Following a month-long Tennessee medical malpractice jury trial and eight hours of jury deliberations, a Nashville medical malpractice jury returned its verdict in the amount of $16.1 million for a 26-year-old man who suffered cardiac arrest, strokes, and resulting brain damage that his lawyers argued were due to his doctors negligently failing to properly assess and treat a bile leak after the routine gallbladder removal surgery.
The Gallbladder
The gallbladder is located on the inferior aspect of the liver bed, more specifically under liver segments 4b and 5. The gallbladder can be up to 10 cm in length and physiologically can hold up to 50 cc of fluid (bile). A line from the gallbladder to the inferior vena cava separates the liver into right and left lobes. Normally, the gallbladder empties its contents in response to physiologic changes associated with digestion (cholecystokinin, vagal input from antral distension, migrating myoelectric complex). High concentrations of cholesterol within the gallbladder is a known cause for precipitation of cholesterol gallstones.
There are four anatomical sections to the gallbladder: fundus, body, infundibulum, and neck. There is great variation in the biliary ductal anatomy. The cystic duct most commonly arises from the common bile duct and inserts at the neck of the gallbladder. The branch point of the cystic duct from the common bile duct marks the beginning of the common hepatic duct superiorly. The blood supply to the gallbladder is from the cystic artery which originates approximately 90% of the time from the right hepatic artery. Again, there is great variation in the course and origin of the cystic artery. The hepatocystic triangle (triangle of Calot) is a surgical anatomical landmark created by the cystic duct laterally, the common hepatic duct medially, and the liver edge superiorly. This triangle is of surgical importance because this is the location for the most common path of the cystic artery to the gallbladder. There sentinel lymph node of the gallbladder resides within the hepatocystic triangle, also known as Lund’s node (and erroneously referred to as the node of Calot).
A classic finding for gallbladder disease is right upper quadrant or epigastric abdominal pain. An abdominal examination should specifically check for a “Murphy’s Sign”: deep palpation in the right upper quadrant while the patient inspires deeply. A positive test is when the patient abruptly stops their inspiration secondary to pain.
The pain typically has an onset 30 minutes to two hours after consumption of fatty foods. The pain can last from one to two hours, up to more than 24 hours. Pain lasting more than 24 hours is associated with a secondary infection known as acute cholecystitis. Pain radiates from the right upper quadrant to the right flank, and occasionally to the right shoulder due to sympathetic innervation. Associated symptoms include but are not limited to nausea, vomit (bilious), fever, chills, and diarrhea. Less specific symptoms may be experienced like indigestion, GERD-like symptoms, PUD symptoms, and dyspepsia. Earlier in the disease process pain will be intermittent and associated with oral intake of fatty foods. As the process progresses, pain may become more frequent and occur regardless of oral intake.
Laparoscopic cholecystectomy is a minimally invasive surgical procedure used for the removal of a diseased gallbladder. Since the early 1990s, this technique has largely replaced the open technique for cholecystectomies. Laparoscopic cholecystectomy is currently indicated for the treatment of acute or chronic cholecystitis, symptomatic cholelithiasis, biliary dyskinesia, acalculous cholecystitis, gallstone pancreatitis, and gallbladder masses or polyps.
Common complications include but are not limited to bleeding, infection, and damage to the surrounding structure. Bleeding is a common complication as the liver is a very vascular organ. Experienced surgeons must be knowledgeable about anatomical anomalies of arteries to prevent potential significant blood loss. The most severe complication is an iatrogenic injury of the common bile/hepatic duct. Injury to either of these structures may require a further surgical procedure to divert the flow of bile into the intestines. This procedure usually requires a specially trained hepatobiliary surgeon.
Bile leaks might complicate the procedure and present with vague abdominal pain fever, with or without the characteristic features of direct hyperbilirubinemia. The complicated patients usually present within the first week following the surgery. Management should be initiated with diagnostic ultrasonography and or abdominal CT scan. In the case of retained choledocholithiasis, biliary sphincterotomy is mandatory. High-grade leaks should be managed with sphincterotomy and stenting. A HIDA scan evaluating bile leaks is recommended in equivocal findings on CT or ultrasonography.
If you or a loved one suffered complications as a result of laparoscopic cholecystectomy in Tennessee or in another U.S. state, you should promptly seek the advice of a Tennessee medical malpractice attorney or a medical malpractice attorney in your state who may investigate your possible medical malpractice claim for you and represent you or your loved one in a medical malpractice case, if appropriate.
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