Medicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery

doi:10.1016/S0002-9610(05)80189-8

The American Journal of Surgery

Volume 168, Issue 3, September 1994, Pages 217-222

https://doi.org/10.1016/S0002-9610(05)80189-8 Get rights and content

To understand the medicolegal impact of bile duct injury, we analyzed 68 cases of biliary injury resulting from open cholecystectomy and abdominal surgery. Cases were litigated within the US civil justice system between 1970 and 1991. Operations resulting in bile duct complications included cholecystectomy for cholelithiasis in 49 patients (72%), common bile duct exploration in 5 patients (7%), and other abdominal operations in 7 patients (10%); 7 operations were of unknown type. The average delay in recognition of injury was 16 days (range 3 to 42). The mortality rate was 18% (12 of 68). Median jury verdict awards in successfully litigated cases were twice that of out-of-court settlements ($500,000 versus $250,000, P = 0.01).

Bile duct injury after open cholecystectomy and abdominal surgery has a high mortality rate when diagnosed late, and is expensive to litigate. This review may be useful in defining the medicolegal outcome of similar injuries from laparoscopic cholecystectomy.

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Implications of routine cholangiography during laparoscopic cholecystectomy on postoperative testing: Review of more than 2,300 cases in a community-based practice
2023, American Journal of Surgery
We hypothesized that routine cholangiography during laparoscopic cholecystectomy may increase use of postoperative imaging and invasive testing.
A retrospective review was performed of laparoscopic cholecystectomy cases at 6 community hospitals from 2017 through 2020. For surgeons performing routine vs selective cholangiography, we compared primary outcomes of operative time, 30-day complications, and postoperative imaging or procedures.
In total, 2359 laparoscopic cholecystectomy procedures were performed. Eighteen surgeons performed routine cholangiography (1125 cases), and 13 performed selective (1234 cases). Mean operative time was longer in the routine group (125.3 vs 98.7 min, P < .001). Between groups, 30-day complications were similar. Two common bile duct injuries were identified in the routine group. Postoperatively, the routine group underwent 2.5 times more imaging and invasive testing (P < .001).
In community hospitals, laparoscopic cholecystectomy can be performed safely by surgeons using cholangiography routinely or selectively. Routine cholangiography resulted in more postoperative imaging and invasive testing.
Inside the courtroom: An analysis of malpractice litigation in gallbladder surgery
2020, Surgery (United States)
Citation Excerpt :
The Westlaw legal research service is a database that has previously been used to examine malpractice claims related to neurosurgery, otolaryngology, and plastic surgery.17-19 Data on causes and outcomes of cholecystectomy-related lawsuits in the United States, however, are limited.13,20,21-23 Therefore, the objective of the current study was to examine the causes and outcomes of cholecystectomy related lawsuits in the United States.
Cholecystectomy is one of the most commonly performed operations in the United States, yet it still carries up to a 6% risk of major morbidity. Lawsuits are a major source of emotional, financial, and personal stress for surgeons. We sought to characterize malpractice claims associated with gallbladder surgery as well as define contributing factors and costs with these claims.
The Westlaw database (Thomson Reuters Corporation, Toronto, Canada) was queried for jury verdicts and settlements related to cholecystectomy and malpractice between 2000 and 2018. Data were abstracted from the case files and details of the settlements, jury verdicts, and factors related to the claims were assessed.
Among 231 cases, a plaintiff verdict was reached in 45 (19.5%) and a defendant verdict was reached in 122 (53%); other cases were either settled (n = 29, 12%), dismissed (n = 31, 13%), or denied (n = 4, 2%). Plaintiff cases often involved young (median age, 44 years [interquartile range: 35–57]) female (n = 146, 63%) patients. The attending surgeon accounted for 59% of defendants. Procedural error (49%), wrongful death (18%), or failure to treat in a timely manner (13%) were the most commonly cited reasons for litigation. Among the 134 cases where a second surgical procedure was performed, the most common types of procedures were biliary tract repair (n = 82, 61%) and bowel repair (n = 16, 12%). The total cost of the claims over the study period was $22 million with a median payout of $500,000; the median time from operative event to final disposition was over 5 years (interquartile range: 4–7).
A plaintiff verdict or settlement was reached in 1 in 3 cases, and large payouts were common. Minimizing procedural error and improving care of patients after cholecystectomy complications should be emphasized.
Iatrogenic injuries of the extrahepatic biliary system
2017, Journal of Surgical Research
Citation Excerpt :
The mean time for delayed recognition of injury in our series was 44.9 d. This is in contrast with other reported series with mean range of 12 and 16 d delay in recognition of injuries.10,17 Because of missing data, we cannot precisely justify the long delay in diagnosis of injury.
Iatrogenic traumatic extrahepatic biliary tract injuries though rarely occur; they can lead to exceedingly morbid complications. The aim of this study was to evaluate the management strategies and outcomes of patients presented with iatrogenic bile duct injuries.
This is a retrospective study. Over 19 y, 124 patients were managed for iatrogenic biliary injuries at our institution. The data related to the etiology of biliary tract injury, symptoms of injury, laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, hospitalization time, and postoperative complications were reviewed.
