Learning from cases - General SurgeryArticle

This case is based on a real scenario, with some facts altered to preserve confidentiality.Dividing RuleFollowing two episodes of acute cholecystitis, a 41-year-old woman attended a consultant general surgeon privately for consideration of a cholecystectomy.The surgeon recommended a laparoscopic cholecystectomy and advised the patient of the risks of conversion to an open procedure, bleeding, bile leak, and infection. Consent was taken on the same day as the surgery.During the operation, the gallbladder was found to be very inflamed, and multiple adhesions were identified. The adhesions were divided, and the gallbladder was ‘removed with great difficulty’. A drain was sited, and antibiotics prescribed. The operation notes were sparse but mentioned that the anatomy had been difficult to define, and adhesions had been dense. Over the next three days, there continued to be bile leakage into the drain. This was considered to be arising from the liver surface rather than a bile duct injury. The patient complained of left upper quadrant pain, nausea, and vomiting. No jaundice or fever was noted. A tachycardia was identified but this was considered to be due to pain.An ultrasound was performed on the fifth post-operative day. This revealed free fluid in the pelvis of 5cm in depth, and no fluid collection within the gallbladder fossa. The common bile duct was noted to measure 4.1mm with no intrahepatic biliary dilatation.As bile drainage was negligible at this point, the drain was removed, and the patient discharged. Observations taken shortly before discharge identified that the patient’s temperature was 38°C, and her heart rate was 102 BPM. Her CRP had risen from the previous test taken two days previously, but was still lower than it had been on the first post-operative day. Five days following discharge (ten days post-operatively), the patient re-presented with worsening upper abdominal pain and increasing tachycardia, along with a temperature of 38.2°C. Her CRP was markedly raised. The operative surgeon suspected a biliary leak. A CT scan demonstrated a pelvic collection and a small amount of fluid around the right lobe of the liver. On US guided aspiration 110mls of green-tinged straw-coloured fluid was aspirated. The patient’s symptoms continued, and a diagnostic laparoscopy was performed, revealing 700ml of bilious fluid in the right side of the abdomen. The abdomen was washed out and a drain placed. Bile continued to drain, and the patient was transferred to a hepatobiliary unit. Three weeks following the original surgery, the patient underwent a laparotomy and bile duct exploration, where it was discovered that the right anterior bile duct had been divided and clipped. A hepaticojejunostomy was performed and the patient made a good recovery after this. The patient brought a claim against the surgeon who had performed the laparoscopic cholecystectomy, alleging failure to correctly identify the structures in the triangle of Calot, failure to convert to open cholecystectomy, failure to correctly identify the right anterior bile duct, and instead mistaking it for the cystic duct, and subsequently clipping and dividing it. It was alleged that had the surgeon proceeded to open cholecystectomy, the structures would have been identified correctly and the patient would not have suffered the bile leak and the requirement for further surgery. She sought compensation for the pain and suffering she had endured, additional scarring and risk of incisional hernia, and the risk of adhesions requiring further surgery. An expert report obtained during the investigation of the claim was critical of the surgeon for the following reasons:

The consent process and the surgery took place on the same day – as this was elective surgery the patient should have been provided with an opportunity to consider her options.

Further, although some serious and frequently occurring risks (including bile leak) were discussed, the possibility of bile duct injury was not. It was stated by the expert that a bile leak could not be held to be synonymous with a bile duct injury.

The operation notes were very limited, and it was not clear whether the anatomy was fully identified and whether dissection was in line with good practice.

In the event the surgeon was struggling with identification of structures due to dense adhesions and inflammation (as suggested by the operative note), the procedure should have been converted to open. Alternatively, a retrograde or sub-total cholecystectomy could have been considered.

While the expert was sympathetic to anatomical variation of the biliary tree, and that the patient’s anatomy may have been particularly unusual, on balance of probabilities they considered that the surgeon had failed to identify the anatomy correctly in this case, leading to the right anterior duct being clipped and divided, rather than the cystic duct.

It was considered this error would have been avoided had the procedure been converted to an open cholecystectomy.

On that basis, the patient would have avoided the bile leak, and the need for further surgery.

The claim was settled for a total cost of approximately £150,000.
Learning PointsDividing Rule 2If the anatomy is unclear or other difficulties are experienced during laparoscopic surgery, consideration should be given to converting to an open procedure.It is difficult to investigate and defend any subsequent claim arising from the performance of a surgical procedure where the documentation is limited or incomplete.The consent process should allow patients time to consider their options, and ensure that all serious and frequently occurring risks are discussed.
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