Case Study: Hernia Repair

This case involved a middle-aged male patient with bilateral inguinal hernias. The right side had both direct and indirect hernia, so the defendant repaired it with pre-cut mesh. The left side had smaller direct and indirect hernias, as well as an incarceration of a loop of the sigmoid. The defendant released the sigmoid colon and then used pre-cut mesh to repair this defect as well. Several weeks postoperatively, the patient began to complain of left groin burning and post-ejaculation testicular pain. His complaints varied over the next weeks, but then localized to pain in the right groin. The patient saw multiple doctors but his physical exams and multiple tests were essentially normal. His discomfort and minor urinary issues persisted and remained unrelieved by medications and trigger point injections.

About 15 months after the original surgery, the patient underwent a left inguinal hernia repair and division of the ilioinguinal nerve. During that procedure, adhesions were lysed and the ilioinguinal nerve was found to be adherent to the underside of the external oblique aponeurosis. The nerve was isolated and ligated proximally and distally to the entrapment. The hernia was repaired, the sigmoid was released, and the tissues were closed. The pathology was consistent with neuroma and the patient experienced relief of pain after the procedure for about 8 weeks.

The pain returned however and despite more trigger point injections and a number of visits to different physicians, he had no relief of pain or a diagnosis. He underwent mesh removal by another surgeon a year later, and shortly after he underwent a left orchiectomy. About three and a half years after the defendant’s original surgery, the patient underwent surgical removal of neuromas on the genitofemoral nerve, iliohypogastric nerve, and ilioinguinal nerve, embedding the proximal stumps in muscle.

The plaintiff alleged that the defendant improperly placed the mesh, resulting in damage to the splanchnic nerves on the vessels supplying the left testis. The defense contended that this patient was treated within the standard of care and that his postoperative problems were the result of nerve entrapment from adhesions.

The first visual exhibit used in this case was designed to explain the anatomy of this patient’s hernia and to help the defendant explain to the jury what he encountered during surgery, how he repaired the hernia, and most importantly, how he placed the mesh.


Hernia Repair


Hernia Repair 2


Once the jury could see that the procedure was performed within the standard of care, the next visual exhibit offered them an alternative explanation for the cause of this patient’s postoperative pain. The exhibit explains how adhesions form in the area after a surgical procedure, showing how they can encase and eventually distort and entrap the nerve, causing pain for the patient.


Nerve Entrapment


An overlay dropped down over this exhibit to further explain how adhesions can actually disrupt the blood supply of the nerve and result in the formation of a neuroma.


Nerve Entrapment Overlay


Overall the visual defense strategy in this case was to make sure that the jury understood that the defendant performed the patient’s surgery within the standard of care and there was no negligence. The visual exhibits then provided the jury an alternative cause and mechanism for this patient’s ongoing postoperative pain.

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI


Case Study: Lower Extremity Amputation

This case involved a previously healthy 67-year-old male patient who presented with nearly fatal urosepsis from kidney stones. During this acute illness, he developed multisystem organ failure that required aggressive treatment. He survived the event but sustained serious microvascular injury to his fingers and toes although his large vessels and pulses remained intact.

Unfortunately, all of the patient’s toes and several of his fingers developed gangrene. The medical team was able to salvage most of the fingers, but the toes required amputation after final demarcation. The lateral heels were gangrenous as well and the patient developed osteomyelitis. He was treated aggressively over the following months with home health care, multiple antibiotics, VAC treatments, and multiple debridements. The wounds waxed and waned, but ultimately the patient required bilateral below-the-knee amputations.

The plaintiff had several allegations, the first of which was that the damage to the patient’s heel was due to decubiti and not microvascular injury. They further alleged that the patient should have been referred to a specialist for a possible microvascular reconstruction and free muscle flap placement.

The defense contended that this patient did not have heel decubiti; his initial illness had caused microvascular damage so that there were no good vessels remaining in his left heel. Further, the success rate of free flaps following heel osteomyelitis is very low. The medical team did everything they could to salvage this patient’s foot, but the microvascular injury was too severe and ultimately resulted in the amputations.

