This case involves a fifty-six-year-old male patient who underwent a single incision laparoscopic cholecystectomy. The procedure was met with some complication as it was noted that the patient had an intrahepatic gallbladder with severe scarring at the triangle of Calot that proved to be a difficult dissection. Postoperatively, the patient was said to be recovering fine and was discharged soon after. The patient was readmitted to the hospital three weeks later for severe pain and jaundice and was noticed to have a large fluid collection that required drainage via ERCP along with a percutaneous left biliary drain placement. A cholangiogram was performed after the drainage which showed significant biliary damage that required referral for an extensive biliary reconstruction procedure.

The most dreaded complication of laparoscopic cholecystectomy is injury to the common bile or common hepatic duct. The estimated incidence of bile duct injury in cholecystectomies performed laparoscopically varies from 0.3-2.7%. In contrast, biliary tract injuries were noted to occur in 0.25-0.5% of open cholecystectomies. A major risk factor for bile duct injury is the experience of the surgeon and other risk factors are the presence of aberrant biliary tree anatomy and the presence of local acute or chronic inflammation.

1. How often is the bile duct injured during this procedure and what are the most likely causes?

Location: Indiana B.A., Texas Christian University M.D., Tufts University School of Medicine M.S., Health Care Policy, The University of Texas-Dallas, Southwestern Medical School M.B.A., The University of Texas-Dallas, Southwestern Medical School Internship, General Surgery, Naval Medical Center Residency, General Surgery, Naval Medical Center Postgraduate, Thoracic and Cardiovascular Surgery, University of Texas Board Certification: Thoracic and Cardiovascular Surgery Active Medical License: Indiana Award, Scholar in Health Policy, American College of Surgeons 2006 Former C******** M***** W******** o* H***** C*** P***** R***** a** A******* Former A******** S****** L*** T********* P****** M******** H******* Current S*** D******* A******* C****** o* S******* O******* G**** Current D******* T******* S****** M**** M****** C***** I******

This expert has been practicing for about 15 years. Aside from his medical degree, he hold a Masters degree in Health Care Policy and an MBA, which make him ideally suited for this case. He has been an ad hoc reviewer of various medical journals for the general thoracic surgery field. He's won many honors and awards and also served in the military. He's also extremely well published, gives invited presentations, and continues to perform research and investigations.

General Surgeon Fails to Protect Bile Duct During Gallbladder Surgery

This case involves a pregnant female who presented to labor and delivery to be evaluated by her primary care/perinatology physician for abdominal pain. She previously had issues becoming pregnant, but was able to conceive after using Bravelle. At the time of the event, she was in her 33rd week of pregnancy. Initial work-up included an abdominal sonogram, which showed cholelithiasis, the likely etiology of the abdominal pain. However, the official report conflicted with the initial finding. It read out that there were no gallstones, normal gallbladder wall thickness, and no sonographic Murphy’s sign, with 1 to 3 mm echogenicities in the gallbladder wall, likely due to small polyps. The patient was told she should undergo an elective laparoscopic cholecystectomy following her delivery. Despite the abdominal pain in the presence of fertility, the physician elected not to perform antenatal testing. Consequently, the pregnancy resulted in a stillbirth one day later.

Occasional abdominal discomfort is a common pregnancy complaint, but it can also be a sign of a serious problem. Severe or persistent abdominal pain during pregnancy is never normal. The point when one experiences abdominal pain or cramping along with spotting, bleeding, fever, chills, vaginal discharge, or faintness is when the doctor must be visited. Symptoms such as discomfort while urinating, nausea, and vomiting, or the pain not subsiding after several minutes of rest, also require a doctor's exam. Severe cases of abdominal pain can be due to ectopic pregnancy, miscarriage, preterm labor, placental abruption, and preeclampsia. Immediate antenatal testing such as transvaginal sonography, biophysical profile, and nonstress test should be carried out. Additional laboratory and imaging studies may also be needed to check fetal viability. Given the patient's symptoms, it is in line with the standard of care to pursue fetal testing such as a biophysical profile and nonstress test. Moreover, the etiology of the patient’s abdominal pain was not likely due to polyps, as they tend to be an incidental finding on sonogram and are often asymptomatic. A more comprehensive workup should have been performed.

