Laparascopic bile duct injuries
Laparascopic bile duct injuries, you can hear the lawyers salivating. The rise in surgical litigation with laparascopic cholecystectomy has been very rapid and although they occurred with the open method they did not seem to carry the same stigma. Is it because they often present after the fact where in the open method they were usually noticed right away and dealt with. Is it because the media who were quick to jump on the negative band wagon with tales of botched procedures and stories of inadequate training. Is it do to the so called learning curve we all went through when our inexperience was a risk factor for bile duct injury. Probably a combination of all these things.
Nevertheless, such injuries are occurring not only with the beginner but also in the hands of accomplished laparascopic surgeons; not only in the community but also in the tertiary centres and with it a rise in litigation. We have all read about such disasters and touch wood, hope it never happens to us.
Why is there this increase in litigation around bile duct injuries and why do patients sue when surgical complications occur all the time. Medicolegal experts suggest litigation for negligence will accompany surgical complications under the following circumstances. First the injury causes major economic loss to the patient, second, the injury causes signficant organ dysfunction, disability or death, third, there may be substantial payout from the lawsuit, and fourth, the patient believes the the injury resulted from negligence.
Some surgeons and definitely all lawyers think that a bile duct injury is self-evident negligence. The term is res ipsa loquitur meaning it speaks for itself. Personally, I feel this assumption is not true. I think there is an inherent risk of bile duct injury with any cholecystectomy even in the best of hands and it is often difficult to decide when surgical misadventure actually becomes negligence and falls below the standard of care. In the surgeon’s favor there was a landmark decision in Louisiana (Charpentier v. Lammico) where the court ruled in favor of the surgeon. Although this was not a laparascopic case it’s decision was that bile duct injuries are not self-evident negligence.
I have reviewed several of these cases for the Canadian Medical Protective Association as the so called community expert and if I learned anything it is you can be the best and most conscientious surgeon out there but Shit happens, you just pray it doesn’t happen in your operating room.
The only other comment I would make is protect yourself DON’T make a video. The first two case I reviewed both had videos. They were not supportive at all but very damaging.
I’ve read about another factor that plays a major role. If the surgeon doesn’t take the time to talk with the patient, or if the patient gets the feeling that the surgeon is arrogant or uncaring it is much more likely to fuel the fire.
There are some other articles, though, that show that talking to the patient (and appearing compassionate, etc.) prevent non-surgical suits, but that even nice, compassionate surgeons who talk to their patients are likely to get sued if they have a bad result.
A while ago I was asked to act as an ‘expert witness” -on the side of the defendent/surgeon- involved in exactly a similar case you described-i.e. “classical” bile duct injury during LC; the injury was recognised and dealt with surgically 2 days later but the outcome was complicated by a chronic hilar stricture. Two “experts” on the side of the plaintiff claimed that this complication represents a breech of the standard of care. In a lenghty written testimony I tried to prove that a certain incidence of CBD injuries is “obligatory” during LC’s and thus does not represent a malpractice. Outcome- the jury found the surgeon “non guilty”.
My guess is that the surgeons to whom this have never happened will cry foul! To those of us to whom this has happened (not cut, but clipped duct) my guess is we’d be more sympathetic. It’s a shame that anyone would brand a surgeon as “bad” because of a lap chole injury. My mishap occurred on my 229th case as primary surgeon and as many more as assistant during the “learning curve”. I’ve been over the case a hundred times and still don’t understand it. Laparoscopic surgery is a different and more dangerous world. I didn’t injure a common duct in 20 years of open surgery.
I am performing lap.cholec.from August,2010 and,now I have near 600. Others said anytimes that surgery is a mental activities.If we forgot this,surgery becomes a manual activities and then,like you said,in spite “”a surgeon divide the second biliary duct,””he is uneble to understand that he have a big problem.
In 2000 I divided a CBD during my number 12 LC (still under supervision) – immediately recognized and repaired end to end over a T tube- left that country six months later- do not know the long-term follow-up.