Malpractice defense: Diagnostic Laparoscopy Resulting in Bowel Injury
I’m the former 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. I continue to follow the company closely and am intrigued by its illustrated verdict series.To learn more contact: Timothy Croke, General Manager of Demonstrative Evidence Group. tcroke@aps-web.com or (617) 275-7300 x7264.Here’s the latest featured case:
Judgment for the Defense Diagnostic Laparoscopy Resulting in Bowel Injury
A 46-year-old woman presented with pelvic pain. She was known to have dense adhesions in her abdomen and pelvis, discovered when undergoing a hysterectomy and a bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries along with uterus and cervix) about 7 years prior. The defendant recommended that she have a diagnostic laparoscopy to determine the cause of her pain, suspecting an ovarian remnant, notorious for causing pain. During the procedure, a large amount of adhesions and several loops of bowel were found adherent to the right pelvic side wall. After dissecting the bowel off of the side wall, the defendant uncovered what was believed to be an ovarian remnant near the infundibulopelvic ligament and sent a tissue sample to pathology for review.The following day, the plaintiff presented to the emergency room with marked abdominal pain, distension and tachycardia. These symptoms raised concern for a possible bowel injury, so she was brought back to the operating room where a 1 cm defect was found in the terminal ileumapproximately 6 inches from the ileocecal valve. Additionally, the pathology report from her procedure the day before reported the presumed “ovarian remnant” was actually a segment of small bowel wall with serosal fibrosis.PLAINTIFF'S CLAIM:The defendant was negligent in removing a piece of small bowel wall rather than an ovarian remnant. She was also at fault for not thoroughly examining the bowel at the time of the procedure to ensure it was not injured during dissection of the dense adhesions.DEFENSE'S ARGUMENT:The defendant followed standard of care by carefully examining the bowel during the procedure but the adhesions and fibrosis of the bowel serosa made it difficult to identify a defect in the bowel. The defense also argued that the size of the tissue sent to pathology, if taken directly from the terminal ileum, would have resulted in symptoms of a bowel perforation almost immediately following the procedure, and not a day later. They proposed the perforation likely stemmed from a small tear in the bowel wall, created by pulling on adhesions during the dissection, which opened up over time._______________________________________________VISUAL STRATEGY:Collaborating with the defense attorney, APS created a visual strategy that helped experts explain that the defendant properly followed standard of care during the procedure by removing what was believed to be an ovarian remnant.Several diagrams were used to help the jury understand the anatomy of the female pelvis and bowel.
- Normal female pelvic anatomy, superior view
- Normal female pelvic anatomy, anterior and sagittal views
- Normal digestive system
- Normal dissection of the abdomen
- Normal small bowel blood supply
Another diagram was developed to show the hysterectomy and bilateral oophorectomy the plaintiff had approximately 7 years prior.Another diagram demonstrated the diagnostic laparoscopy performed by the defendant.The final diagram illustrated how a small bowel injury to the outer serosal layer can progress to a full thickness defect in the bowel wall.This series of illustrations helped the defense successfully convey to the jury the following key points:
- The amount and location of adhesions in this case made it difficult to identify a defect in the bowel at the time of the procedure.
- Illustrating the location of the removed tissue helped show it could have been mistaken for an ovarian remnant and also that the defendant did not take it directly from the bowel as the plaintiff claimed.
- A bowel perforation can develop over time and not result only from an injury during surgery—an explanation more consistent with the timing of the plaintiff’s procedure and presentation of her symptoms.
RESULT:The jury found in favor of the defense. "Defense verdict after 5 minutes of deliberation; your illustrations were very helpful. Thanks for handling on stat basis!"