Mistaken Assumptions After Surgical Complication

Description

A 60-year-old male with diabetes and prostate cancer lost vision in his right eye after extensive bleeding—possibly caused by a malfunctioning staple gun—during surgery to remove his left kidney and adrenal gland.

Key Lessons

• A quick response to a surgical complication and an early call for help are key considerations for observers after the fact.
• Speaking or writing into the chart any speculation about causes of problems in care can exacerbate the defense for lawsuits against the treating provider and trigger subpoenas for subsequent treating clinicians.
• Juries are instructed that physicians are only liable for an adverse outcome if he or she caused it through a deviation in the standard of care.

Clinical Sequence

A 60-year-old male was diagnosed with kidney cancer while he was being treated for prostate cancer. After consultation with a urologist, he agreed to a nephrectomy. Two weeks before the operation, the surgeon explained the procedure to the patient in detail, along with a discussion of the risks of injury to major arteries and excessive bleeding that would require a conversion to an open procedure.

After the patient experienced some pre-operative difficulty tolerating insufflation of the abdomen with CO2, the surgery began. A vascular stapling device was applied to the left renal artery and the stapler was fired. When the surgeon released the stapler, he encountered a massive hemorrhage from the staple site. The surgeon attempted to use the stapling device to clamp the area; however the stapling mechanism would not activate.

The surgeon communicated the events and the urgency of the situation to the anesthesia team and rapidly opened the abdomen to get control of the bleeding at the renal artery stump. The anesthesia team was able to resuscitate the patient while pressure was holding over the bleeding site. Blood was typed and cross-matched and ready for administration within 10 to 15 minutes. Meanwhile, the surgeon asked for emergency assistance from senior members of the urology team and from vascular surgery. A portion of the aorta was torn (2–3 centimeters in length) and had to be repaired with a graft.

Because of the extensive blood loss (12 liters), the patient became hypotensive (BP 40/20), resulting in rhabdomyolysis and blindness in his right eye.

Allegation

The patient sued the urologist, alleging he failed to fully identify and dissect the renal artery prior to using the stapling device and mistakenly stapled the aorta as well as the left renal artery, resulting in excessive blood loss and blindness.

Disposition

After a two-week trial and an eight-hour deliberation, the jury returned a verdict for the defense.

Analysis

1. This case involved a complication that the surgeon immediately recognized and responded to, quickly converting to an open procedure and controlling the bleeding until acquiring emergent consults with more senior members of urology and vascular surgery.
   Having a resilient team that responds promptly, correctly, and with adequate resources can optimize the outcome in an emergency. It requires the surgeon to own the problem and a real commitment from everyone involved. Standardizing communication and removing professional silos through teamwork training is a strong start in developing a culture of safety in the OR.
2. During the trial, the patient’s lawyer highlighted nine entries in the medical record stating “stapled aorta” or “transected aorta” that various clinicians—none of whom had witnessed the laparoscopic portion of the procedure—entered and copied.
   Without an immediate and singular explanation for an adverse outcome, avoid drawing or “confirming” a wrong conclusion, no matter how logical the speculation. Injuries often result from a cascade of errors, or even attempts to rescue a patient from a standard complication. In cases involving an instrument, a mechanism failure might be to blame.
3. The patient refused to sign the discharge form after the urologist seemed to change his explanation about the event, from saying he nicked the aorta during the procedure to saying the staple gun misfired.
   Although it is tempting to try to provide answers immediately following an adverse event and a patient’s anxious questions, never speculate. Often, facts emerge later with careful investigation and, then, even if the second explanation is more accurate, it will likely be perceived with suspicion. When added to inaccuracies in the record, a patient or family may be further motivated to pursue a lawsuit to investigate.
4. The defense was that the surgeon did in fact properly identify the renal artery which had to be cut very close to the aorta due to the location of the renal tumor, and it was not clear why the bleeding occurred. The bleeding and the loss of vision are two risks that were specifically noted in the consent form that the patient signed.
   A patient who undergoes a surgical procedure and suffers an injury is not entitled to a recovery simply because there was a complication that he or she was warned about ahead of time. The jury will be instructed that doctors cannot guarantee a good result, and that they are not liable unless they deviate from the standard of care and cause the patient’s injury.