Case details

Patient’s cystic duct leak a known risk of surgery: defense





Result type

Not present

bile duct, chest pain, shortness of breath
In 2013, plaintiff Martha Estrella, 50, underwent gallbladder surgery, which was performed by Dr. Said Hemmati, a general surgeon. Estrella was previously referred to Hemmati by her family practitioner. Hemmati then evaluated Estrella, and he informed her that she had the option of undergoing a laparoscopic cholecystectomy, which was an open laparotomy for removal of her gallbladder, or to continue with conservative care. Estrella opted for the laparoscopic cholecystectomy with the expectation that she would remain in the hospital overnight, post-surgery, and then be discharged home the next day. The laparoscopic procedure turned out to be somewhat difficult because of considerable amount of scarring and a thickened gallbladder full of gallbladder stones. As a result, the surgery lasted approximately 2.5 hours, but was ultimately completed without obvious complication. However, the next day, Estrella was found to be leaking serosanguineous fluid from her Jackson-Pratt drains (closed-suction medical devices that are commonly used as post-operative drains for collecting bodily fluids from surgical sites), which became an obvious bile leak over the next 48 hours that required the insertion of stents to assist with the drainage. However, it was Hemmati’s impression that the condition was a cystic duct leak, rather than leakage from a common bile duct injury. On the fourth post-op day, Estrella developed shortness of breath and chest pain, for which consultation was obtained with a pulmonologist and a cardiac surgeon. The consulting physicians ultimately diagnosed a pulmonary embolism and deep vein thrombosis. Estrella sued Hemmati and Valley Presbyterian Hospital. Estrella alleged that Hemmati was negligent in the performance of the laparoscopic cholecystectomy and was negligent in providing post-operative care. She alleged that Hemmati’s negligence constituted medical malpractice and that the hospital was liable for Hemmati’s actions. Valley Presbyterian Hospital was ultimately dismissed from the case, and the matter continued against Hemmati only. Plaintiff’s counsel contended that Estrella sustained a common bile duct injury during the surgery due to a laceration or the placement of staples. Counsel argued that Hemmati failed to recognize the common bile duct injury during the surgery and that because of existing scar tissue and the difficult anatomy, Hemmati should have performed an intraoperative cholangiogram to make certain that he was transecting the cystic duct rather than the common bile duct. Plaintiff’s counsel further contended that the postoperative endoscopic retrograde cholangiopancreatography films demonstrated that there were staples going into the common bile duct in the area that was transected. In addition, plaintiff’s counsel argued that inadequate precautions were taken post-operatively to prevent deep vein thrombosis and pulmonary embolis and that once the bile leak developed, Estrella should have been placed on low-dose Heparin to avoid further complications. One of the defense’s experts, a general surgeon from St. John’s Medical Center, testified that Estrella suffered a post-operative cystic duct leak, which is an inherent risk of any gallbladder surgery, and that there was no way plaintiff’s counsel could say the endoscopic retrograde cholangiopancreatography study demonstrated staples in the common bile duct based on the films that he reviewed. Defense counsel also argued that Hemmati had ordered Estrella to be ambulated four times a day, post-operatively, and that the order constituted sufficient prophylaxis against the development of deep vein thrombosis. In addition, counsel contended that an order for a low dose of Heparin may have exposed Estrella to hemorrhaging because serosanguineous fluid was being expelled through the Jackson-Pratt drains post-operatively., Estrella claimed that she sustained a common bile duct laceration, resulting in a bile leak that required the insertion of stents to assist with the drainage. She eventually developed shortness of breath and chest pain, and was diagnosed with a pulmonary embolism and deep vein thrombosis. A patent foramen ovale — a hole in the heart that didn’t close the way it should after birth — was also diagnosed with a large clot going from Estrella’s right ventricle to the left ventricle. As a result, Estrella required a repair of the patent foramen ovale by open heart surgery. After the surgery, she continued to drain bile through pigtail catheters into a collecting bag and through stents into the duodenum. Over time, the drainage lessened and eventually the catheters and stents were removed. Estrella recovered from her bile leak and pulmonary emboli, but she claimed she developed deep vein thrombosis in her legs.
Superior Court of Los Angeles County, Los Angeles, CA

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