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Medico-legal problems related to cholecystectomy: Intestinal complications
An article for physicians by physicians
Originally published March 2010
P1001-5-E

Complications from cholecystectomy can be hard to diagnose and can cause significant difficulties for both patients and physicians.

The CMPA reviewed 131 legal cases with surgical complications from cholecystectomy. In 19% of the cases, the complications experienced by patients were from intestinal injuries. In 100% of the cases, surgeons were sued, and sometimes the legal actions included other physicians. For example, family or emergency physicians involved in the patient’s post-operative care may see patients with as yet undiagnosed complications of recent cholecystectomy.

The 131 reviewed cases were closed between 2003 and 2007. They included both laparoscopy and laparotomy procedures. The most frequent complications were biliary tract injuries (53%), followed by intestinal injuries (19%) and vascular/hemorrhagic injuries (11%). The remaining cases (17%) concerned other complications such as incisional wound infections, acute coronary syndromes, pulmonary emboli or retained foreign body material (Figure 1).

Figure 1: Complications from cholecystectomy

Intestinal complications

Case study

A 62-year-old male patient with symptoms of biliary colic was referred for surgery. An earlier ultrasound had confirmed gallstones. The patient underwent a seemingly uneventful laparoscopic cholecystectomy. The patient was kept in hospital over night for control of nausea. As the surgeon was going on a one-week holiday on the evening of the surgery, he transferred the care of the patient to another surgeon.

On the first post-operative day, the patient developed an ileus.

On the following day, he developed increasing abdominal distension and discomfort. Investigations showed no biliary tract abnormalities but confirmed distended loops of small bowel and a sub-hepatic fluid collection extending down the right paracolic gutter that was not accessible for percutaneous drainage.

On the fourth post-operative day, the patient developed a small pleural effusion that was treated conservatively. The ileus, however, persisted. The surgical team attributed it to a hematoma, noting there was significant abdominal ecchymosis.

For the next two days, the clinical picture and daily radiographic plain film findings went unchanged. 

On the seventh post-operative day, the original surgeon returned from holidays. Realizing the patient’s condition was not improving, he reviewed the previous investigations. The surgeon was suspicious of peritoneal irritation on physical examination and ordered a CT scan for the next morning. This showed a right paracolic fluid collection that was interpreted as a hematoma. Purulent material was drained percutaneously the same day and antibiotics were started. 

On the seventeenth post-operative day, the patient developed a fever and elevated white blood cell count (WBC). A repeat CT scan showed a new fluid collection in the gallbladder bed and the pararectal area, but complete resolution of the previously-drained abscess. Percutaneous drainage of the new collections was contemplated, but the following day the patient became septic and was taken to the operating room for a laparotomy, which demonstrated a perforated terminal ileum and peritonitis. Fifty-six centimeters of bowel were resected and primary anastomosis was performed 10 cm from the ileo-caecal valve. The patient was discharged nine days later with partially-controlled diarrhea.

A legal action followed. The patient alleged a delay in diagnosis of the bowel perforation resulting in severe peritonitis.

Surgical experts opined that the laparoscopy was done according to standard and intestinal injury is an inherent risk of such surgery. They also agreed that percutaneous drainage of the abscess was appropriate. They did state, however, that the laparotomy should have been done sooner because the etiology of the abscess was not established and the patient continued to have an ileus.

Because the experts could not support the care given, a settlement was paid to the patient by the CMPA on behalf of the operating surgeon. 

Review of findings

This CMPA review of 131 legal actions identified 25 cases (19%) in which patients developed intestinal complications following cholecystectomy. Findings from the 25 cases included the following:

Deaths: Seven patients (28%) died.

Laparoscopic vs. open approach: Twenty-two patients (88%) underwent a laparoscopic approach, and only three patients (12%) had a planned open approach. In four of the laparoscopic cases, the prompt recognition of an intestinal injury resulted in conversion to laparotomy. 

Non-traumatic vs. traumatic complications: Five patients (20%) had non-traumatic intestinal complications. One of these patients, with known severe atherosclerotic vascular disease, had a delayed diagnosis of a complete superior mesenteric artery thrombosis and died. The remaining four patients presented with small bowel obstruction requiring exploration, with two requiring intestinal resection.

The remaining 20 patients (80%) had direct intestinal trauma as follows:

• 10 duodenal injuries, resulting in three deaths
• 9 jejuno-ileal injuries, resulting in three deaths
• 1 transverse colon injury

Mechanism of injury: The exact mechanism of injury was often difficult to determine, as there was frequently significant inflammatory response by the time the site of the intestinal damage was visually examined. Manipulation of tissues, or the use of cautery or other instruments such as retractors were often postulated as mechanisms of injury. 

Expert opinions

Peer experts reviewing the care in these cases were often critical of the surgical technique and/or delays in diagnosing a complication. 

Surgical experts identified a technical surgical issue in 17 of the 25 patients with intestinal complications. They commented on the need for careful attention when manipulating the intestine and mesentery, when freeing adhesions, and when using cautery.

In nine of the 17 patients, the complication was compounded by a delay in diagnosis. In the remaining eight, the experts considered the technical approach to have been sound. Recognizing that complications can occur despite appropriate surgical technique, the experts were supportive of the care provided to five of the eight where physicians quickly addressed the patients’ symptoms with appropriate investigation and treatment. However, in the other three cases there was a delay in doing so. In these cases, experts were critical of the physicians’ failure to recognize the bowel injury earlier in the post-operative period. They were also critical of the failure to pursue investigation of possible other reasons for peritonitis when biliary tract injury was ruled out.

Of the 25 cases with intestinal complications, 52% were settled in favour of the patient. This percentage is higher than the overall CMPA experience with legal actions. 

Risk management considerations

Based on the review of the 131 cholecystectomy closed legal cases, the CMPA has the following suggestions.

For the operating surgeon:

• Have you provided a sufficient consent discussion?
• Does the operative note reflect any significant difficulties encountered in the procedure?
• Would it be helpful to other providers to include a timely entry in the progress notes reflecting any significant difficulties encountered in the procedure?
• Have you given the patient discharge instructions that include potential symptoms and signs of a complication, the urgency of seeking additional care and where to find that care?
• Have you documented your discharge instructions?

For any physician attending in the post-operative period:

• Do you have a high index of suspicion for potential complications of the surgery?
• Are investigations and/or referrals indicated to rule out, for example, bile duct or intestinal injury?
• Should the attending/operating or on-call surgeon be notified of the patient’s condition?

The bottom line

• An informed consent discussion for laparoscopic cholecystectomy should not leave the patient with the impression that it is a minor procedure without the possibility of significant complications.
• The symptoms and signs of post-operative complications of cholecystectomy (by laparoscopy or laparotomy) may be non-specific initially and may develop hours to several days after the surgery. Discharge instructions alerting patients to the possible symptoms of complications may prompt them to seek early attention. 
• Family or emergency physicians often face the challenge of assessing patients post-operatively with early and non-specific symptoms of a complication.