Allegation:
Patient Alleges Defendant General Surgeon Negligently Failed to Perform an Intraoperative Cholangiogram.
The Case:
A 63 YOF (5’4”, 142 lbs.) had an informal consultation with the defendant general surgeon for worsening right upper quadrant pain. The patient was a holding room nurse at a hospital where the defendant operated. She was examined a few days later and underwent a hepatobiliary iminodiacetic acid (HIDA) scan, which was normal. The defendant general surgeon informed the patient of the results and that the symptoms may not subside. The defendant offered the patient the options of doing nothing or proceeding with a laparoscopic cholecystectomy.
Two weeks later, the patient presented for surgery. The defendant general surgeon visualized the area of the cystic duct and cystic artery, dissected posteriorly, and placed clips. The operative note describes the location of the cystic duct as being “more posteriorly” but the anatomy seemed to be normal. After 22 minutes, the procedure was complete without any apparent complications.
The patient returned to work a week later. She did not contact the surgeon regarding her dark urine and “chalky-looking” bowel movements. Eight days postoperatively, the patient saw the defendant’s partner with complaints of abdominal pain and nausea. The partner ordered lab work and a HIDA scan. The patient’s bilirubin level was high at 5.1 (0.2-1.2), and the scan showed no evidence of extrahepatic biliary or intestinal activity after two hours. The partner discussed the results with the patient, and the defendant surgeon ordered repeat labs that showed the bilirubin increased to 6.0 and elevated liver function levels. A gastroenterologist was consulted and recommended labs be repeated in two weeks since the elevated levels could be a result of medication given after surgery.
Roughly two weeks postoperatively, the patient had a bilirubin level of 10.5. The gastroenterologist performed a magnetic resonance cholangiopancreatography (MRCP) which showed a questionable filling defect in the distal common duct. An endoscopic retrograde cholangiopancreatography (ERCP) was performed a week later and revealed a high-level, if not complete, obstruction across the common bile duct. The defendant general surgeon discussed results with the patient, and referred her to a biliary surgeon who specialized in the repair of bile duct injuries.
The biliary surgeon placed a percutaneous transhepatic cholangiography (PTC) drain, and later performed a hepaticojejunostomy to repair the common bile duct. The patient’s bilirubin decreased and she was discharged a week after surgery. Although the patient had issues after her PTC drain became dislodged and had to be replaced, she did return to work roughly eight weeks after the bile duct repair.
The patient alleged the defendant general surgeon negligently failed to perform an intraoperative cholangiogram, allowing clipping and injury to the common bile duct and common hepatic duct. She testified the defendant did not provide an informed consent discussion. Although as a holding room nurse, she ensures patients sign consent forms before surgery, the patient signed her consent form without reading it and was unsure of its contents. The defendant general surgeon testified the associated surgical risks are always discussed with patients as part of their routine practice. Due to their working relationship, the general surgeon specifically remembered the patient’s preoperative appointment.
Plaintiff’s experts argued the operative note indicated confusion about the anatomy, thus requiring an intraoperative cholangiogram. Defense experts explained the patient probably had an extremely short cystic duct which when clipped, led to the clipping of the common hepatic and bile ducts. The defense argued an intraoperative cholangiogram was not required to meet the standard of care, and if performed in this case, would likely have led to a bile duct injury requiring the same procedure the patient later received.
A bile duct injury is a recognized complication of a cholecystectomy, which can occur despite adherence to the standard of care. Obtaining the patient’s informed consent prior to surgery involved a discussion by the defendant general surgeon with the patient about the risks, benefits, and alternatives to surgery. The jury returned a defense verdict.
Verdict:
Despite an unexpected outcome and need for a second surgery, the jury returned a defense verdict in favor of the defendant general surgeon.
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