Missouri Injury Law Blog

As a St Louis Missouri medical malpractice lawyer, one of the most common defenses I hear is that the injury the patient suffered is a "known risk" or "complication" of the procedure, therefore, to cause the injury is not medically negligent. Complications are not always like side effects, which are unavoidable in certain situations and result without negligence. May times complications are unavoidable and not the result of negligence, however, just because a certain complication is a known risk of the procedure does not absolve the doctor of any negligence. Inattentive mistakes (medical negligence) is a "known risk" of surgery, inattentive mistakes are a known risk of just about anything we do, but they are still mistakes.

Lets take for example Gallbladder removal operations, the defense is often that injury to the common bile duct is a known risk of the procedure so its not negligence to cause the injury. So, does mistaking the common duct for the cystic duct and then cutting it not negligent? or putting and leaving clips on the common bile duct not negligent? Obviously that is negligence. Maybe a situation where the surgeon nicks the common duct and then realizes his error and corrects it appropriately, then I would agree, it is not negligent.

Malpractice defense lawyers love to argue that it is a known risk or complication, the doctor had no bad intent, and he was doing his best. Despite the fact the rules of surgery were broken. A known risk of most operations, or anytime you go under general anesthesia, is death. So if the surgeon is negligent and the patient dies is the health care provider absolved from any Missouri wrongful death action simply because death is a known risk of a procedure? Of course not, it is a known risk but may have been caused for avoidable or unavoidable reasons.

Lets put the "known risk" defense in context with something most of us do everyday, driving. Every time we drive anywhere it is a known risk that we may be in a car accident and suffer injury.

It is a "known risk" (complication) every time you drive through an intersection that someone may run a red light and hit you broadside.

It is a "known risk" (complication) that another driver could drift across the center line and cause a head on collision.

It is a "known risk" when you stop at a red light or stop sign an inattentive driver could run into the rear of your car. In fact this is a very well known risk as it is the most common type of motor vehicle accident.

We take on a "known risk" (complication) of possibly being in a car accident every time we drive.

So, since the above situations are "known risks" of driving does that mean the other driver that did not follow the rules of the road, was therefore negligent, and caused the car or truck accident resulting in personal injury should not be held accountable? because it is a known risk (i.e. complication) of driving? Of course not!

A personal injury lawyer must make these distinctions clear to a jury, as they, like most people, are not familiar with medical terms and rules, and when they hear "known risk" or "known complication" they are trying to be tricked into believing that is a get out of jail free card for the health care provider. Injury attorneys need to clearly explain the difference between known risks and unavoidable side effects. I like the analogy of the rules of the road above to dispel the know risks defense, then to further explain, unavoidable complications are like medicine side effects, if you take Aspirin, you may get stomach pain, not because someone was negligent, but it is an unavoidable complication or side effect that can occur.

Continue reading "Common Defenses Used in Missouri Medical Malpractice Cases - Putting the "Known Risk" Defense in Context " »

Medical mistakes and injuries in gallbladder removal operations that lead to Missouri medical malpractice case, can often be avoided by knowing the anatomy. See St Louis Injury Lawyer Article about Lap-Cholis and the Anatomy

One of the methods for properly identifying the anatomy is call the "Critical View of Safety" or CVS for short. Using the CVS technique, Calot's triangle is completely unfolded by mobilizing the gallbladder neck from the gallbladder bed of the liver before transecting the cystic artery and duct. Thus proper identification of the anatomy and fewer instances of surgical medical malpractice related to laparoscopic gallbladder removal.

The figure to the right is a depiction of the critical view of safety. Circumferential dissection, visualization of the anatomy via the triangle of calot, and using the CVS technique; a surgeon can obtain confident identification of the anatomy, and use of an intraoperative cholangiogram if there is any doubt by the surgeon. See St Louis Injury Lawyer Article about Knowing the Indications for an Intraoperative Cholangiogram. The CVS approach eliminates complications from negligent identification of the anatomy, as the improper or just lack of anatomical identification leads to cutting and or clipping of the wrong ducts or vessels.

The operative video below is a must watch for any personal injury lawyer trying to understand the critical view of safety. The video was done to show the anatomy of gall bladder region, the safe zone, dangerous zone, and the critical view of safety.

