The plaintiff was admitted to the hospital following a five-day history of abdominal pain. An abdominal/pelvic CT scan revealed diverticulitis in his sigmoid colon with an associated 2 cm intramural abscess. (Fig 1-1)

Fig 1-1 --- Click on Images to Enlarge
The plaintiff was placed on IV antibiotic therapy and, after a brief stay, was discharged on oral antibiotics when his condition stabilized. A few weeks later, he was seen by the defendant, a colorectal surgeon, for a surgical consult. The defendant recommended that the plaintiff have an interval colonic resection done. A few months later, the plaintiff underwent a robotic low anterior resection of colon with primary anastomosis, performed by the defendant. (Fig 1-2)
Fig 1-2
Upon completion of the anastomosis, the defendant checked the anastomosis by filling the abdomen with fluid and using a sigmoidoscope to blow air into the rectum. This insufflation resulted in a line of bubbles, revealing an air leak at or near the level of the anastomosis on the posterior (back) side. The defendant elected to perform a diverting loop ileostomy to divert enteric content away from the leaking anastomosis. (Fig 1-3)
Fig 1-3

Over the next few days, the plaintiff's ileostomy evidenced diminished output, and the plaintiff displayed symptoms suggestive of onset postoperative sepsis. He was transferred to the intensive care unit, where an abdominal/pelvic CT showed a small amount of free air within the abdominal cavity, as well as the presence of ascitic fluid. The patient was taken to the operating room, and another surgeon found a significant amount of fluid in the patient's abdominal cavity. This surgeon stapled the colon closed proximal to the anastomosis to prevent further contamination of the peritoneal cavity through the defect.(Fig 1-4)

Fig 1-4

The plaintiff remained an intpatient for several weeks following this procedure with multiple complications throughout his hospital course.


The defendant failed to diagnose the anastomotic leak in a timely fashion and failed to properly repair the anastomotic defect, resulting in intra-abdominal sepsis following surgery and multiple complications in the plaintiff's postoperative hospital course.


When the defendant discovered the leak in the anastomosis, he had three surgical options. The first option was to repair the hole, which the defendant chose not to do because the leak was in the posterior and the colon is deep in the pelvis. The leak would have been difficult to access, as the male pelvis, which is narrower than the female pelvis to begin with, narrows further along the sigmoid intestine. The mobilization that would have been required would have caused more dissection and had a higher potential for injury of the nerves and vessels in that area. (Fig 2-1)
Fig 2-1
The plaintiff was also obese, which made it possible that a failed repair could have resulted in a permanent ostomy. The second option was to redo the anastomosis, which the defendant chose not to do for the same reasons he chose not to repair the hole. Redoing the anastomosis would have meant trying to access the sigmoid colon at the narrowest part of the pelvis, making anastomosis more likely to fail and/or leak. The defendant chose the third and most conservative option, which was creating a temporary ileostomy and leaving the leak alone to try to let it heal.


Collaborating with the defense attorney, Illustrated Verdict created a visual strategy to help illustrate the relevant anatomy in this case along with images showing the surgical care by the defendant.

Three normal anatomy boards displayed the pelvic anatomy and the location of all structures relevant to where the defendant performed his surgery.
(Figs 3-1, 3-2 and 3-3)

Fig 3-1

Fig 3-2
Fig 3-3

Next, a board showed the several steps the defendant performed to remove the area of sigmoid colon with diverticulitis and abscess, and to create the anastomosis of the remaining colon. (Fig 3-4)

Fig 3-4

Another series of illustrations detailed the completed anastomosis, as well as the test that revealed the air leak in the posterior colon at the level of the anastomosis.
(Fig 3-5)

Fig 3-5

Finally, a board showed the diverting loop ileostomy that the defendant performed to divert enteric content away from the leaking anastomosis. (Fig 3-6)

Fig 3-6

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

  • The defendant performed the anastomosis properly, including checking the anastomosis with the air leak test.
  • Upon the revelation of the air leak at the posterior aspect of the anastomosis, the defendant appropriately chose the most conservative option to treat the issue.
  • Had the defendant chosen either of the more aggressive treatment options-repairing the hole or redoing the anastomosis-he ran the risk of causing injury to the plaintiff’s pelvic nerves and/or vessels, as well as the possible risk of the plaintiff having to have a permanent ostomy.
The jury found in favor of the defense.  

"We won the case. The demonstratives were quite helpful and were used throughout the entire case. Thank you so much for your help on this and for checking in."

- Attorney Andrew Wildstein, Danaher Lagnese, P.C., Hartford, CT


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