Category: Blog

Laparoscopic Cholecystectomy Cases: Maximizing Your Client’s Recovery

Introduction

If you’re hoping for a comprehensive “how-to” book on handling botched gallbladder surgery cases from the initial consultation through the large deposit into your trust account, you’ll be greatly disappointed in what you’re about to read. Many others have undertaken that task, and I will share some of their work so you can check it out if you like. This presentation will focus on some of the practical challenges in handling botched gallbladder surgery[1] cases to help you prioritize your responsibilities and (hopefully) make the most out of your client’s case.

This paper begins with the overused “Top Ten Tips” for handling botched gallbladder surgery cases, followed by specific examples to illustrate how these tips play out in the real world. It concludes with a detailed list of resources that will significantly enhance your understanding of botched gallbladder surgery cases and will provide you with valuable information to assist your clients, with appropriate credit to the authors who truly deserve it.

Top Ten Tips:

  • Know the anatomy
  • Know the indications for surgery
  • Know the risks of surgery
  • Know the instruments used during surgery
  • Know the indications for intraoperative cholangiogram
  • Know the proper surgical technique
  • Know the complications
  • Know the repair techniques
  • Know the likely defenses
  • Know your damages

Know The Anatomy

The SAGES Manual and ACS Surgery (see below) have many helpful illustrations describing the critical anatomy in lap chole cases. Take the necessary time to familiarize yourself with the critical anatomy. In fact, ATLA member Mike Abourezk of Rapid City, South Dakota became frustrated with the lack of anatomical charts showing the process and sequence of lap chole surgery, so he taught himself to use a dry erase board during his opening to accurately draw the anatomy, clip and cut the cystic duct, remove the gallbladder, and perform the Roux-en-Y repair.

Know The Indications For Surgery

Some surgeons use nonspecific complaints of abdominal pain to justify the need for lap chole surgery. According to the American College of Surgeons, the Average Patient who undergoes lap chole surgery is middle-aged, muscular or obese, has recurrent biliary colic, a normal gallbladder wall, and previous pelvic surgery. “Difficult patients” include those who are elderly, morbidly obese, suffer from acute cholecystitis, have a thick or contracted gallbladder wall, and have had previous upper abdominal surgery with potential adhesions. The most important contraindication is “surgical inexperience.”[2] When you obtain your client’s medical records, be sure to determine their preoperative health and review the surgeon’s pre-op notes to nail down the indications for performing surgery.

Know The Risks Of Surgery

The known risks of lap chole surgery include excessive bleeding, infection, injury to surrounding organs, injury to the common bile duct, blood clots, injury to the lower digestive tract, and death. These risks are frequently covered in patient education materials given to the patient when surgery is discussed. Always review these materials in detail with the Defendant to establish the Defendant’s recollection of what was said/how the pamphlet was used, and what reasonable expectations the patient had going into the surgery. It is also important to understand the basis for these risks to deal with the potential defenses discussed below.

Know The Instruments Used During Surgery

The SAGES Manual, ACS Surgery, and many surgical texts describe the operating room layout and equipment needed to successfully perform a lap chole surgery. The equipment includes the following: an optical system, an electronic insufflator, trocars (cannulas), surgical instruments, and hemostatic devices.

The optical system includes a laparoscope, a high-intensity light source, a miniature video camera and camera box, and a high-resolution video monitor. The insufflator creates a working space within the abdomen by inserting carbon dioxide under positive pressure. The trocars are simply ports used to see the operative field inside the patient’s abdomen and to provide access for light and visual images and the surgical instruments. A minimal set of instruments for a lap chole surgery includes graspers, dissectors, clip applicators, scissors, a dissecting electrocautery hook, probes, reducers, endoloops, a Veress needle, needle holders, and a cholangiography catheter system. Hemostasis is typically achieved with electrocautery or the laser.

Know The Indications For Intraoperative Cholangiogram

If the patient is morbidly obese, has a significant prior history of disease or surgery in their abdomen, or if the surgical field is difficult to see due to the patient’s anatomy or internal bleeding, the surgeon can always attempt an intraoperative cholangiogram (IOC) to verify the precise location of the common bile duct before clipping and cutting the cystic duct. Many surgeons, particularly those practicing in a university setting, suggest that IOC be used in every lap chole case. Unfortunately, the national consensus conference called by the National Institutes of Health in 1992 concluded that routine IOC was not a necessary requirement for lap chole procedures, and it is not considered to be part of the standard of care for routine lap chole surgeries. Instead, it is often used as a condition of continued privileging for those surgeons who cause repeated injuries to the common bile duct during gallbladder surgery.

Know The Proper Surgical Technique

[Note: see SAGES Manual, pp. 130-32,”Trocar Position and Choice of Laparoscope” for a discussion of recommended trocar positions and recommendation for a 30-degree laparoscope vs. 0-degree laparoscope.]
Using two atraumatic graspers, gently elevate the liver by passing the graspers under the visible liver edge.
If the gallbladder is not visible, carefully dissect adhesions to the underside of the liver and gallbladder using as little cautery as possible.
If the gallbladder is inflamed and tense, it must be decompressed before attempting to grasp it. This is done using a Veress needle to stab and suction the gallbladder.
When the fundus[3] of the gallbladder is exposed, the first assistant grasps the fundus with an atraumatic locking grasper and pushes the gallbladder over the liver toward the right shoulder to open the subhepatic space and expose the infundibulum.[4]
The surgeon or assistant places a second atraumatic grasper on the base of the gallbladder. KEY: “The direction of traction is critical to prevent errors in identification of the ductal structures in this area.” The infundibular grasper must be retracted laterally while the fundus is retracted toward the right axilla to expose Calot’s triangle.[5] If the infundibulum is retracted anteriorly or upward it creates a “tenting” effect that tends to collapse Calot’s triangle and increase the risk of ductal injury.
Begin dissection “directly adjacent to the gallbladder.” Any adhesions should be sharply taken down to the base of the gallbladder.
“Identify the cystic duct where it enters the gallbladder.” [This is the point where surgical error frequently begins.] The infundibular grasper should be moved backward and forward and side-to-side so the junction of the cystic duct and the gallbladder can be identified with certainty.
Additional incisions can be created in the peritoneum to elevate the gallbladder and create a space behind it to make it easier to identify the ductal structures.
If a cholangiogram is going to be performed, the cystic duct must be dissected free for at least 1 cm to allow cholangiography.
Two clips are placed side-by-side as close to the gallbladder as possible and two similar clips are placed on the cystic duct, using care not to place them too close to the junction of the cystic duct and the common duct.
The infundibular grasper is repositioned to grasp the gallbladder next to the cystic duct. The gallbladder is retracted anteriorly and laterally to expose the cystic artery for dissection.
The cystic artery is divided with clips, leaving a minimum of two clips on the stump of the artery. This division allows the gallbladder to be pulled farther away using the infundibular grasper.
The gallbladder is dissected away from its bed. The instruments used for this vary from hook cautery to cautery scissors or spatulas to laser.
Before the gallbladder is removed, the gallbladder bed and ducts should be closely examined for evidence of bleeding.
Irrigate with saline, using care to prevent dislodging the clips.
After hemostasis is achieved, the gallbladder is freed from the liver.
A grasper is used through one of the trocars to grasp the gallbladder near the cystic duct.
The gallbladder is removed. If the gallbladder contains bile or stones, they should first be aspirated from the gallbladder before it is withdrawn through the trocar.
After removing the gallbladder, the surgical site should be inspected for bleeding.
If necessary, a closed suction drain can be placed. [Open drains are not recommended, because they can increase the risk of infection.]
Remove the trocars and close the wounds in normal fashion.[6]

Know The Complications

The major complications of a botched gallbladder surgery include bleeding, gallbladder problems, post-op bile leakage, and bile duct injury. Although inconsequential oozing of blood is not uncommon, hemostasis is critical before the patient is closed. Any unusual bleeding in the triangle of Calot is cause for concern. Surgeons should not apply clips blindly or they will risk injury to the right hepatic duct, right hepatic artery, or common bile duct. Another difficult source of bleeding is from the gallbladder fossa. Any bleeding between the posterior wall of the inflamed gallbladder and the liver bed should be controlled immediately.

