CASE XI:  EVALUATION OF CLIPPED HEPATIC DUCT

SUMMARY:

On, 06/25/01, M.D., diagnosed gallbladder disease, hepatomegaly, hypertension and diabetes mellitus and performed laparoscopy which demonstrated a lot of adhesions without adhesion in the right subcostal area, an edematous and acutely inflamed gallbladder which was dissected with difficulty because of the edematous condition; the cystic duct was secured with three hemoclips and divided; the cystic artery was secured and divided; other clips were required to be applied to control the bleeding. The gallbladder was removed by electrocautery; the operative site was irrigated; no bleeding point was noted, and the site was closed with staples, and the patient was in satisfactory condition.

On, 06/28/01, M.D., noted the examinee had acute and chronic cholecystitis, which had started last night with abdominal pain, severe vomiting for which the examinee sought emergency department evaluation and was diagnosed with gallbladder disease, confirmed by ultrasonography, followed by laparoscopic cholecystectomy after which the examinee improved.

On, 07/02/01 ,  M.D., recorded a discharge summary, which indicated the examinee had obstructive jaundice subsequent to laparoscopic cholecystectomy for acute cholecystitis and cholelithiasis, was seen in the emergency room about four to five days ago, diagnosed with jaundice and was referred to Hospital via ambulance for ERCP gastroenterologist for injury to the common duct.

On, 07/11/01, M.D. noted having transfused the 58-year-old male, who was transferred on 07/03/01 from the Hospital with .painless jaundice and a bilirubin of 6.1 which occurred several days post laparoscopic cholecystectomy.   Esophagogastroduodenoscopy with ERCP revealed a clip across the common hepatic duct.

With a small wisp of contrast going into the intrahepatic biliary tree and the common hepatic duct was visualized above the clip; guidewire was inserted and successive dilatation was performed over an endoscopically placed guidewire; endoscopic sphincterotomy and stenting after ligation of common hepatic duct was done with a laparoscopic clip.  Fortunately the clip could be dislodged endoscopically; stent was placed with continuity of the biliary tree maintained The clip was extruded from the common duct, and no further compression was noted after final dilatation. (12 cm, #12 French stent was placed into the right hepatic duct.) 

The examinee was discharged in good condition, and the bilirubin fell to 1.4 as outpatient.

Subsequently the examinee called and was feeling weak and (pale), was lightheaded when standing; stools became dark two days after returning home from the hospital; on recent admission to the hospital hemoccult was positive, iron and TIBC were 70 and 438, respectively, and ferritin was elevated at 1646.  Medications included Lortab, Glucophage, gemfibrozil, glipizide, Tiazac, Dyazide, aspirin and Levaquin. 

Hemoglobin was 7.9, and bleeding from sphincterotomy site or the area where the clip was placed in manipulation dilatation of the biliary tree or even a stent within the intrahepatic biliary tree was suspected The examinee was  transfused.

Endoscopy demonstrated reflux esophagitis without any other abnormalities, bleeding and clear bile from the sphincterotomy site as well as to the stent without evidence of visible vessel ulceration or bleeding at the site. The examinee was discharged after blood transfusion in good, stable condition with additional medications, including ferrous sulphate and Prilosec.

On 08/17/01, M.D., gastroenterologist, noted excellent flow from common duct of bile status post cholecystectomy, intraoperatively had staple across the common hepatic duct underwent endoscopic retrograde cholangiopancreatography with balloon dilatation of the common duct and displacement of the staple; a stent was placed to ensure appropriate drainage. Examinee was referred for reevaluation of the common duct and possible stent removal. The bile stent was found and snared, removed and discarded, and the common duct was selectively cannulated and dye injected which demonstrated a normal caliber lumen without any evidence of intraluminal opacification, narrowing, stricture or any pathology and excellent drainage.

CONCLUSIONS:

1.      Laparoscopic cholecystectomy was the appropriate treatment for the examinee’s                      diagnosis of acute and chronic cholecystitis.

2.      The surgeon inadvertently clipped the hepatic duct during the surgical procedure leading to the development of clinical jaundice, which was appropriately diagnosed after a second visit to the hospital emergency department on the 5th postoperative day (3 days post discharge from hospital).

3.      The examinee was subsequently admitted to the hospital and then transferred in a timely manner to another hospital for specialized care by a gastroenterologist.

4.      The gastroenterologist, who extracted the clip, may have inadvertently triggered bleeding in the presumably edematous postoperative site leading to a transfusion though on endoscopic reevaluation, no bleeding site was appreciated

5.      About 7 weeks postoperatively another gastroenterologist selectively cannulated and dye injected the common hepatic duct and demonstrated a normal caliber lumen without any evidence of intraluminal opacification, narrowing, stricture or any pathology and excellent drainage.

6.      The examinee did not feel he was fully informed of the potential complications of the laparoscopic cholecystectomy procedure; additional information regarding informed consent is unavailable for evaluation.

7.      According to a Board Certified general surgeon, clipping of the hepatic duct occurs more frequently at the earlier stages of one’s experience with the procedure.

COMMENTS:

1.                Additional information with regard to informed consent may establish whether the examinee was advised of potential complications of the laparoscopic cholecystectomy procedure.

2.        Review of the surgeon’s training and experience may provide insight into whether the surgeon acted in a negligent manner in clipping the hepatic duct or whether this was, in actuality, an inadvertent act which may have been an anticipated complication in certain particular situations.

3.                The initial gastroenterologist removed the clip, placed by another physician, and may, in retrospect, have subsequently observed or recommended closer followup of the examinee.

Within a reasonable degree of medical probability, the examinee’s medical care was within the prevailing standard of care, and although the examinee incurred additional morbidity, he sustained no permanent impairment as a consequence of the misplaced clip on the hepatic duct, which was subsequently removed.

The review of additional pertinent records may have the effect of modifying the aforementioned conclusions.  

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