Malpractice defense: Hysterectomy Leading to Vesicovaginal Fistula

In addition to my consulting work and writing the Health Business Blog, I’m chairman of the board of Advanced Practice Strategies, a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety. Here’s the Advanced Practice Strategies case of the month.For previous examples see Fetal assessment and response,  Stroke after lung surgery,  Coronary artery disease vs. medication administration and tPA administration leads to brain hemorrhage.

Illustrated Verdict by APSEvery month APS's Demonstrative Evidence Group shares case examples from our archives to show how a visual strategy can support the defense effort. We hope that it is of value in your practice as you develop your defense strategies on behalf of health care providers. Please feel free to forward it to colleagues or clients.About UsAPS is a leading provider of demonstrative evidence for the defense of medical malpractice claims. Our team of medical illustrators consults with defense teams to educate the lay jury audience about the complexities of medical care. We do this by developing a visual strategy with expert witnesses including high-quality case-specific medical illustrations, x-ray enhancements, and multimedia presentations. To learn more, e-mail us or call 877.APS.4500.Case RequestIf you have an upcoming case in any of the following areas, please send us an e-mail and we’d be happy to show you some relevant examples of our work:Bariatric/Gastric BypassBirth Injury & DefectsBrain InjuriesCancersCosmetic SurgeryDelayed / MisdiagnosisD ental IssuesDigestive Tract IssuesEmergency RoomFemale ReproductionFilm Duplication/DigitizingFilm EnlargementHeart Attack & CardiacInfectionLasik Eye SurgeryMale ReproductionMedication IssuesSpinal Cord InjuriesSurgical IssuesGeneral Inquiries I.V. LibraryClick to view other editions:Fetal Assessment / ResponseStroke After Lung SurgeryShoulder DystociaSpleen Injury and Bleed Cardiac Artery DiseaseGastric BypasstPA InfusionRecurrent Hiatal HerniaHysterectomy / Fistula

Judgment for the DefenseHysterectomy Leading to Vesicovaginal Fistula PLAINTIFF'S CLAIM:The Plaintiff claimed that the Defendant was negligent in two respects: First, by bluntly dissecting during a total hysterectomy, thereby creating a vesicovaginal fistula through which urine leaked from the bladder into the vagina, and second, by failing to diagnose the existence of the fistula in a timely manner.DEFENSE'S ARGUMENT:This 36 year-old plaintiff underwent a hysterectomy because of abnormal vaginal bleeding and abdominal discomfort from a large, symptomatic 8–10 cm uterine fibroid. The patient’s anatomy was distorted by the mass, resulting in the cervix being pushed anteriorly into the base of the bladder.  This prevented normal visualization of the cervix on a speculum examination.The manner in which the defendant performed the plaintiff’s hysterectomy—sharp dissection using scissors, as well as blunt dissection with her finger—was not only consistent with the standard of care but was (and still is) the method employed by many if not most gynecologists.During the patient’s post-op hospitalization, there were no signs or symptoms that a vesicovaginal fistula had formed. The fistula presumably developed slowly, as evidenced by her symptoms only becoming apparent weeks after surgery. The physician theorized that the slow development stemmed from devascularization of the bladder wall, most likely resulting from a pelvic infection.VISUAL STRATEGY: APS worked with the attorneys and experts to develop a visual strategy that would help explain to the jury in detail that the procedures were performed appropriately:We began by showing normal anatomy to orient the jury to the anatomical landmarks and surrounding structures.We also illustrated the preoperative condition and how the fibroid mass in the uterus distorted the patient’s pelvic anatomy.We created illustrations of the hysterectomy directly from the operative reports with the cooperation of the experts and defendants.We created illustrations of the postoperative anatomy.With illustrations we were able to explain that the vesicovaginal fistula was not diagnosed immediately after surgery because it formed over an extended period of time. We illustrated the pelvic infection, showing adhesions between the small bowel and the adnexa, along with the resultant thinning of the bladder wall. We created a board to show how necrosis weakened the bladder wall and progressed into a vesicovaginal fistula. We illustrated the vesicovaginal fistula based specifically on case documentation and expert review. We concluded with a timeline that helped the jury visualize that the care given and the follow-up recommendations and treatments were all appropriate.This combination of illustrations helped the defense successfully explain that: The manner in which the defendant performed the plaintiff’s hysterectomy—sharp dissection using scissors, as well as blunt dissection with her finger—was not only consistent with the standard of care but was (and still is) the method employed by many if not most gynecologists. The plaintiff did not have a vesicovaginal fistula during her postoperative hospitalization. The fistula developed slowly, becoming evident weeks later, presumably from devascularization of the bladder wall resulting from a pelvic infection.  RESULT:Arbitrator found in favor of the Defendant. In Arbitration: "He found for the defense.  I would like to thank all of you for your invaluable work in making this a successful outcome for our client. " -- Attorney Dennis R. Anti, Partner, Morrison Mahoney LLP., Springfield MA