Even if the gallbladder is highly inflamed (often a major reason to remove the gallbladder in the first place), the CVS technique still works:

[I]n cases of badly inflamed gallbladders, it is often hard to achieve a critical view of safety, because Calot's triangle is often solid and cannot be expanded. In our standardized procedure, which is based on exposing the inner layer of the subserosal layer (the ss-i layer), the critical view of safety can be safely achieved. We have safely performed LC, using our standardized procedure, for many cases with cholecystitis with highly inflamed gallbladders

Quote from: The critical view of safety in laparoscopic cholecystectomy is optimized by exposing the inner layer of the subserosal layer

Continue reading "Understanding the Critical View of Safety "CVS" for use by Injury Lawyers in Missouri Medical Malpractice Cases " »

Know The Indications For Intraoperative Cholangiogram - From my point of view as a practicing St Louis injury attorney, a surgeon should always do one. I am not alone, several surgeons agree, one surgeon wrote:

Cholangiogram! Really no excuse not to do one. You'll feel better about the case if you make cholangiography a routine part of your technique [...] since I've been in practice I plan to do one on every LC. It doesn't add much time. It really doesn't. And the more you do, the faster it goes. Anymore, if I don't do a cholangiogram for some reason (dye leakage, patient body habitus, etc.) I feel like you would if you went to work one day and realized at noon that your zipper had been down all day. A nice cholangiogram just makes me feel all warm and fuzzy inside.

There is no reason for a surgeon to do an intraoperative cholangiogram (IOC) to verify the exact anatomy of the biliary tree and the location of the common duct before clipping and cutting the cystic duct, thus preventing a common reason for St Louis medical malpractice from gallbladder removal. Many surgeons, particularly those practicing in a university setting, suggest that IOC be used in every lap choli case.

Most hospitals do not believe (at least they claim they do not) that a cholangiogram is required to meet the standard of care, they will require it after a surgeon commits gallbladder removal medical malpractice a few times, only then make it a condition of the surgeon's continued staff privileges.

A Cholangiogram is important in laparoscopic cholecystectomy because it clarifies the anatomy of the biliary tree. A Sun Tzu's Art of War states - Know the Terrain before going into battle i.e. know the anatomy before going into surgery, and a cholangiogram is a critical tool for knowing the anatomy. It provides the opportunity to see everything well before cutting anything while keeping dissection away from the area where almost all biliary anomalies would be encountered: the triangle of Calot.

Part I on of a series of 10 must knows from a St Louis personal injury lawyer to successfully pursue a Missouri medical malpractice case arising from a negligently performed gallbladder operation.

Top 10 things a doctor must know well when doing this surgery and the top 10 areas I focus on when pursuing a Missouri medical negligence lawsuit for my clients.

1.KNOW THE ANATOMY

A surgeon must circumstantially dissect the gallbladder, surrounding ducts, and vascular system. The anatomy must be fully identified before the surgeon decides to cut or clip anything. Aberrant anatomy is no excuse for cutting the wrong ducts or vessels as 20-30% of the population has aberrant anatomy.

Adequate dissection and identification of the triangle of calot is generally enough for the surgeon to be able to adequately visualize the anatomy. However, it is also wise for the surgeon to do an inter-operative cholangiogram. This procedure injects contrast through a catheter into the bile ducts to allow full visualization of the biliary duct anatomy prior to the surgeon clipping and cutting. See ERCP image in previous Missouri injury lawyer article about surgical clips left on common bile duct.

This is the #1 most important issue in most negligent gallbladder operation lawsuits. When done properly a gallbladder removal operation is a relatively easy and low risk procedure. Most cases arise from the surgeon cutting the wrong duct, cutting arteries, or clipping the wrong duct prior to cutting it. All cases of identification of the anatomy.

Few things I have seen often that a surgeon should never do intentionally in this procedure but occurs from negligent identification of the anatomy:

Cut the common bile duct;
Cut an artery;
Clip the common bile duct and leave clips on it, causing an occlusion;
Cut and injure the liver;

A few simple things that should never happen when the anatomy is properly identified. Simple mistakes that lead to wrongful death and serious personal injury with life altering problems.

Continue reading "MUST KNOWS to successfully pursue a Negligent Gallbladder Operation Lawsuit in Missouri: #1: KNOW THE ANATOMY " »

As a practicing St Louis personal injury attorney, with a good percentage of my practice devoted to Missouri medical malpractice cases, I have personally seen a rise is biliary injuries with introduction of less invasive laparoscopic cholecystectomy (aka - "Lap-choli" or gallbladder removal surgery). The move from and open procedure (being sliced open) to a laparoscopic procedure (entry through small incisions with a laparoscope) brought the great benefits of being less invasive, causing less pain and generally less recovery time. On the flip side, I believe there are more instances of doctor negligence related to the gallbladder removal. Why? It is more technically difficult to do the surgery guiding little arms rather than being hands on, yet some doctors without sufficient experience do these procedures.

