Excising the Gall Bladder: The Risks of 'Band-Aid' Surgery

In routine gall bladder surgery, the surgeon mistakenly punctures the patient's aorta, a major artery supplying oxygen-rich blood to the body. The patient is 20-year-old Airman Colton Reid. His fiancé watches as Reid's feet turn blue from lack of blood flow; yet there are more than eight hours of delay before Reid is transferred from the teaching hospital at Travis Air Force Base to UC Davis Medical Center in Sacramento, where Reid can get adequate treatment. Because of the lack of blood flow from the punctured aorta, and the delay, doctors at UC Davis are ultimately forced to amputate his legs.Gall bladder surgery is one of the most common surgical procedures performed in hospitals, but the online video segment by ABC News described above shows gall bladder surgery is not without its risks. In Reid's case, what went wrong? The Inflamed Gall BladderThe gall bladder, tucked away near the liver, is small and resembles a pear. The liver produces bile and the gall bladder stores it until bile is needed for digestion of food.In some cases, gall bladder surgery (cholecystectomy) is performed to treat abnormal gall bladder function or cancer, but in the majority of cases the gall bladder becomes inflamed or obstructed because of gallstones, and the patient elects to have it removed.Gallstones are hard, tiny pebbles of cholesterol that form for a number of reasons, from poor diet to genetic inheritance, and cause symptoms that range from chronic indigestion to intense abdominal pain. Removing the gall bladder through laparoscopic surgery helps to alleviate the symptoms.Laparoscopic surgery, colloquially known as "Band-Aid" surgery because of its tiny incisions, became popular among general surgeons in 1990 due to technical advances. It is now the standard procedure largely replacing the more invasive techniques of open surgery. The surgeon makes incisions no greater than one centimeter, inflates the patient's abdomen with carbon dioxide to make room, and inserts a small video camera (the laparoscope). Once inside, the surgeon locates the gall bladder's vessels and ducts, cuts them, and removes the gall bladder through the navel.Laparoscopic surgery is less risky, less painful, and more cosmetically pleasing compared to traditional open surgeries, in which incisions are much larger and internal organs lay bare. But laparoscopic surgery still requires practice and experience on the part of the surgeon.The Laparoscopic SurgeonLaparoscopic surgery carries risks beyond those inherent in general anesthesia, the patient's overall health, and his or her individual prognosis and recovery. Laparoscopic surgery is a minute exercise. Any hand tremors are amplified, compounding any lack of eye-hand coordination. And the surgeon must be comfortable using the laparoscope; chiefly, dexterity of the wrists, hands and fingers is required to safely manipulate the instrument inside the patient's body.The surgeon must know the relevant anatomy. Since gallstones often cause inflammation, the anatomy can be distorted and difficult to identify, and an inexperienced surgeon could mistakenly pierce the wrong organ or clamp the wrong duct--like the bile duct, requiring emergency room treatment and reconstructive surgery--or, in Reid's case, the aorta. In other words, the surgeon must correctly interpret the image displayed by the laparoscope and couple that with his or her experience and dexterity; if the surgeon fails at this, the complicationsare serious.From Pierced Aorta to Legal CulpabilityFor Airman Colton Reid, whose legs were amputated, the central issue is the apparent negligence of the laparoscopic surgeon who cut his aorta--as the triggering event--made worse by the fact that Reid's transfer was delayed much longer than the few hours a patient can go without blood flow to his limbs before he risks losing them.As applied in a case with facts similar to Reid's (Reid does not have access to civil malpractice laws because he was treated by a military doctor), New York pattern jury instructions define medical malpractice as the negligence of a doctor, in which the doctor does something that a reasonably prudent doctor would not do under the circumstances, or fails to do something that a reasonably prudent doctor would do under the circumstances.Reid would have to prove both proximate cause and resulting damages; typically, a jury would decide whether there was surgical malpractice in piercing the aorta, whether the pierced aorta caused the amputation, or whether it was primarily due to the eight hour delay.More than one million gall bladder surgeries are performed every year in the nation, most of them laparoscopically. And according to the American College of Surgeons, the mortality rate is relatively low: 0 to 1 patient dies in every 1,000 cases. But this statistic does not include injuries like Reid's, such as the amputation of his legs and the rehabilitation he no doubt needed. What happened to Reid shows that relatively uncommon risks can still make Band-Aid surgery anything but routine.