1. What are the appropriate steps in managing a pregnant woman with abdominal pain?

Family Medicine Expert Witness Discusses Pregnant Patient’s Work-Up

A hospitalist expert witness opines on a case of a patient with a hepatic abscess who was discharged from a hospital without adequate care. This case involves a fifty-five-year-old male patient with a past medical history of obesity and hypertension. The patient presented to the emergency department with a one week history of right upper quadrant abdominal pain. An abdominal CT scan was performed which revealed a lesion on the patient’s liver. A gastroenterologist reviewed the patient’s scan and described the lesion as vascular in character. At the time of diagnosis, the lesion was biopsied and found to be nonmalignant. The patient underwent a hepatic angiogram with embolization. During the procedure the lesion was diagnosed as a hemangioma with necrosis and hemorrhage. Following the procedure, the patient experienced loss of appetite which was never regained. He was discharged from the hospital despite the fact that he was not feeling well. The treating physician advised the patient that there was nothing more that could be done for him. Unhappy with this dismissal, the patient sought a second opinion at another hospital. After further evaluation the patient was diagnosed with a hepatic abscess. He required a right hepatic lobectomy and cholecystectomy which resulted in intraoperative hemorrhage warranting resuscitation and intubation.

It appears that the patient should have received more thorough care in the original hospital he initially presented to. However this could only be confirmed after reviewing the patient’s complaints at the time of discharge, his oral intake, pain levels and the reason why the physicians treating him believed that he was stable enough for discharge despite his protests. If the patient’s condition warranted further evaluation at the time of discharge and there was clear evidence of this in his medical records, discharging the patient would be a breach of the standard of care. Care must be taken not to discharge a patient who is not completely stable. Furthermore, it is difficult to assess whether or not the patient received the appropriate post-operative care. This would be absolutely critical. During the course of my career, I cared almost exclusively for hepatic patients, of which many were post embolizations as was this case for this patient.

1. Have you ever cared for a patient postoperatively who underwent a liver angiogram with embolization? 2. Did this hospital performing this procedure practice adequate post-operative care in this patient? 3. If not, what further testing and measures should have been performed?

Location: Maryland B.S., Duke University M.D., University of Medicine and Dentistry of New Jersey Residency, Internal Medicine and Pediatrics, University of Chicago Fellowship, Hospitalist Scholars Training Program, University of Chicago Board Certification: Internal Medicine Member, Society of Hospital Medicine Member, Society of General Medicine Member, American Medical Association Member, American College of Physicians Published, 15 peer-reviewed medical publications Research, 7 clinical research projects Former D******* A******* H***** Current A******** P******** D********* o* I******* M******* m**** m****** u********* Current H********** m******* m**** m****** c******

This board certified expert has been practicing for over a decade. She earned her M.D. at the University of Medicine and Dentistry of New Jersey and went on to complete a residency in Internal Medicine and Pediatrics at the University of Chicago. She then underwent additional training in the University of Chicago's Hospitalist fellowship program. Her work has been published in the likes of the "Journal of Hospital Medicine", the "Journal of Invasive Cardiology", and "Archives of Internal Medicine", while she has also completed numerous research projects funded by organizations such as the American Cancer Society and the American Lung Association. Currently, this expert is an Assistant Professor in the Department of Internal Medicine at a major medical university, as well as an attending Hospitalist at multiple major hospitals.

