Settled Through Mediation: The Honorable Diane M. Strickland (Ret.).
Type of Case: Medical Malpractice – Robotically-Assisted Laparoscopic Cholecystectomy (Gallbladder Removal Surgery)
Plaintiff’s Attorneys: William B. Kilduff and Thomas J. McNally, Richmond
Summary: Plaintiff, a 56-year-old male, began experiencing abdominal pain and nausea in the spring of 2019. An ultrasound showed a constricted gallbladder and a HIDA scan showed a lack of filling of the gallbladder consistent with an obstructed cystic duct.
Plaintiff subsequently consulted with the defendant, a general surgeon, for evaluation of his gallbladder. The general surgeon diagnosed the plaintiff to have chronic cholecystitis and recommended surgical removal of the gallbladder. Based on preoperative radiographic studies, the surgeon expected to find significant inflammation intraoperatively and that it would be a difficult surgical procedure. The surgeon recommended that the surgery be performed with the assistance of a DaVinci robot.
Once the surgery was underway, the surgeon encountered dense adhesions and was not able to visualize the “critical view of safety”, which is a benchmark used to identify the critical structures surrounding the gallbladder. Not being able to obtain the critical view of safety, the surgeon then attempted to perform a dome-down dissection hoping to identify the appropriate relevant anatomical structures, including the cystic artery and cystic duct. Unfortunately for the plaintiff, the surgeon transected the common hepatic duct during the dissection. The surgeon became aware of the error when she noticed a trickle of bile from the liver. The surgeon confirmed the bile leak through use of the “Firefly technology” used in robotic surgeries.
Upon suspecting the ductal injury, the surgeon performed a cholangiogram, which confirmed the bile duct injury during the surgery.
The surgeon immediately contacted another surgeon who specialized in repairing bile duct injuries. That surgeon performed repair surgery the following day that involved repair of the biliary injury by way of a Roux-en-Y hepaticojejunostomy. During that surgery the surgeon confirmed that the general surgeon had completely lacerated the common hepatic duct during the initial robotic surgery.
Plaintiff was hospitalized for approximately 20 additional days rather than being discharged on the date of the original surgery as was planned. Subsequently, the plaintiff also developed a wound abscess and was hospitalized for approximately four days seven months following the surgery.
The plaintiff’s two experts opined that the general surgeon violated the standard of care in performing the gallbladder removal surgery by the surgeon’s failure to properly appreciate the anatomy of the plaintiff’s gallbladder and related structures; failure to obtain a proper view of the structures before dissecting or cutting around the ductal structures; failing to discontinue the surgery or change the procedure to an open cholecystectomy; failing to perform a subtotal (partial) cholecystectomy when proper visualization could not be obtained; and failing to perform a cholangiogram once it became apparent that the patient’s anatomy was inflamed or aberrant.
The plaintiff’s experts further opined that if the defendant had used proper dissection techniques and/or employed alternate surgical techniques rather than simply marching on when confronted with the inflamed anatomy and aberrant structures, the plaintiff would not have sustained the common hepatic duct injury.
The defense retained two general surgeons who had extensive experience performing robotically-assisted laparoscopic cholecystectomies. In sum, the defense experts opined that the general surgeon complied with the standard of care in every way during the surgery, and that the common hepatic duct injury was unavoidable based on the size of the shrunken gallbladder as well as the inflamed structures and dense adhesions in the surgical plane. The defendants’ experts also opined that the subsequent abscess that developed seven months after the robotically-assisted laparoscopic cholecystectomy was not related to the transection of the common hepatic duct, but was more likely the result of an inflamed and infected gallbladder that did not develop as a result of the general surgeon’s care and treatment of the plaintiff.
This case presented a classic case of a “battle of the experts” wherein the plaintiff’s experts and the defendant’s experts reached diametrically opposite conclusions regarding whether or not the general surgeon breached the standard of care doing the robotically-assisted laparoscopic cholecystectomy surgery.