Malpractice defense: Internal Hernia Following Laparoscopic Right Colectomy
In addition to my consulting work and writing the Health Business Blog, I’m chairman of the board of Advanced Practice Strategies (APS), a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety.To learn more contact: Timothy Croke, Director of Demonstrative Evidence Group. tcroke@aps-web.com or 617-357-0553 ext. 6664.Here’s the Advanced Practice Strategies case of the month.
Judgment for the DefenseInternal Hernia FollowingLaparoscopic Right Colectomy
The plaintiff underwent a laparoscopic right colectomy to remove a recurrent sessile neoplastic lesion that was not amenable to safe colonoscopic removal due to its size and configuration. The operation was uneventful, and the postoperative recovery was also initially without incident. Worsening clinical findings, however, resulted in further evaluation, including a CT scan. The radiologic findings, coupled with the patient’s clinical condition, necessitated a return to the operating room. Exploration revealed an internal hernia along with an anastomotic leak and associated abscess—known complications of the original procedure. The defendant resected the previous ileocolic anastomosis and created a new ileocolic anastomosis. The patient’s postoperative recovery was long and complicated, involving two subsequent major procedures and several minor procedures, but ultimately he recovered fully.
PLAINTIFF'S CLAIM: The plaintiff believed the defendant failed to follow standard of care by not closing the mesenteric defect between the terminal ileum and the transverse colon. Plaintiff’s lawyers argued that the defect allowed an internal hernia to occur, resulting in an anastomotic leak and subsequent complications. The plaintiff maintained that failure to close the mesenteric defect was the "sole cause" of his difficult and complicated recovery from the laparoscopic right colectomy.
DEFENSE'S ARGUMENT:Resection of the plaintiff’s neoplastic disease created a defect in the mesentery of the bowel. Defense experts testified that the standard of care does not require routine closure of the mesentery after performing a right colectomy. They also testified that an anastomotic leak is known to be a serious possible complication of this type of surgery. Furthermore, during the original procedure, the defendant followed standard practice for minimizing the risk of an anastomotic leak, using proven, safe techniques to perform the anastomosis to ensure there was no tension between the two segments of intestine and that each margin was healthy and viable.
___________________________________________________________________VISUAL STRATEGY:Collaborating with the defendant and his attorney, APS created illustrations to help convey his recollection of events to the jury.APS started with an illustration of the normal anatomy of the abdomen and an illustration clarifying the anatomy of the mesentery and colon.Another diagram illustrated the laparoscopic port positions.An additional illustration detailed the relevant surgical anatomy and, specifically, the right colon and mesentery removed during the right colectomy.The anastomosis created between the ileum and colon following excision of the specimen was depicted on another illustration board.The last board showed the internal hernia that the defendant believed led to the anastomotic leak.
This series of illustrations helped the defense successfully convey the following key points to the jury:
- The surgery was done correctly and followed the standard of care.
- Anastomotic leaks are a known risk of these procedures.
- Although its occurrence in this case was unfortunate, the anastomotic leak was recognized and corrected promptly and appropriately.
RESULT:The jury found in favor of the defense. "We received a defense verdict on the case and the illustrations were very helpful in the process. Thank you for all of your assistance."