Hospitalist expert witness advises on hospital discharge procedures

This case involves a forty-one year-old male patient with a past medical history of gallstones. The patient presented to the emergency room with signs and symptoms of acute cholecystitis. The patient was admitted to hospital and after several investigations it was recommended that he undergo a single incision laparoscopic cholecystectomy. The procedure was met with some complication. Intraoperatively it was noted that the patient had an intrahepatic gallbladder with severe scarring at the triangle of Calot that proved to be a difficult dissection. Post operatively, the patient was said to be recovering well and did not encounter any complications whilst in recovery. The patient was discharged several days after the surgery. The patient was readmitted to the hospital three weeks later after he presented to the emergency room via ambulance complaining of a two day history of severe abdominal pain and jaundice. On physical examination it was noted that the patient appeared to have a large fluid collection in the abdomen which required drainage via ERCP procedure along with a percutaneous left biliary drain placement. A cholangiogram was performed after the drainage was complete which revealed that the patient had suffered biliary damage. This proved to be the cause of the patient’s abdominal pain and jaundice. The patient was transferred to another facility for a biliary reconstruction procedure to repair the damage that had occurred during the SILS cholecystectomy.

I am a board certified General Surgeon with additional fellowship training in minimally invasive and bariatric surgery. I was one of the first surgeons at my hospital to perform a single incision laparoscopic cholecystectomy, and the first to perform SILS appendectomies. I currently teach this approach to residents. Single incision cholecystectomy is something that I perform regularly and from experience I can say that it requires a high level of caution to perform well. The surgeon should not hesitate in placing additional ports to allow accurate identification of important landmarks such as the triangle of Calot. To visualize this, the "critical view" must be established whereby the fundus of the gallbladder is retracted superiorly and the infundibulum is retracted laterally. This is difficult to perform with sils cholecystectomies and I question if if this surgeon adequately dissected out the gallbladder before dividing structures.

What steps can a surgeon take to ensure the identification and protection of the biliary tract to prevent such damage?

Location: New York, NY B.S., San Jose State University M.D., Chicago Medical School Internship, General Surgery, Case Western Reserve University Residency, Endocrine Surgery, University of California San Francisco Fellowship, Laparoscopic Surgery Board Certified in General Surgery Member, American College of Surgeons Member, American Thyroid Association Member, Society of Thyroid Oncology Published, 40 + abstracts, book chapters, peer-reviewed publications Research, 10+ grant funded medical research projects Lectures, 10+ nationally invited lectures Current D******* o* E********* M******* C***** t** m****** c***** Current A******** S****** m**** m****** c***** Current A******** P******** o* S****** t** m****** u*********

This board certified general surgeon was trained at top medical universities. She is a member of multiple prestigious medical societies and has been published over 40 times in peer-reviewed publications. She currently directs the Esophageal Motility Center at a top medical center as well as pursues research interests at a top medical university.

Laparoscopic cholecystectomy results in biliary damage

This case involves a forty-four-year-old woman who was admitted to a hospital for a cholecystectomy. The woman had a history of smoking, and her vitals were normal, with a blood pressure of 124/82. She was properly prepped by both the surgeon and the anesthesiologist and was informed that she would be receiving Ketalar as her anesthetic. However, during intubation, the patient’s oxygen count began to slightly decline, and the anesthesiologist shifted the tube. The shift caused the patient’s oxygen’s level to decline further, and the endotracheal tube was removed approximately 45 seconds later. The operation was stopped, and the operating physician had the patient checked for any signs of injury. It was determined that the trauma from the tube damaged the thyroid cartilage, causing a loss of oxygen and had a severely negative impact on the patient’s voice. The surgery was never completed, and the patient’s quality of life decreased substantially due to the damage on the vocal cords. The patient was a secretary and was unable to return to work due to her loss of voice.

One of the main objectives for an anesthesiologist is to protect the patient’s airway. In my opinion, the standard of care was poor due to the injury during intubation. Intubation is a commonly practiced technique, and the anesthesiologist failed to notice that something was wrong during the first attempt. It is a standard technique and one of the most vital. Various tools exist to ensure proper execution in a timely manner. By shifting the tube, he caused further damage to the patient and put the patient at risk of complete lack of oxygen. Loss of oxygen can be damage many parts of the human body, with the brain being a high possibility. The patient was also at risk for neurological damage as well, which could cause an even further reduction in quality of life. The tube should have been removed sooner than 45 seconds after complications arose.