Since most of the issues in this case were closely related to the microvascular arterial supply of this patient’s feet, the defense first had to educate the jury on the anatomy of the blood supply to the foot and specifically, to the heel. The first exhibit of the defense’s visual strategy utilized areas of highlight and shading to simply explain to the jury which arteries supply the lateral versus medial heel. This simply demonstrated to the jury the pattern of damage that would be expected with damage to the lateral calcaneal artery compared to what would be expected with a heel decubiti. A corresponding exhibit showed the damage to this patient’s feet, thus allowing the jury to easily see that the patient’s pattern of damage was consistent with lateral calcaneal artery injury and did not match what would be expected for a heel decubiti.


Blood Supply To The Heel


Blood Supply To The Heel Overlay


Blood Supply To The Heel Overlay 2




With the next exhibit, the defense gave the jury a deeper understanding of the condition of osteomyelitis, showing how it occurs and why it is so difficult to manage.




Osteomyelitis 2


In order to counter the plaintiff’s allegation that the patient should have been referred to a specialist for a free flap closure of the defect, we created an exhibit to explain free flap microvascular anastomses to the jury. The exhibit also highlighted the high rate of amputation in patients with heel ulcers and osteomyelitis who undergo this procedure. This exhibit was designed to draw the jury’s attention to the fact that even if this patient had undergone this invasive procedure, there is no guarantee that he would have avoided amputation.


Free Flap Microvascular Anastomosis


Lastly, the defense sought to visually explain to the jury why VAC therapy was a good option for this patient. By simply showing how this system heals wounds, it was the defense’s hope that the jury would see why this treatment option was valid and certainly did not constitute negligence.


V.A.C. Therapy


—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI


Case Study: Cancer

This case involved a middle-aged male patient diagnosed with carcinoma in situ of the bladder. At the time of diagnosis, doctors found no signs of metastasis. Further complicating the patient’s course was a long-standing history of severe kidney disease preventing use of any contrast for radiology studies.

The patient underwent an initial resection before presenting to the defendant for a second opinion. The defendant recommended a transurethral resection (TUR) to completely eradicate all disease and Bacillus Calmette-Guerin (BCG) therapy. The TUR was performed within the following few weeks. During surgery, a partially resected nodular tumor was found on the posterior wall. The tumor was completely resected and staged as a high grade T1 tumor and carcinoma in situ. Postoperatively, BCG therapy was started.

A repeat TUR 4 months later revealed no invasive carcinoma. Urine was collected and cytology was positive for malignant cells. This is fairly typical after a resection and was not immediately concerning. Several more cystoscopies were done and although none showed any evidence of cancer within the bladder, urine cytology was positive for malignant cells on several occasions. The patient was monitored closely with cystoscopies but no additional imaging was ordered.

During a routine work-up for the kidney transplant list, a rectal mass was identified on MRI. Biopsy revealed high-grade urothelial cell carcinoma with metastasis. Unfortunately the patient declined rapidly and passed away. An autopsy revealed a tumor involving the urinary bladder with spread into the rectum and extensive metastases though out the body.

The plaintiff alleged the defendant team failed to properly follow and treat the patient’s bladder cancer.

The defense contended this patient was followed extremely closely and appropriately throughout his care. Imaging with contrast was not an option and imaging without contrast would not have been overly helpful for diagnosis and treatment. This patient’s cancer was especially aggressive and he had undetectable micrometastasis at the time of his initial diagnosis. Sadly, an earlier diagnosis of the metastases would not have changed the outcome.

The first visual exhibit was designed to explain gross and microscopic anatomy of the urinary bladder. By showing the jury normal venous and lymph drainage of this tissue, the defense team laid a foundation for later discussion of metastasis and micrometastasis.


©2014 S&A Medical Graphics, LLC


Once normal anatomy was introduced visually, the defense was able to more clearly explain micrometastasis, how it occurs, and how the cancer can spread while ultimately still undiagnosable. This type of spread is extremely difficult to identify early through testing like cystoscopy.



