You can't avoid complications in surgery, but how you investigate and document them can mean the difference between your nurses and anesthesia providers going to court as witnesses or defendants in a malpractice lawsuit. As this case shows, you'll limit your legal exposure if you can:

• prove that, in spite of the known risk factors and co-morbidities, your staff acted in accordance with established policy and procedure and delivered care within the standard; and
• demonstrate that your facility conducted a root-cause analysis after the investigation and made appropriate plans to continue providing quality care.

Trocar punctures splenic vein
After years of failed diets, a 48-year-old obese woman decided to undergo a gastric bypass. She suffered from hypertension, fatty liver and sleep apnea.

After discussing these issues with her primary care physician, she met with a surgeon to review available procedures. Around this time, she reported abdominal discomfort with occasional spotting. Tests revealed a moderate-sized ovarian cyst. After consulting with her gynecologist, she decided to undergo a dual procedure: laparoscopic gastric bypass and removal of the cyst. Her medication regimen at the time included amlodipine besylate and quinapril for high blood pressure and hydrochlorothiazide for edema caused by the fatty liver.

The woman was cleared for surgery and signed an informed consent form. On the day of surgery, she was prepped and given general anesthesia without incident. The surgeon introduced an optical trocar and noted that it was difficult to see because the abdominal cavity was not adequately insufflated with CO2. The operative report said the surgeon had a hard time distinguishing between the subcutaneous fat and the intraperitoneal fat.

The surgeon also noted bleeding at the trocar site and removed the trocar. The surgeon's operative report said that the bleeding was "not an inordinate amount." As the surgeon prepared to insert the trocar into a second site, the patient had a severe hypotensive episode, which required an immediate exploratory laparotomy. Once inside the abdomen the surgeon found that the trocar had punctured the splenic vein. The patient was bleeding profusely, but the surgeon and anesthetist managed to recover hemostasis once the splenic vein was sutured. During the exploratory laparotomy, the hospital called the gynecologist to tell him that the procedure had evolved into an open procedure. After the repair of the splenic vein, the gynecologist arrived and removed the left ovary and fallopian tube.

Afterward, the patient's abdomen was irrigated and re-examined. She was no longer bleeding, so the surgeon closed the laparotomy and inserted a drain.

The woman was taken to the ICU, where she required ventilation, pressor support, and an infusion of IV fluids and blood products. Over the next 20 days, the patient suffered worsening acidosis, respiratory failure and, eventually, multi-organ system failure. The patient had to undergo several other procedures to address her deteriorating condition. She developed acute respiratory distress syndrome that required a tracheotomy. She also suffered a tension pneumothorax and abdominal compartment syndrome that required surgical intervention. As a result, the surgeon couldn't close her abdomen for nearly a week. Shortly after closure, sepsis appeared. She then suffered acute renal failure and a cardiac arrest and, finally, died.

The woman's family states its case

The woman's family filed a lawsuit against the surgeon, gynecologist, anesthesia provider and hospital. The complaint alleged that the surgeon was negligent for severing the splenic vein and inadequately insufflating the patient. Although bleeding is a known risk in gastric bypass, improper insufflation made it difficult to see in the abdominal cavity and ultimately led to the splenic vein laceration.

The family also claimed that the surgeon was negligent for employing inadequate resuscitation methods during surgery. There was no evidence to show that the surgical team used aggressive fluid resuscitation before the vein was repaired. There were differing opinions among experts on this. Some believed that the surgeon didn't allow full resuscitative measures to take place before closure of the vein.

As the case was developing, attorneys learned that the hospital's patient safety committee had concerns regarding the effectiveness of the resuscitation before surgical repair. The safety committee said that the operative report indicated there was minimal blood loss, when anesthesia records said the patient lost 4,000cc of blood.

Lack of communication played a large part in the outcome of the procedure and, in turn, the lawsuit. Had anesthesia or nursing communicated to the surgeon their concerns regarding the patient's continued blood loss, their legal exposure would have been much less.

Another key issue was whether the patient's hypovolemic shock was a result of her compromised state due to morbid obesity, or whether it was the surgeon's failure to adequately resuscitate before surgical repair. On the issue of exposing the patient to increased risk by having the ovarian mass removed, experts agreed that the patient got no benefit from having this portion of the surgery performed. At the same time, there was no evidence that the cyst removal caused any subsequent complications.

Case settles
The defense had 2 main issues to deal with: the inadequate insufflation causing poor visibility in the abdomen (the surgeon admitted this during his deposition) and the resuscitation methods used before repair. Experts in trauma medicine were critical of the fact that the surgeon, who had a background in trauma, didn't allow for proper fluid resuscitation before starting to repair the vein, which could have precipitated the patient's hypovolemic shock.

All defendants consented to settle for an undisclosed amount after discovery. In fashioning a dollar amount for settlement, the patient's age, salary, life expectancy and pain and suffering were considered. According to the patient's record, up to the day of her death she was responding to stimuli, which gave credence to the claim of pain and suffering.

Lesson learned
When complications occur, investigate fully as soon as possible and try to determine the exposure of your agents, typically your nursing and anesthesia personnel. In this case, if the anesthesia provider or nurse had documented that they had clearly communicated to the surgeon their concern that the drop in blood pressure was associated with the bleeding, then, in theory, they'd be further removed from the surgeon's decision to repair the vein without resuscitation first. Moreover, it would have been helpful if the anesthesia provider would have documented his concern about performing an additional elective procedure (removing the cyst) after a significant complication had already occurred during the primary surgery.