Gallbladder problems include an inflamed gallbladder (difficult to grasp), a perforated gallbladder (leading to contamination of the peritoneal cavity and potential infection), gallbladders containing large stones (difficult to remove through abdominal cavity) and undiagnosed carcinoma. The potential for contamination of the peritoneal cavity is one factor that needs to be considered in the pre-op assessment of whether prophylactic antibiotics should be given before gallbladder surgery.

Post-op bile leakage can result from injury to the cystic duct or right hepatic duct, cystic duct stump leakage, or injury to an accessory[7] bile duct. Any suspected collection of bile post-op should be investigated with radionucleide scan and ERCP, which is used for both diagnosis and treatment.

Most injuries to the hepatic ducts, the hepatic common duct, or the common duct occur during dissection at the triangle of Calot. Improper cephalad traction can cause the cystic duct to lie in a straight line with the common duct, which is then mistaken for the cystic duct. If the injury is detected during the procedure, the surgeon should immediately convert to an open procedure to allow for better access for repair.

Know The Repair Techniques

Depending on where and when the injury to the common duct is detected, it may be as simple to repair as reconstructing the duct over a T-tube, or as complex as performing a reconstruction of with a hepaticojejunostomy/Roux-en-Y procedure. Injuries to the lateral wall of the common duct may be treated with external drainage and biliary stenting.

Electronic Discovery

We paralegals are in the story business. Through our work on legal cases, we are introduced to the skeleton of an account and must try to reconstruct the truth using the discovery process.

Most of our working hours are spent filling in the blanks. What we find when we do our jobs, and how we find it, can change a case’s direction, focus and even outcome.

Electronic discovery has revolutionized the way paralegals work and has given us unparalleled access to information. So our new challenges are time management and resource management: We must locate the most relevant information without becoming bogged down in the sheer supply of material. When we have accomplished this, the information fills in the gaps and can bolster our clients’ cases.

Not very long ago, discovery was limited to the hard copy files our clients kept (or did not keep). Ten associates and paralegals locked in a conference room would review 50 boxes of paper for days on end, creating “hot” document binders and sorting documents by relevance and issue. Numerous days and billable hours were required to weed through the information and then organize the material for use in a variety of trial scenarios.

Before the electronic database defined a new age of discovery, we occasionally found hidden gems of evidence or new ideas to support the client’s strongest position. But the infrequent cry of “Eureka!” is downright routine today. Because we have more data and it’s better organized, it’s so much easier to find new ideas and approaches. If a new approach to a case comes up during a document review, we can more frequently “discover” supporting information electronically.

This ability to more effectively manage the case information through the use of databases is just one example of how technology improves the litigation process.

At my firm we have established a practice group that focuses on providing discovery counsel, document review and production and litigation support services. At every stage, this group uses technology to improve its processes: by using databases to provide litigation support, by leveraging technology to assist in substantive document reviews for responsiveness and by conducting narrowly focused “snapshot” reviews even before the litigation is filed.

A perfect example of how technology enables litigation professionals to provide services that may not have been possible in the past, all-paper world is the snapshot review. It is a limited review done in order to quickly locate key information for the client Ñ e.g., for internal investigations or for pre-litigation risk assessment. This type of review can save firms and clients time and expense by allowing us to quickly get to the heart of the matter. And it can often help to produce an amicable settlement.