1. Is the damage that affected the patient’s voice a deviation of the standard of care for the anesthesiologist?

Intubation by Anesthesiologist Severely Damages Vocal Cords

A hematology expert witness opines on post-operative anticoagulation in patients with multiple comorbidities. This case involves a fifty-four-year-old female patient with a past medical history of obesity and Atrial Fibrillation. The patient was being treated by her primary care physician and had been prescribed Coumadin for her arrhythmia. It was decided by her cardiologist that the patient required a cardiac ablation. The surgery was performed without complications; however in the post-operative recovery period the treating surgeons recognized that the patient required an emergent cholecystectomy. The procedure was initially intended to be performed laparascopically, however had to be converted to open technique due to complications intraoperatively. The surgery was completed and the patient was transferred to the PACU. Post-operatively, physicians had a difficult time controlling the patient’s PTT. The patient was given a large dose of Heparin on post-operative day six. She coded and died as a result of internal hemorrhaging.

This is a scenario I encounter frequently in my practice, a patient at simultaneous risk for clotting (stroke from atrial fibrillation, obesity) and for bleeding (recovering from an open cholecystectomy). My clinical practice focuses on the diagnosis and management of bleeding and clotting disorders, particularly in unique populations such as pregnant women and critically ill hospitalized patients. Deciding whether to give heparin in a scenario like this is complicated because either withholding or administering anticoagulation carries risks, and these risks need to be discussed with the patient and family, all treating physicians, and thoroughly documented in the medical records. Doctors frequently either fail to have this conversation, or do not adequately document the risks and benefits of anticoagulation (and the fact that they were discussed with the family and other treating physicians), in the medical record. The annual risk of stroke for patients with atrial fibrillation who do not receive anticoagulation is about 5%, meaning that the risk of stroke if someone does not receive treatment for a week is less than 1%. Doctors often do not appreciate this and may insist on administering heparin to patients who are at high risk for bleeding. This is an inappropriate approach. When evaluating this case, it would be important to assess whether the doctors had the conversations outlined above with the patient and family, and if heparin was administered correctly. It will also be important to determine if the presence of bleeding was adequately assessed.

Are you familiar with post op Heparin guidelines for a patient in this condition?

Location: California B.S., Physics, MIT Ph.D., Neurosciences	, University of California, San Diego M.D., University of California, San Diego Internship, Internal Medicine, University of Chicago Hospital Residency, Internal Medicine, Brigham and Women's Hospital Fellowship, Hematology/Oncology, Dana Farber Cancer Institute & Massachusetts General Hospital Board Certification, Internal Medicine Board Certification, Hematology Board Certification, Medical Oncology Honor, American Society of Hematology Junior Faculty Research Scholar Award Honor, Translational Research Training in Hematology Award Lectures, invited guest speaker both nationally and internationally Published, multiple peer-reviewed journal articles Former I********* i* H********* H****** A********* H******* Current A******** P******** o* H****************** a* a m**** u*********

This triple board certified Hematology expert received an M.D. and Ph.D at University of California, San Diego. He later went on to complete a Residency in Internal Medicine ar the Harvard affiliated Brigham and Women's Hospital. He is Fellowship trained in Hematology/Oncology. He has received numerous honors throughout his career, most notably the American Society of Hematology Junior Faculty Research Scholar Award and the Translational Research Training in Hematology Award for his contribution to the field of Hematology. A well-respected academic, this expert is freuently invited guest speaker both nationally and internationally and has taught medical students at Harvard and residents, fellows at Harvard affiliated hospitals. He is currently an Assistant Professor of Hematology/Oncology at a major university.

Cholecystectomy Expert Witnesses

Find an expert witness near you

Cholecystectomy Expert Witness Case Studies

General Surgeon Fails to Protect Bile Duct During Gallbladder Surgery

Family Medicine Expert Witness Discusses Pregnant Patient’s Work-Up

Hospitalist expert witness advises on hospital discharge procedures

Laparoscopic cholecystectomy results in biliary damage

Intubation by Anesthesiologist Severely Damages Vocal Cords

Hematology expert witness advises on anticoagulation in patients at risk for stroke

Connect with the Cholecystectomy expert witness you need to win your case