This case involved a middle-aged woman who was diagnosed with a villous adenoma in her cecum by laparoscopy and biopsy. During the subsequent laparoscopic hand-assisted hemicolectomy, the cecum was found to be attached to the omentum. There were no apparent complications.
Three days postoperatively, the plaintiff began feeling uncomfortable, but a CT showed no evidence of a leak. She was monitored for two more days and became increasingly ill. A barium enema at that time revealed an anastomotic leak, so she was returned to the OR for an exploratory laparotomy. When her abdomen was opened, several liters of dirty fluid were evacuated. The disrupted bowel was resected, fibrinous exudate was peeled from surfaces, and the abdomen was copiously irrigated. An ileostomy was created in the right lower quadrant. After a difficult postoperative course, complicated by sepsis and wound infection, the plaintiff was ultimately discharged about a month after her original hemicolectomy surgery.
The plaintiff alleged that the defendant failed to diagnose the anastomotic leak in a timely fashion. The defense contended that the plaintiff was properly managed throughout her hospital stay. She was appropriately evaluated for a leak and none was found, but when she continued to worsen a second evaluation was performed, at which time the leak was discovered and repaired. Anastomotic leak and sepsis are unfortunate but well-known complications of this procedure.
The first step in the visual defense strategy was to educate the jury on the original hemicolectomy procedure. A simple graphic explaining the plaintiff’s pre-operative and post-operative anatomy allowed the defendant to become a teacher and an expert in front of the jury.
Another exhibit was developed to help explain why free air seen in the immediate post-operative films was not diagnostic of an anastomotic leak. The illustration shows that free air is normally found in the abdomen after such laparoscopic surgery and is the result of insufflated air not being completely evacuated before closing. These residual air pockets are harmless and are absorbed by the body within a few days. Fluid seen in the inferior aspect of the abdomen was simply residual irrigant from the procedure.
The last portion of the visual defense strategy aimed to explain to the jury the normal movement of bowel contents compared to what is seen during ileus and gastrogaffin enema. This illustrated the defense theory that the contrast material pushed the fecal material back up the colon, with the increased back pressure causing the anastomosis to rupture and leak.
—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Russ Edwards, MS, CMI