3. Hospital admission:
On July 19, 2007,
Maria Santos is brought to the emergency
room of St. Elizabeth Hospital
with complaints of severe abdominal pain,
fever and nausea.
3
4. Diagnosis:
acute cholecystitis
and
cholelithiasis
4
8. Biliary Flow
The liver produces bile and other digestive enzymes
necessary for the breakdown of fats in the diet.
Bile is transported from the liver to the gallbladder
through a series of biliary ducts – and then to the
small intestine.
Any prolonged obstruction that blocks the flow
of bile from the liver to the small intestine
can result in life-threatening consequences.
8
9. Biliary Flow
The liver produces bile and other digestive enzymes
necessary for the breakdown of fats in the diet.
Liver
Common hepatic duct
Cystic duct Common bile duct
9
10. Bile is delivered from the liver
to the common hepatic duct.
Common
hepatic duct
10
11. From the common hepatic duct,
bile is delivered to the cystic duct.
Cystic duct
11
12. From the cystic duct, bile enters the gallbladder
where it is concentrated and stored until needed.
Gallbladder
12
13. When fatty foods are eaten, the gallbladder contracts and
sends stored bile back through the cystic duct and common
bile duct into the small intestine.
Small intestine
13
14. Any prolonged obstruction that blocks the flow
of bile from the liver to the small intestine
can result in life-threatening consequences.
14
18. Through the Abdominal Wall
The entire procedure
is performed through
4 small incisions
in the abdomen.
18
19. Anatomy of the Surgical Area
Critical Structures
Cystic artery
Hepatic artery
Gallbladder Common
hepatic duct
Cystic duct
Common
bile duct
19
20. Standard of Care
The correct procedure
for the performance of a
laparoscopic cholecystectomy
is as follows:
This is what Dr. Tauber should have done.
20
24. The Surgeon’s Cardinal Rule:
No anatomic structures should be clipped or
cut until the surgeon is unequivocally certain
that they have been correctly identified.
24
25. Deviation from Standard
of Care
These are the 3 major surgical errors
committed by Dr. Tauber.
This is what Dr. Tauber did...
and what he did not do.
25
26. Surgical Error # 1
Failure to identify the common
hepatic duct
26
29. Additional Errors:
Dr. Tauber chose not to use
operative cholangiography or ultrasound
which would have helped him
to identify critical structures.
29
30. Additional Errors:
Dr. Tauber failed to recognize his surgical errors
and therefore failed to diagnose the clipped duct
as the cause of biliary obstruction.
30
31. Blocked Duct
Clipping the common hepatic duct blocks the flow of bile
and eventually destroys the duct.
Blocked flow
31
32. Consequences of Surgical Errors
1. Irreparable damage to the common bile duct.
2. Development of biliary obstruction
3. Multiple invasive diagnostic procedures.
4. Necessity for reconstructive surgery
5. Exposure to additional procedural risks.
6. Permanent scarring and disfigurement.
32
33. 1. Irreparable damage to the common
hepatic and common bile duct.
Damages to the duct
as a result of clipping:
• Stricture
• Narrowing
• Scarring
• Deterioration
33
34. 2. Development of biliary obstruction.
Any prolonged obstruction
that blocks the flow of bile
from the liver to the small intestine
can cause serious, life-threatening
consequences.
34
36. Continuing Symptoms
Soon after laparoscopic cholecystectomy,
Maria Santos was discharged from the hospital.
Throughout the following weeks,
her symptoms grew steadily worse.
Twenty-one days later she was re-admitted with
a diagnosis of acute biliary obstruction.
36
37. 3. Exposure to Additional
Risks and Complications
Maria Santos had to endure
many invasive diagnostic procedures –
each with its own set of risks
and complications.
37
39. Diagnostic tests
HIDA Scan
A radioactive acid is
injected into a large
vein.
Site of blockage is
revealed.
Blockage
at staple
39
40. Risks and Complications of HIDA
Nuclear medicine tests are not performed
in pregnant women
or breast-feeding mothers.
40
41. PTC
A thin needle is inserted
through the skin into the liver, and into a biliary duct.
A radio-opaque dye is injected into the biliary system.
Liver
41
42. Risks and Complications of PTC
• Bleeding
• Blood poisoning
• Infection
• Inflammation of the bile ducts
42
43. PBD
A catheter is inserted into the liver to drain off excess bile
accumulated as a result of blocked flow.
43
44. Risks and Complications of PBD
• Pain and discomfort at insertion site
• Injury to blood vessels
• Puncture of duct, liver or bowel
• Bile leakage and bleeding
• Liver infection
44
45. ERCP 1
A flexible tube is
inserted into the
mouth and passed
down the esophagus
until it reaches the
small intestine.
Small intestine
45
46. ERCP 2
A thin catheter within the tube is advanced and
inserted into the bile duct.
Insertion point
46
47. ERCP 3
Dye is injected into the bile duct
and moves uptoward the liver.
Source of blockage
confirmed.
47
48. Risks and Complications of ERCP
• Nausea, blurred vision, urine retention
• Bleeding
• Perforation of small bowel
• Pancreatitis (inflammation and infection of
the pancreas)
48
49. Diagnostic tests confirm the diagnosis of biliary
obstruction due to the clipped duct.
Open, reconstructive surgery
becomes necessary.
49
50. 5. Surgical Reconstruction
Second Operation
After amputation of bile duct... a new “bile duct” is created
using a section of small bowel.
Small bowel
“New
bile duct”
50
51. Risks and Complications of
Reconstructive Surgery
• Stricture
• Infection
• Bleeding
• Bile leakage
• Liver failure
51
54. Summary
1. During the first gallbladder operation,
Dr. Tauber erroneously clipped the
common hepatic duct.
2. The clipped duct was the direct cause of
biliary obstruction.
3. Worsening symptoms of biliary
obstruction necessitated multiple, invasive
diagnostic tests.
54
55. Summary
4. A second operation was necessary to
reconstruct the damaged bile duct and
restore the flow of bile.
5. Further diagnostic tests and therapeutic
procedures became necessary to correct
the complications of the second operation.
6. Maria Santos is left with unsightly scars,
puncture wounds and unremitting pain
requiring periodic hospitalizations.
55
