Malpractice defense: Laparoscopic Hysterectomy Leads to Ureter and Bowel Injury

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.

Illustrated Verdictby 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. APS receives judgment for the defense in over 94% of the cases we participate in, as compared to the national average of 73%. Additionally insurers who supply us with their trial list enjoy a win rate of up to 97%. 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 would 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 / FistulaDiseased Coronary Bypasses Hysterectomy / Ureter Injury

Judgment for the DefenseLaparoscopic Hysterectomy Leads toUreter and Bowel Injury PLAINTIFF'S CLAIM:Negligence during a laparoscopic hysterectomy caused unnecessary post-op surgeries. The alleged negligence included perforating the bowel at the level of the proximal ileum and transecting the right ureter at the ureterovesical junction.  The plaintiff claimed these injuries should have been noticed in the initial surgery and corrected immediately. Instead, the patient was sent home and the injuries were not discovered until an open laparotomy days later, causing the patient unnecessary pain and suffering.DEFENSE'S ARGUMENT:On the bowel injury, the defense believed the injury might have occurred during the subsequent laparotomy.   The perforation of the bowel occurred away from the area of dissection during the laparoscopic hysterectomy.   During the second surgery, the urologist, who did not do the first surgery, performed blunt dissection of extensive adhesions in the area of the proximal ileum, the area of injury.On the ureteral injury, the defense position was that the injury to the ureter (at the ureterovesical junction) was the result of a thermal injury during ligation of the cervical vessels. This is a recognized risk of the procedure, associated with cauterization of the cervical vessels.  The area of injury, at the ureterovesical junction, is beneath tissue and therefore not visible to the surgeon during the procedure.  A slight thermal injury could have occurred while cauterizing the vessels without being detectable by the surgeon at that time. These injuries typically worsen over time and in this case, the patient presented a few days post operatively with symptoms. The surgeon performed the surgery accurately and appropriately as described in the record, and the resulting injury was a recognized risk that had been discussed with the patient beforehand. VISUAL STRATEGY: APS worked with the attorneys and experts to develop a visual strategy that would help explain to the jury in detail how the plaintiff’s laparoscopic hysterectomy was done appropriately. The primary focus was on the ureteral injury because the defendants believed the bowel injury resulted from a subsequent surgery.We began by showing normal anatomy of the female pelvis to orient the jury on the location of the ureter, the uterus, and the surrounding structures.We also illustrated the normal anatomy of the uterus with vasculature to orient the jury on the location of the ureter in relation to the vessels.We also created a deep dissection of the pelvis with part of the peritoneum removed to show exactly where the ureter lies in relation to the deep uterine vessels following dissection.We created a board of the laparoscopic view which helped show the close proximity of the ureter (indicated as a dotted line) to the uterine vessels and how it wasn’t visible to the surgeon. This was used to explain how an undetectable injury could have occurred.We illustrated the surgical positioning (Trendelenburg position) that the patient was placed in during the insertion of the trocars into the abdomen.  This illustrated the location of the pelvic and abdominal organs during the insertion.  This board showed that while the patient was in the Trendelenburg position, the intestine was back in the abdominal cavity superior to the surgical site and remained that way during the whole procedure.Finally, we showed a normal anatomy board of the abdomen to help the experts explain the location of the surgical field in relationship to the bowel.We utilized web meeting software throughout the process to communicate directly with experts and counsel and fine tune the exhibits.This combination of illustrations helped the defense successfully explain that: The ureter sustained a thermal injury that worsened over time, causing the symptoms to present days later. The ureter is close in proximity to the uterine vessels, and a thermal injury might not be apparent to the surgeon. The surgery was performed appropriately and within the standard of care. The position of the patient, the area of the surgical site, and the careful steps taken during the laparoscopic hysterectomy made it unlikely that the bowel injury could have been caused by our client. RESULT:The jury found in favor of the defense.Attorney Donna Zito emailed to share her verdict and give thanks:“Thank you very much for your extraordinary efforts to help me translate my ever evolving ideas for illustrations into reality.  The illustrations made a big difference, and allowed us to receive the defendants' verdict that my client so deserved.” -- Attorney Donna Zito, O'Brien, Tanski & Young, LLP, Hartford, CT