ramos last revised july 6 09 for ppt copy 2

Surgical ErrorsSurgical ErrorsCommitted by Committed by

William J.Tauber, MDWilliam J.Tauber, MD

General SurgeonGeneral SurgeonSt. Elizabeth HospitalSt. Elizabeth HospitalDetroit, MichiganDetroit, Michigan

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The Patient:The Patient:

Maria SantosMaria Santos

School teacher, single parent,32 years of age,mother of 2 young children.

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On July 19, 2007, Maria Santos is brought to the

emergency room of St. Elizabeth Hospital

with complaints of severe abdominal pain, fever and nausea.

Hospital admission:

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Diagnosis:Diagnosis:

acute cholecystitis acute cholecystitis and and

cholelithiasischolelithiasis

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An inflammed and infected gallbladder containing multiple stones.

Translation:Translation:

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Concentrated bile, cholesterol and calcium can lead to the formation of gallstones in the gallbladder.

Gallstones

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Orientation

LiverRib cage

GallbladderStomach

Small intestine

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The liver produces bile and other digestive enzymes necessary for the breakdown of fats in the diet.

Bile is transported from the liver to the gallbladderthrough a series of biliary ducts – and then to the small intestine.

Any prolonged obstruction that blocks the flowof bile from the liver to the small intestine can result in life-threatening consequences.

Biliary Flow

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The liver produces bile and other digestive enzymes necessary for the breakdown of fats in

the diet.

Biliary Flow

Liver

Gallbladder

Cystic duct

Common hepatic duct

Common bile duct

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Bile is delivered from the liver to the common hepatic duct.

Common hepatic duct

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From the common hepatic duct, bile is delivered to the cystic duct.

Cystic duct

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From the cystic duct, bile enters the gallbladder where it is concentrated and stored until

needed.

Gallbladder

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When fatty foods are eaten, the gallbladder contracts and sends stored bile back through the cystic duct

and common bile duct into the small intestine.

Small intestine

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Any prolonged obstruction that blocks the flowof bile from the liver to the small intestine can result in life-threatening consequences.

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The First Operation:The First Operation:

Dr. Tauber elects to Dr. Tauber elects to perform perform

a laparoscopic a laparoscopic cholecystectomy.cholecystectomy.

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A laparoscopic cholecystectomy

is the surgical removal of the gallbladder through the abdominal wall

with the aid of a laparoscope.

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Laparoscopic CholecystectomyLaparoscopic Cholecystectomy

Laparoscope

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The entire procedure is performed through 4 small incisions in the abdomen.

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Through the Abdominal Wall

Anatomy of the Surgical Area

Gallbladder Common hepatic duct

Cystic artery

Cystic duct

Common bile duct

Hepatic artery

Critical Structures

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Standard of Care

The correct procedurefor the performance of a

laparoscopic cholecystectomyis as follows:

This is what Dr. Tauber should have done.

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Step 1

Identify, clip and cut the cystic duct.

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Step 2Identify, clip and cut the cystic

artery.

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Step 3

Remove the gallbladder.

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No anatomic structures should be clipped or cut until the surgeon is

unequivocally certain that they have been correctly identified.

The Surgeon’s Cardinal Rule:

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Deviation from Standard of Care

These are the 3 major surgical errors committed by Dr. Tauber.

This is what Dr. Tauber did... and what he did not do.

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Surgical Error # 1

Failure to identify the common hepatic duct

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Surgical Error # 2

Failure to identify the cystic duct

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Surgical Error # 3

Clipping the common hepatic duct

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Additional Errors:

Dr. Tauber chose not to use operative cholangiography or ultrasound

which would have helped him to identify critical structures.

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Dr. Tauber failed to recognize his surgical errors and therefore failed to diagnose the clipped duct

as the cause of biliary obstruction.

Additional Errors:

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Clipping the common hepatic duct blocks the flow of

bile and eventually destroys the duct.

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Blocked Duct

Blocked flow

Consequences of Surgical Errors

1. Irreparable damage to the common bile duct.

2. Development of biliary obstruction

3. Multiple invasive diagnostic procedures.

4. Necessity for reconstructive surgery

5. Exposure to additional procedural risks.

6. Permanent scarring and disfigurement.

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1. Irreparable damage to the common hepatic and common

bile duct.

•Stricture

•Narrowing

•Scarring

•Deterioration

Damages to the ductas a result of clipping:

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Any prolonged obstruction that blocks the flow of bile

from the liver to the small intestine can cause serious, life-threatening

consequences.

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2. Development of biliary obstruction.

Obstruction

Biliary Obstruction

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Soon after laparoscopic cholecystectomy,Maria Santos was discharged from the

hospital.

Twenty-one days later she was re-admitted with

a diagnosis of acute biliary obstruction.

Continuing Symptoms

Throughout the following weeks, her symptoms grew steadily worse.

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Maria Santos had to endure many invasive diagnostic procedures –

each with its own set of risks and complications.

3. Exposure to Additional Risks and Complications

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4. Multiple Invasive Diagnostic Procedures

•HIDA Scan

•ERCP

•PTC

•PBD

Hydroxy iminodiacetic acid

Endoscopic retrograde cholangiopancreatography

Percutaneous transhepatic cholangiography

Percutaneous biliary drainage38

HIDA Scan

A radioactive acid is injected into a large vein.

Site of blockage is revealed.

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Diagnostic tests

Blockageat staple

Risks and Complications of HIDA

Nuclear medicine tests are not performed in pregnant women

or breast-feeding mothers.

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A thin needle is insertedthrough the skin into the liver, and into a biliary duct. A radio-opaque dye is injected

into the biliary system.

PTC

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Liver

• Bleeding

• Blood poisoning

• Infection

• Inflammation of the bile ducts

Risks and Complications of PTC

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PBDA catheter is inserted into the liver to drain off excess bile

accumulated as a result of blocked flow.

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Risks and Complications of PBD

•Pain and discomfort at insertion site

•Injury to blood vessel/bleeding

•Puncture of duct, liver or bowel

•Bile leakage

•Liver infection

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ERCP 1

A flexible tube is inserted into the mouth and passed down the esophagus until it reaches the small intestine.

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Small intestine

Dye is injected into the bile duct and moves uptoward the liver.

Source of blockageconfirmed.

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ERCP 3

A thin catheter within the tube is advanced and inserted into the bile duct.

Insertion point

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ERCP 2

•Nausea, blurred vision, urine retention

•Bleeding

•Perforation of small bowel

•Pancreatitis (inflammation and infection of the pancreas)

Risks and Complications of ERCP

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Diagnostic tests confirm the diagnosis of biliary obstruction due to the clipped

duct.

Open, reconstructive surgery becomes necessary.

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5. Surgical ReconstructionSecond Operation

a new “bile duct” is createdusing a section of small bowel.

After amputation of bile duct...

Small bowel

“Newbile duct”

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Risks and Complications ofReconstructive Surgery

•Stricture

•Infection

•Bleeding

•Bile leakage

•Liver failure

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6. Permanent Scarring and Disfigurement

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Puncture Wounds

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Summary1. During the first gallbladder operation, Dr. Tauber erroneously clipped the common hepatic duct. 2. The clipped duct was the direct cause of biliary obstruction.3. Worsening symptoms of biliary

obstruction necessitated multiple, invasive

diagnostic tests.

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Summary4. A second operation was necessary to

reconstruct the damaged bile duct and restore the flow of bile.

5. Further diagnostic tests and therapeutic procedures became necessary to correct the complications of the second operation. 6. Maria Santos is left with unsightly scars, puncture wounds and unremitting pain requiring periodic hospitalizations.

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