Allegation:
Improper performance of surgery resulted in extensive patient injury leading to death.
The Case:
65 YOF presented to the ED with a chief complaint of 10/10 RUQ abdominal pain with associated headache, nausea, and vomiting for the previous six days. Her past medical history was noted to be significant for pancreatitis, left arm amputation, and DVT (on chronic Coumadin and ASA).
On exam, her abdomen was soft and non-distended with tenderness to palpation in the RUQ. There was no associated guarding or rebound tenderness. Vital signs revealed mild tachycardia but were otherwise normal.
Abdominal ultrasound revealed a mildly nodular hepatic contour and a thickened contracted gallbladder with trace pericholecystic fluid, a positive Murphy’s sign, and no visualized gallstones. Lab work revealed a normal white blood cell count, elevated liver function tests, and prolonged clotting time.
The ED physician’s assessment was acute cholecystitis. After discussing the case with the general surgeon on call (Surgeon A), he admitted the patient. Surgeon A examined the patient, agreed with the diagnosis of acute cholecystitis, and planned for surgical intervention. He consulted the hospitalist to manage her chronic medical conditions and her anticoagulant therapy.
The hospitalist noted a more extensive medical history including diabetes, neuropathy, fibromyalgia, asthma, PVD, HTN, GERD, and tobacco use/dependence. He agreed with the diagnosis of acute cholecystitis and the need for surgery and ordered a Coumadin hold after consulting with her cardiologist.
On day 2 of her hospitalization, the patient was seen by a different general surgeon (Surgeon B). He ordered a HIDA scan to rule out acalculous cholecystitis and noted her symptoms could be related to cirrhosis. The HIDA scan revealed a patent cystic duct, making cholecystitis less likely. He consulted a gastroenterologist for further evaluation of possible common bile duct obstruction.
The gastroenterologist evaluated the patient and documented that the patient did not have a surgical abdomen and did not require any endoscopic procedure. His impression was acalculous cholecystitis and noted the patient may require a cholecystectomy.
On day 3 of her hospitalization, the patient was seen by Surgeon A and she reported no complaints. Her lab work revealed a normal WBC, but worsening liver function tests. His assessment was acute cholecystitis with a plan for laparoscopic cholecystectomy the following day. He discussed the risks and benefits of the surgery as well as the alternatives and the patient wished to proceed.
On day 4 of her hospitalization, the patient was taken to surgery by Surgeon A after her INR was noted to be 1.38. Since the Veress needle the surgeon needed to enter the abdomen was not readily available he did not proceed with his usual Veress technique to enter the abdomen and insufflate prior to placing the trocars. Instead, he proceeded with the cut down approach in which the outer layers of skin were cut down to the level of the fascia and the trocars were placed without prior insufflation.
Specifically, he placed a small incision above the patient’s umbilicus and then attempted to place a 12 mm trocar into the abdomen but encountered significant bleeding. He converted to an open procedure. During the exploratory laparotomy, he noted bleeding coming from the retroperitoneum near the area of the IVC and aorta. He packed the abdomen and called in the vascular surgeon.
The vascular surgeon immediately presented to the OR and noted massive bleeding. He identified multiple vascular injuries, which were all repaired, and the skin was closed. The plan was to perform a subsequent exploratory laparotomy once the patient stabilized.
Surgeon A discussed the complications encountered during the procedure with the patient’s husband during which the patient’s condition declined. Her husband stated he did not want aggressive resuscitation measures. Despite being on pressors, the patient’s condition continued to worsen, and she died a few hours later.
Defense Expert Testimony
There were three unsupportive reviews. One expert was critical of the decision to perform surgery on this patient and questioned whether the surgery was medically indicated. Another expert opined this was a complicated surgical patient, and with her history of cirrhosis and chronic Coumadin extra caution should have been taken during surgery. All three experts could support utilizing a cut down entry method but were unsupportive of Surgeon A’s cut down technique. They noted that placement of a large, bladed trocar directly through the fascia without prior insufflation directly resulted in the patient’s injuries. It was also noted that the surgeon could have retrieved the Veress needle from down the hall to avoid performing the procedure with this technique.
Verdict:
Due to lack of support from defense experts regarding the surgical technique and the decision to operate on this patient, the case resulted in a reasonable settlement.
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