Consider this scenario: A client calls his law firm for help with a case. Adamant about his position, he waves around what he considers to be a “smoking gun” document and says he wants to file a complaint as soon as possible. The law firm persuades the client to conduct a snapshot review for additional fact-finding before filing. The firm harvests e-mail and other electronic documents from a few key players at the client’s organization. Using special software, the firm culls out redundant materials, applies date ranges and runs keyword searches – greatly reducing the volume of material for review. The attorneys then review the remaining documents, using the software’s visual mapping and search capabilities to quickly home in on the most relevant documents. They locate not only the smoking gun document that the client first brought to their attention, but also a number of e-mails and documents that clearly show the client’s case is not as strong as originally believed.

The snapshot review process has changed the complexion of early negotiations. The client now has a more accurate view of the situation and may decide not to pursue the case after all. But had the snapshot review shown his position to be well supported, the client could have proceeded to file the complaint and aggressively approach the next phase of litigation, confident that the more extensive document review required by the discovery phase would not likely introduce unexpected plot twists.

Technology also plays an important role in the discovery phase, where an even larger collection of information must be reduced to the subset of responsive documents that will be given to the opposing side and loaded into litigation support databases. And once again the litigation support team will need to zero in on the most important pieces of information.

Paralegals who effectively use electronic discovery and take advantage of technological innovations can bring clarity to a case. And with that clearer picture, the client has more data points to consider trial strategy and settlement negotiations.

Ideas for the Law Firm – research using GOOGLE.COM

Every day we are asked to “find” something….I’ve found Google to be a good research tool for many tasks. Some of the more common uses utilized in the Plaintiff Law Firm are given below:

If you use Google’s “advanced search” feature, you can limit your search to Powerpoint files.

On the “file format” section, set the search parameter to return only files in the format “Microsoft Powerpoint (.ppt)”. Then enter your search term, e.g., “Laminectomy”. All hits will be in the form of Powerpoint presentations, many of these are posted by medical students, doctors, etc.

Another way to search for PPT presentations is to use your search term (such as laminectomy) plus the word “powerpoint”.

It is also useful to use Google to locate images, most of which can then be downloaded and used in Powerpoint. An image search for “laminectomy” returns over 230 hits.

The image search is selected from the main (home) page of Google, not on the advanced search page.

And if you are looking for say “daubert motion Steven Clark” sometimes you can get lucky there and find them online with a google search in the general search feature.

Another idea is to do a search for “motion” “brief” with key words…..and if you don’t find it at the search result link, use the “cache” feature.

The cache feature will highlight with a different color for each search term everywhere it occurs in the webpage/document. Very handy for looking for a certain name, etc. I have found warrants, court orders, etc. More and more documents are being archived online and available to the public.

New Feature to monitor appearance of future references to search terms

Now on Google you can specifiy a search term, and google will let you know via email if it appears on the web…you can use it to search for any term you wish…put in the name of a surgical procedure, an expert, a defendant, even your “favorite” opposing attorney…this feature is found at http://www.google.com/webalerts/

Too many results?

Ever do a search and still feel like you have too many results? Instead of trying a new search, you might have more luck narrowing down the set of matches you’ve already generated. Google makes this process easy through a “Search Within” feature. After performing a search, click on the “Search within results” link that appears at the bottom of the results page, next to the search box, on the results page.

Customize your results using the Preferences Page

Pick the Language…you can do a search in the translation of your choice from the Preferences Page OR you can translate a page in a language foreign to you by selecting the “translate” feature on the search results page…

Select the number of results per page, the default is 10, but you can select 20, 30, 50 or 100 if you wish Using the “New Results Page” feature allows you to keep your search page open, and any link clicked on will open in a new browser page/window…this eliminates back browsing and repetitive search requests.

Various search commands

  • Include search term “+” sign (most do this by default but it will not hurt to use this symbol) this has same effect as AND
  • Exclude search term “-” sign (in effect same as NOT)
  • Must include phrase “” (quotes around phrase to be included)

Yellow Page Directory-type search feature

Google Local integrates yellow pages-style information right into your search. Search for pizza 75662 or pizza marshall,tx and up will pop a little compass with a couple results. Click the compass, and you’ll get a full listing of nearby results, with distance, maps, directions, related web pages, phone numbers, and more. You can narrow it down by category and distance, and look at a map of all the results. Wireless Froogle Froogle is Google’s product search service. To use Froogle on your cell phone, just point your phone’s brower to http://wml.froogle.com/ Then enter your search terms in the box/select search, using your phone’s keypad arrows to scroll through the results. At the store looking for a PDA, whip out your cell phone/use Froogle and never wonder again if you paid too much.