©2014 S&A Medical Graphics, LLC



©2014 S&A Medical Graphics, LLC


Another critical concept for the defense team to convey visually was cystoscopy and the limited view this procedure gives the caregiver. Since contrast was not an option for this patient, it was nearly impossible to identify cancer outside the bladder interior.



13228-3 Final



13228-3 Final


For a patient with end stage kidney disease, contrast dye cannot be processed and excreted properly. Instead, the dye (gadolinium) would disperse through the body causing a devastating reaction throughout multiple organ systems. Further, contrast would not have been overly helpful in this case as it helps illuminate or outline hollow structures within the body. A mass within soft tissue would be ill-defined at best.



©2014 S&A Medical Graphics, LLC



©2014 S&A Medical Graphics, LLC


Finally, the defense wanted to show the extent of this patient’s metastasis in order to demonstrate this particular cancer’s aggressiveness. This exhibit also allowed the defense team to explain that the early framework for these metastases was laid at the time of the initial diagnosis. It was undetectable at that time and it would have been impossible to prevent further spread.


©2014 S&A Medical Graphics, LLC


—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI


Case Study: Stroke & tPA

This case involved a 51 year-old man with a history of multiple myeloma, amyloidosis, hypertension, and hypercalcemia who awoke around 2:30 am unable to speak or hold himself up on his right side. His wife reported he had gone to bed at 11 pm the previous night after having a headache all day and, at that time, had been acting normally.

Emergency responders arrived at 2:38 am noting the patient was experiencing confusion and facial droop. He arrived at the defendant hospital by 3:30 am nonverbal with right-sided paralysis and was diagnosed with a stroke. Medical staff agreed he was not a good candidate for tPA treatment because he was outside the 3-hour safe window for the drug.

The plaintiff was transferred to another institution for further treatment of his stroke, multiple myeloma, and amyloidosis. There, his diagnosis was complete thrombotic occlusion of the left internal carotid artery and a symptomatic left middle cerebral artery infarction. Caregivers felt he was outside the treatment window for thrombolytic and thrombectomy care. Imaging showed moderate swelling of the brain with mild compression of the left lateral ventricle and midline shift with no bleeding. Several days later he was transferred to a rehabilitation center. Unfortunately, he did not recover and continues to have severe deficits in almost all aspects of life.

The plaintiff alleges the defendant institution should have administered tPA to treat this patient’s stroke.

The defense contended this patient was out the safe window for administration of tPA. Giving tPA beyond 3 hours would have put the patient at a much greater risk of brain bleed and death. Further, this patient’s thrombus was so large that tPA treatment would not have been effective.

The first visual exhibits, in this case, were designed to educate the jury on the anatomy of the brain and magnitude of this patient’s thrombus. Given the size of the clot, even giving tPA within the three-hour safe zone would have been completely ineffective. Both delivery routes, IV, and intra-arterial, would have been unable to treat this condition and would have made the patient more susceptible to a dangerous brain bleed.





Often data can be used to help the defense but can be ineffective when presented on its own. By interpreting scientific information into easier to read visuals, the defense team was able to demonstrate the risk of brain bleeds even when this drug is given within the 3-hour time frame.



It was also important for the defense to visually explain the risks of giving tPA outside the safe window. In this case, there was no way to be certain when symptoms began. Care providers could only use the patient’s last known well time, which was over 3 hours before the patient presented to the defendants.



A key part of the visual defense strategy was to establish the severity and size of this patient’s thrombus. This was done using an illustrative interpretation of the patient’s actual films allowing the defense to show the jury complex imaging studies in a way that more effectively communicated with a non-medical audience.





Finally, this patient’s medical condition was complicated by his overall poor health. In order to give context to these conditions, we created exhibits demonstrating the severity of the patient’s multiple myeloma, amyloidosis, and subsequent heart failure.



—Editorial & Illustrations contributed by Kate Galloway, MA, CMI


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