The medical literature recognizes that the introduction of less invasive procedures has led to more instances of injuries: See: "Development Of Laparoscopic Single-Site Cholecystectomy Mandates Critical View Of Safety Dissection and Routine Intraoperative Cholangiography" - Journal of the American College of Surgeons - Volume 212, Issue 3 (March 2011) stating:

The uncontrolled introduction of laparoscopy was associated with a dramatic rise in the incidence of biliary injuries. This should not be repeated with the introduction of laparoendoscopic single-site surgery (LESS). We should not forget principles of safety elaborated during decades of minimally invasive cholecystectomy. Although the benefits of LESS cholecystectomy will rely mainly on cosmesis, we cannot accept a rise in biliary lesion incidence and its related morbidity

The most common mistake I see as a St Louis negligent gallbladder removal lawyer , and that I believe the medical field sees with these cases, is negligent cutting of the wrong duct, at first is not recognized (or maybe covered up), and invariably leads to the patient being admitted to the ER within a few days with a distended abdomen with pain and an infectious process ongoing from the bile leaking into the peritoneum. The patient is usually then urgently sent to another hospital or health care provider specializing in biliary, hepatic, and liver surgery.

St Louis Medical Malpractice Lawyer Site: Where surgeons go wrong in lap-choli procedures

Continue reading "Instances of biliary injuries Rise with use of Lap-Choli Procedure" »

Sansone / Lauber receives numerous requests to represent patients injured as a result of a failed gallbladder surgery in St Louis and throughout Missouri. As stated in a prior blog, we have recently been retained to represent a woman who has ongoing medical maladies as the result of negligence in her gallbladder removal surgery. Specifically, the wrong ducts were cut, the surgical clips were placed improperly, and surgical clips were left in her body on the wrong ducts creating a bile blockage.

Gallbladder removal surgery, or "lap-choli" is a fairly common procedure and as such, most times not taken as seriously by some medical providers as maybe it should be. Therefore, it is also fairly common to see Missouri and Illinois medical negligence and/or medical malpractice lawsuits associated with it. As an experienced medical malpractice and St Louis wrongful death lawyer, I have seen very avoidable mistakes that occur in a lap-choli procedure lead to death several months later.

The first steps in determining if their was negligence is to review the medical records, particularly, the surgeon's operative report, which is probably the most important document to get asap if you suspect medical malpractice. It is always wise for the patient or the family to immediately request the available records, I have seen these records get changed later on - that is where the term "doctoring the records" comes from!. See 2nd half of this article - Medical Record Alteration in Wrongful Death Lawsuit.

It is also necessary to review the materials provided to the patient/client, the conversation that they had with the surgeon prior to the surgery, what the patient understood to be the outcome of the surgery, and what risks were laid out to them and why. The most common risk is what we saw with this most recent case: severe damage to the common bile duct and just a lack of attention to care and detail. Blood clots, internal bleeding, injury to neighboring organs, trocar-induced bowel damage, infections from leaking bile, and death are other risks associated with this procedure.

Continue reading "First steps to investigating a negligent gallbaldder removal claim" »

Currently our St Louis medical malpractice law firm, Sansone / Lauber, is handling multiple Missouri negligent gallbladder removal cases involving laparoscopic procedures known as a "lap-choli". The common theme in these cases is the negligent surgeon's failure to adequately dissect and identify the anatomy of the gallbladder, and the adjacent bile ducts and vascular system before proceeding to clip, cut, and remove.

Recently we were contacted by young Missouri woman who has spent the last several months in the hospital because the negligent lap choli surgeon left surgical clips on her common bile duct creating an "occlusion" or in lay terms, a blockage. See clips left on common bile duct in radiology image to the right. Prior to removing a gallbladder the surgeon must identify and dissect the anatomy in order to confirm the cystic duct, clip and cut it, not the common bile duct.

See Missouri Negligent Gallbladder Removal Surgery Article for Details of Surgery

As always, the negligent Missouri surgeon's operative report was flawless and according to him the original procedure went perfectly, he identified the anatomy properly, did full circumferential dissection of the gallbladder and ducts, separated the cystic artery from the cystic duct, applied two clips to the cystic duct, cut between them, and then removed the gallbladder.

However the post op evidence tells a very different story. The patient suffered symptoms of severe abdominal pain and subsequent testing showed that the surgeon left surgical clips on the common bile duct. See the ERCP test results below from 1 week post lap choli:

Continue reading "Surgical Clips Left on Common Bile Duct by Missouri Surgeon after Gallbladder Removal, Caused Duct Occlusion and Severe Complications for Patient" »

Laparoscopic gallbladder removal or "lap-choli" is the current standard of care for the removal of a gallbladder. Until about 10-15 years ago the accepted method was an open procedure which was more invasive as it required a larger wound and longer recovery. The introduction of the laparoscopic procedure is not without its problems, it requires certain degree of skill and learning and some surgeons simply do not have the proper pedigree to perform these procedures multiple times without eventually running into problems they cannot handle.