Travel Information

To see delays and weather conditions at a particular airport, type the airport’s three letter code followed by the word “airport.” For example, San Francisco International Airport updates can be found by searching for “sfo airport.”

Google has added more search by number features:

UPS tracking numbers – example search: “1Z9999W999999999”
FedEx tracking numbers – example search: “999999999999”
USPS tracking numbers – example search: “9999 9999 9999 9999 9999 99”
Vehicle ID (VIN) numbers – example search: “AAAAA999A9AA99999”
UPC codes – example search: “073333531084”
Telephone area codes – example search: “650”
Patent numbers – example search: “patent 5123123”. Remember to put the word “patent” before your patent number.
FAA airplane registration numbers – example search: “n199ua”. An airplane’s FAA registration number is typically printed on its tail.
FCC equipment IDs – example search: “fcc B4Z-34009-PIR”. Remember to put the word “fcc” before the equipment ID.

More Google Web Search Features

Google has many special features to help you to find exactly what you’re looking for. Go here to find more information on each feature listed below:

Cached Links – View a snapshot of each page as it looked when we indexed it.
Calculator – Use Google to evaluate mathematical expressions.
Definitions – Use Google to get glossary definitions gathered from various online sources.
File Types – Search for non-HTML file formats including PDF documents and others.
Froogle – To find a product for sale online, use Froogle – Google’s product search service.
I’m Feeling Lucky – Bypass our results and go to the first web page returned for your query.
Local Search – New! – Search for local businesses and services.
News Headlines – Enhances your search results with the latest related news stories.
PhoneBook – Look up U.S. street address and phone number information.
Search By Number – Use Google to access package tracking information, US patents, and a variety of online databases.
Similar Pages – Display pages that are related to a particular result.
Site Search – Restrict your search to a specific site.
Spell Checker – Offers alternative spelling for queries.
Stock Quotes – Use Google to get stock and mutual fund information.
Street Maps – Use Google to find U.S. street maps.
Travel Information – Check the status of an airline flight in the U.S. or view airport delays and weather conditions.
Web Page Translation – Provides English speakers access to a variety.

New Search Features:

GOOGLE for Mobile Devices – If you have a mobile device and need to Google something, they released a mobile page you can navigate to via your Palm, Pocket PC or phone. Just load http://www.google.com/xhtml in your browser and it will come up.

PICASSA 2 – A great idea for picture organization on your computer. (As well as sharing photos with others, and allows you to edit the quaility of photos as well.

GOOGLE – Desktop Search – Google Desktop Search is how our brains would work if we had photographic memories. It’s a desktop search application that provides full text search over your email, computer files, chats and web pages you’ve viewed. By making your computer searchable, Desktop Search puts your information easily within your reach and frees you from having to manually organize your files, emails and bookmarks. After you download Google Desktop Search, the application creates an index of all your searchable information and stores it on your computer, allowing you to search your personal items as easily as you search the Internet using Google. Unlike traditional computer search software that updates once a day, Desktop Search updates continually for most file types; when you receive a new email in Outlook, for example, you can search for it within seconds. To download and read more information on this feature.

Google Earth – Mapping/Image search – Want to know more about a specific location? Dive right in — Google Earth combines satellite imagery, maps and the power of Google Search to put the worlds geographic information at your fingertips. Some of the features include Visually fly from space to your neighborhood, type in an address and zoom right in, Search for schools, parks, restaurants, hotels, get driving directions And you can tilt and rotate the view to see 3D terrain and buildings. In addition, you can save and share your searches and favorites…even add your own notations. This is a great resource for exhibits, school projects… and just for fun! ..and the best news? It is free.