Aside from the COVID-19 pandemic, a key theme of 2020 has been diversity and inclusivity. This two-part update addresses this theme in detail
Gall bladder surgery
The information known about the pre-operative anatomy is important. In most cases a client will have had a history of cholecystitis (inflammation of the gallbladder, usually due to infection) as well as stones in the common bile duct. If non-surgical treatment, generally antibiotics and a careful diet does not relieve a patient of the very painful symptoms then surgery will be considered a suitable option.
Pre-surgery investigations will generally include an ultrasound scan and an ERCP. The latter investigation is a procedure, where the risks of serious complications are low, by which the doctor can look at the gall bladder by inserting a tube with a light on the end, sometimes through the patient’s mouth under sedation, and the images are displayed onto a video screen. One of the purposes of these non-invasive investigations is to allow the surgeon to see the anatomy to be able to assess the risks then associated with more invasive surgery.
Below we highlight some of the common issues arising from each case, of course each case is investigated and is determined on its own unique set of facts:
- A patient’s anatomy can be distorted due to damage caused by longstanding infection, scar tissue, fibroids or general anatomical abnormalities. These should then assist the surgeon in making the decision as to whether it is reasonable to then perform surgery to remove the gall bladder laparoscopically (keyhole) or laparotomy (open surgery involving an abdominal cut and scar).
- The surgery to remove the gallbladder is known as a cholecystectomy. The issue of overriding importance with this surgical procedure is for the surgeon to locate and identify each and every part of the relevant anatomy in this area, and it is critical this is done before any attempts are made to cut the cystic duct to remove the gall bladder. It may be difficult for the surgeon to identify the relevant parts of the anatomy if some of the problems referred to above are present, and these may obscure a surgeons view, particularly with keyhole surgery, and increase the risk of misidentifying parts of the anatomy. If a surgeon is at all unsure he/she should either advise that open surgery is recommended from the outset or convert keyhole surgery to open surgery, to allow a better view of the area.
- The anatomy in the area that can be damaged with a lack of care is the liver, and the biliary tree (the hepatic duct, common bile duct, the portal vein and hepatic artery).
Common outcomes to these ligation claims are damage to the biliary tree anatomy. This is generally as a result of the surgeon misidentifying the anatomy and cutting the hepatic duct or the common bile duct in the mistaken belief it is the cystic duct. The patient will usually start to become symptomatic with acute pains and will pass bile. This will result in the need for emergency surgery to repair the damaged area, by creating a join (anastomosis) and there is likely to be a recovery period in intensive care.
In one particular case, where we dealt with an injury to the biliary tree, this was caused by the surgeon over zealously using the diathermy (electrical heat used when dissecting away the anatomy in order to gain access to the cystic duct/gallbladder) and ‘burning’ the biliary tree. Whilst in the majority of cases the reconstructive surgery is successful, the entire experience can be and often is life changing for most patients. At the very least the patient will have to remain under the care of the liver team, with the need for repeat liver function tests.
There are long term risks which in the worst case can mean, if the anastomosis breaks down, total liver failure.
Examples of cases we have settled have included large "loss of earnings claims" as whilst physically the client may have recovered and repeat liver function tests are showing no abnormalities, psychologically there has been a major injury. Typical symptoms can include lack of energy, inability to concentrate and generally an inability to return to the level of activities pre-surgery. These have all been proven with expert psychological opinion to be a typical response to someone having to undergo this type of unexpected, major surgery involving intensive care admission.
To quote a surgical expert we have worked with in these cases “these bile duct injuries are avoidable and should be avoided with the exercise of reasonable skill and care on the part of the surgeon”.
For more information
If you have suffered this type of injury, or are concerned about any adverse outcome following surgery, please contact Sarah Huntbach (Senior Associate in our Clinical Negligence Team) on 0121 212 7476 or email@example.com.
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