Recently, my law firm, Sansone / Lauber, filed a St Louis county lap-choli medical malpractice and wrongful death lawsuit

About 6 months ago I discussed this St Louis wrongful death case and the specifics of gallbladder procedures and some of the reasons for bad outcomes.

In the St Louis wrongful death case recently filed by my Missouri injury law firm, the primary reason for the horrific outcome and death of my client's father was the simple fact that the negligent surgeon failed to completely and circumferentially dissect the gallbladder and the relevant arteries and bile ducts, confidentially identify them ,and then... and only then... cut what the surgeon thought to be the cystic duct, but was actually the common bile duct and the right hepatic artery, which lead to the death of my client's father. Simply from the failure to take his time and properly identify the anatomy.

Continue reading "Surgeon Negligent During Lap-Choli Procedure leading to St Louis County Wrongful Death Lawsuit" »

Recently, a jury handed down a decision in a Medical Negligence case in the amount of $4.08 million in damages. The medical malpractice personal injury lawsuit ensued after a patient negligently had his gallbladder removed. Three months after the negligent gallbladder removal surgery, the man was rushed to the emergency room with a high fever and in severe pain. CT scans showed that not only had a surgical sponge been left inside of him, but his gallbladder had not even been removed.

For more detail on Missouri medical malpractice related to gallbladder removal surgery (lap-choli) see this previous Missouri injury law article by by St Louis Personal Injury Attorney and Missouri medical malpractice lawyer Ben Sansone - Negligent Gallbladder Removal Missouri

After several months in the hospital and suffering from the complications of the negligent gallbladder surgery the personal injury victim accumulated several hundred thousand dollars in medical bills. Even after the medical malpractice victim was released he still suffers ongoing medical problems and symptoms from the negligent acts of the doctors.

The Defendant and accused negligent hospital argued that the man came to the hospital with prior stomach problems, and though they were willing to take responsibility of the sponges left in him, they were not willing to accept full responsibility nor agree to the amount of damages the plaintiff sought.

The negligent doctor removed a mass that was shown on the scans taken prior to the surgery; however, the mass, despite being in the same area as the gallbladder, was not the gallbladder.

As a Missouri personal injury lawyer who has handled St Louis medical malpractice lap-choli / gallbladder removal cases, I am amazed that this could happen and to me this is a situation of the doctor and the hospital staff asleep at the wheel. How could a random mass be confused with a gallbladder! The gallbladder has very distinctive anatomy, contains bile, and has very specific arteries and ducts that run to it that the surgeon must identify so that he can properly cut the bile ducts and arteries without cutting off blood supply to the liver or causing a severe infection.

Laparoscopic Gallbladder Surgery, medically known as a Laparoscopic Cholecystectomy and often abbreviated as Lap Choli, is a surgical procedure that is performed through several small incisions in the abdomen and using surgical probes (laparoscopes) to perform the surgery to remove a problem or diseased gallbladder. Gallbladder Removal Surgery Details.

Unfortunately, some doctors performing these procedures are not proficient in the laparoscopic techniques, they may do many surgeries without any major complications or medical negligence, however, eventually their lack of skill and risky approach will result in a serious personal injury complication or wrongful death constituting medical malpractice in Missouri and under the medical standard of care.

Biliary injury is the most common reason for medical malpractice in gallbladder removal surgery. This is caused by the surgeons lack of knowledge or attention to the varying anatomy of the gallbladder and the surrounding arteries and ducts.

Prevention of gallbladder removal surgery malpractice from biliary injuries (injury to the bile ducts) requires the doctor to perform meticulous dissection so that only the ducts, arteries,and other structures that have been unequivocally and conclusively identified are divided, clamped, and cut. In my experience as a medical malpractice lawyer in St Louis Missouri, this would prevent most serious complications, injuries, and deaths related to gallbladder removals / lap cholis.

It is well known in the medical community that it is fairly common that different patients arterial and ductal anatomy will vary, and thus a doctor cannot "shoot from the hip" and do a simple quick dissection and cut the first duct that appears to by the cystic duct. It is medical malpractice when this approach leads to the cutting or serious injury of the common bile duct or hepatic artery, which can lead to the wrongful death or serious personal injury of the patient.

Currently our St Louis Personal Injury / Medical Malpractice Law Office is handling Gallbladder Removal Malpractice and Wrongful Death Cases - If you need a Personal Injury Lawyer in St Louis Missouri please call Personal Injury Lawyer Ben Sansone (314) 726-1817.