The main clinical presentations were jaundice or recurrent cholangitis in 64 (51.61%) patients, followed by bile peritonitis in 34 (56.67%) and biliary fistula in 26 (43.33%) patients. Only in 23 (18.54%) cases, the injury was recognized intraoperatively. The most frequent surgical procedure was open cholecystectomy in 81 (65.32%) of 124 patients. The remaining patients were operated on laparoscopically. Good results were achieved in 99 of 101 patients with direct suture repair including hepaticojejunostomy, choledocoduodenostomy, and choledochocholedochostomy (98.02% success rate) at the first attempt. Three cases (2.97%) of biliary strictures after direct suture technique and four (3.96%) cases of postoperative mortalities were detected. The mortality rate was mostly affected by male gender, advanced age, and existence of bile peritonitis. Totally, 111 (89.52%) patients are still alive with a mean follow-up time of 78 ± 38 (2–230) mo.
Biliary injuries can be sometimes life-threatening complications. A successful repair may provide patients with a lifelong relief from symptoms, whereas a failed repair may result in recurrent biliary obstruction, reoperation, and even death.
Radiologic Assessment of Hepatobiliary Surgical Complications
2013, Seminars in Ultrasound, CT and MRI
The complexity of hepatobiliary procedures continues to evolve at a rapid rate, with an increasing number of living donor liver transplants and extensive cancer resections being performed. The associated complications are a significant cause of morbidity and mortality, and are often complex injuries, involving both vascular and biliary structures. In this paper we describe the complications associated with laparoscopic cholecystectomy, liver transplant surgery, and hepatic resection. Focus is on the classical imaging appearances, imaging modality options, and varying management strategies for these injuries, to show how the radiologist's role is vital in ensuring the correct diagnosis is made and the appropriate treatment is instigated.
Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy
2009, HPB
Citation Excerpt :
This is comparable with reported mortality rates (for all injuries following LC) of 16%18 and 13%4 amongst claimants. The average cost per claim was approximately £53 000 according to the NHSLA database; this is in contrast with average payments per claim of $436 0004 and $500 00015 reported in two studies from the USA. The costs of medical malpractice, including a successful claim for BDI after LC, are significantly lower in England compared with in the USA.
When laparoscopic cholecystectomy (LC) is performed successfully, recovery is faster than after open cholecystectomy. However, LC results in higher incidences of biliary, bowel and vascular injury.
We performed a retrospective review of LC-related claims reported to the National Health Service Litigation Authority (NHSLA) during 2000–2005. The data were analysed from a medicolegal perspective to assess the effects of type of injury and delay in recognition on litigation costs.
A total of 208 claims following laparoscopic procedures in general surgery were reported to NHSLA during 2000–2005, of which 133 (64%) were related to LC. Bile duct injury (BDI) accounted for the majority of claims (72%); bowel injury and ‘others’ accounted for 9% and 19%, respectively. Only 20% of BDIs were recognized during surgery; the majority were missed and diagnosed later. Claims related to LC resulted in payments totalling £6 m, of which £4.3 m was paid out for BDIs. The average cost was higher for patients who suffered a delay in diagnosis, as was the chance of a successful claim.
Bile duct injury incurred during LC remains a serious hazard for patients. The resulting complications have led to litigation that has caused a huge financial drain on the health care system. Delayed recognition appears to correlate with more costly litigation.
Characteristics and outcomes of malpractice claims after tonsillectomy
2008, Otolaryngology - Head and Neck Surgery
Citation Excerpt :
Accordingly, it is critical to review liability insurance company cases as well. Although malpractice after surgical complications has been studied in the areas of bile duct injury, facial nerve injury, and complications of thyroid and endoscopic sinus surgery,6,7,12,14 these studies have been limited to court trial analysis only. The American Society of Anesthesiologists, however, has been particularly active in review of medical liability insurance claims.15-17
To characterize the background and outcomes of tonsillectomy malpractice claims.
Review of 69 New York State insurance claims (Part I) and 87 national court trials (Part II) alleging injury after tonsillectomy.
Part I. New York State insurance cases were most commonly discontinued (44%) or settled (42%) before trial. Compensations with a settlement or verdict were made in 48 percent of cases. Part II. Death or major injury occurred in 52 percent of insurance cases, with a mean award of $403,656 being made to plaintiffs. Of cases reaching trial, 60 percent of plaintiffs were compensated. Awards against anesthesiologists were more frequent and higher than against surgeons ($5 million vs $839,650). Death or major injury occurred in 52 percent of court cases, resulting in mean indemnity of $3.8 million. Most cases of death or major injury were attributable to airway complications.
Approximately half of both New York state claims and court cases involved death or devastating morbidity, mostly related to airway complications, resulting in large awards. Tonsillectomy is a source of uncommon but potentially high-dollar–value litigation exposure to the surgeon, often attributable to non-surgical complications.

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Scientific PaperMedicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery

Am J Surg

Am J Surg

Surg Clin North Am

Am J Surg

Am J Surg

Am J Surg

Am J Surg

Am J Surg

Am J Surg

Surg Clin North Am

Am J Surg

A plea for a safer technique of cholecystectomy

Surgery

Iatrogenic injuries to extrahepatic bile ducts and associated vessels: a 25-year analysis

J Natl Med Assoc

Accidental lesions of the common bile duct at cholecystectomy II: results of treatment

Ann Surg

The improving results of cholecystectomy

Arch Surg

Modern standards for comparison of cholecystectomy with alternative treatments for symptomatic cholelithiasis with emphasis on long term relief of symptoms

Surg Gynecol Obstet

Open cholecystectomy. A contemporary analysis of 42,474 patients

Ann Surg

Recent results of elective open cholecystectomy in a North American and a European center

Ann Surg

Benign postoperative biliary strictures: operate or dilate?

Ann Surg

Scientific Paper
Medicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery