Removal of the gallbladder is one of the most common surgeries performed in the United States and around the world. Despite surgical and technological advancements in laparoscopic (minimally invasive) surgery over the last three decades, complications still routinely occur during gallbladder surgery. Litigation focuses on whether poor outcomes arose from natural occurrences or negligence, and the stakes are higher than ever as evidenced by recent multimillion-dollar verdicts including a $7.335M award. Given the inherent risks for both plaintiff and defense, trial attorneys must understand the most fundamental factor on which cases are won and lost: the Critical View of Safety.
Gallbladder removal, also known as cholecystectomy, requires the surgeon to carefully expose the gallbladder to identify two structures that must be cut in order to successfully free the gallbladder. The first is the blood supply to the gallbladder known as the cystic artery, and the second is the outflow tract of the gallbladder which is called the cystic duct. Once the gallbladder is directly visualized and the surgeon definitively confirms that the only attached structures are the cystic artery and the cystic duct, it is safe to cut both structures and remove the gallbladder. When essential anatomic structures are not definitively identified, the surgeon risks cutting an inadvertent structure such as the common bile duct, hepatic duct, or hepatic artery. Injuries to these structures results in immediate complications, and even with timely recognition and repair, the outcome can be devastating. Securing excellent visualization is the key to avoiding damage to adjacent structures, and during cholecystectomy this decisive anatomical view is described in modern surgical literature as the “Critical View of Safety.” Given the significance of this anatomic vantage point, nearly every claim of negligence arising from complications of gallbladder surgery focuses on the Critical View of Safety (CVS).
Typical plaintiffs’ claims lead with the argument that the CVS was not visualized because, had it been seen, adjacent structures would not have been misidentified and cut. In many situations, the plaintiff theory is advanced by the failure of the attending surgeon to document visualization of the CVS, or by notes describing the difficulty in identifying the CVS prior to cutting. The main defense argument is that injuries to adjacent structures are common in gallbladder surgery, and that even with optimal visualization injuries may still occur. The confounding variable is that when surgeons are unable to confidently identify the CVS, there is a proactive step they can take: intraoperative cholangiography (IOC). IOC is a real-time imaging technique, available to all surgeons, that affords immediate identification of all biliary (bile draining) structures of interest during gallbladder surgery. While surgeons may easily secure an IOC at any time, it is difficult to defend the decision not to perform IOC when there is any difficulty definitively confirming the CVS. Similarly, it is a red flag to perform cholangiography after cutting the wrong structure since performing it moments earlier would have averted the complication in the first place. By understanding the fundamentals of gallbladder surgery and the Critical View of Safety, trial attorneys can objectively gage the strength of their case.
To learn more pearls and pitfalls of surgery litigation, please join Dr. Burton Bentley II, CEO of Elite Medical Experts, on December 3, 2020 at 1:00 PM CST (2:00 PM EST) for a 90-minute CLE: Insights Beyond the Law — Fundamentals of Negligence During Gallbladder Surgery. This accredited CLE, sponsored by NBI, will explore every facet of gallbladder surgery litigation from the decision to operate to the prognosis of various surgical errors. Insights Beyond the Law is a series of informative and engaging CLEs directed at trial attorneys who routinely handle medical negligence claims. Fundamentals of Negligence During Gallbladder Surgery is the first in the series.
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About Elite Medical Experts: Elite Medical Experts is a physician-led consulting firms specializing in any issue at the intersection of Medicine & Law. Elite also hand selects leading Professors of Medicine and Surgery to serve as expert witnesses. With over 8000 engagements in all 50 states and internationally, Elite is a first-stage strategic resource for trial attorneys and their clients. To learn more about Elite, please visit EliteMedicalExperts.com, or call [888] 790-1399.
About NBI: The National Business Institute (NBI) is the nation’s largest CLE provider with over 18,000 hours of live and on-demand CLE. By aligning with leading legal authorities across the U.S., NBI curates a diverse catalog of leading-edge seminars spanning every practice area and niche of the law. To learn more about NBI, please visit NBI-sems.com, or call [800] 930-6182.
