizations.

PLAINTIFF'S CLAIM:

The defendant caused the injury to the small bowel by running the bowel without proper visualization and poor placement of the trocars during the lap cholecystectomy. The plaintiff's legal team claimed that there was no predetermined plan for running the bowel prior to the surgery, which put the plaintiff at higher risk for perforations. This led to permanent injuries from multiple unnecessary surgeries and prolonged hospitalization.

DEFENSE'S ARGUMENT:

The defendant properly preformed the lap cholecystectomy. The plaintiff did not present with classic gallbladder symptoms, and it was reasonable and appropriate for the defendant to run the bowel during the operation to determine if the symptoms had a different cause. The defendant's expert witnesses testified that running the bowel during abdominal surgery is a common undertaking for general surgeons. The defense experts also believed that the full thickness tears were initially serosal injuries that post-operatively developed into full thickness perforations

VISUAL STRATEGY:

Collaborating with the defense attorney, Illustrated Verdict created a visual strategy to help illustrate the anatomy of the area of the cholecystectomy and the entire abdomen as well.

Retroperitoneal anatomy was used to demonstrate the location of the gallbladder within the abdomen. (Fig 4-1)

Fig 4-1

 

The anatomy of the full bowel, its relationship to the ligament of Treitz, and the location of the gallbladder were all shown.
(Fig 4-2)

Fig 4-2
 

Trocar placement for the laparoscopic cholecystectomy was illustrated.
(Fig 4-3)

Fig 4-3
 

A board was created to show the abdomen w/ colon and small bowel, as well as detailed illustrations of the layers of the bowel wall. (Fig 4-4)

Fig 4-4
 

Small bowel injury was demonstrated to help the jury understand how a serosal tear can progress into a full thickness injury. (Fig 4-5)

Fig 4-5
 

The illustrations helped the defense successfully convey to the jury the following key points:

  • The trocar placement for the lap cholecystectomy was proper for the defendant physician to perform all parts of the surgery.
  • The anatomy of the abdomen as was discussed in the operative report.
  • Bowel injuries that are minor and not visualized during a procedure can then become problematic if they progress to a full thickness tear into the lumen of the bowel.

 

RESULT:
The jury found in favor of the defense.  

"We obtained a defense verdict in the Young case. The boards of the anatomy were very helpful with our expert's presentation in this particular case, and I believe we utilized each one we had printed during his testimony."

- Attorney Shana Solomon, Preti, Flaherty, Beliveau & Pachios, Chartered, LLP, Portland, ME

 

"On the Young case we achieved a Defense verdict. In my view, there were three reasons for the successful verdict: our expert witness, the visuals which were used by our expert during his testimony, and my co-counsel Shana Solomon, who selected the visuals and conducted the direct exam of our expert. Thanks for your assistance."

- Attorney Daniel Rapaport, Preti, Flaherty, Beliveau & Pachios, Chartered, LLP, Portland, ME

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