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--------------- Print Magazine --------------
 
  May 2016
 
  April 2016
 
 
 
 
KNOW COMPLICATIONS

Smt. Talat Chaudhary v. All India Institute of Medical Sciences

Original Petition No. 114 of 1999 decided on 9th November, 2012 by the National Consumer Disputes Redressal Commission New Delhi.

Facts:  In February, 1997, the complainant had complaint of pain in her abdomen and after consultation with local doctors and radiological and other investigations, she was diagnosed as having stones in the Gall Bladder and was advised surgery for the same. 

Going by the high reputation of opposite party No.1 - All India Institute of Medical Sciences, the complainants approached the said hospital in March 1997 and was advised to undergo laparoscopic cholecystectomy, which would normally require hospitalization of 3-4 days in all. On 25-3-1997, the complainant No.1 was admitted in AIIMS in the private ward of AIIMS after paying the requisite charges and laparoscopic cholecystectomy was conducted on her in the morning of 27-3-1997 by opposite party No. 2 - Surgeon.  

From the discharge summary received by the complainant, it was revealed that some injury was caused to the bile duct during laparoscopic procedure and to repair the same, the abdomen of the complainant No.1 was opened and false excuse was given for covering up the said mistake, which was caused due to the negligence and carelessness of opposite party No.2 and other assisting doctors. 

It was alleged that not only was the injury to the bile duct caused but it was not repaired promptly and properly, which resulted into further complications.  After her discharge from the opposite party No.1-hospital, the complainant No.1 consulted other doctors at Delhi, Patna and Lucknow who tried to treat the complainant No.1 through medicines at a huge cost.   Even then, the level of Alkaline Phosphate increased in the body of complainant No.1 as was found after Nuclear Medicine test at Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow (for short ‘SGPGIMS’) and it was found that there was blockade in the body of the complainant No.1, which prevented free passage of bile and raised alkaline phosphate which was due to the faulty repair of the bile duct injury. 

Despite taking treatment at various medical centers, there was not much improvement in the condition of complainant No.1 and she was advised to undergo second surgery, which could pose a risk to her life.  It was alleged that due to residual defect / disability, the family life of the complainant had also been ruined and the complainants were unable to perform their duties and pursue their social and political activities and claimed a compensation of  `30,58,923.

Defence: It was not denied that the laparoscopic cholecystectomy was conducted by opposite party No.2 on the complainant No.1 at opposite party No.1-hospital and that during the course of the procedure an injury was occasioned to the bile duct of complainant No.1.  However, it was sought to be explained that the alleged injury (defect) is incidental and commonly accepted phenomena to such surgeries, which was assented to by complainant No.2 and therefore, no liability can be enfastened on the opposite parties.  The opposite party No.2 operated complainant No.1 with utmost care and ability and that while removing the stones from the gall bladder through laparoscopic procedure the surgeon encountered with a situation when it became eminent for him to convert the laparoscopic procedure into open / conventional cholecystectomy procedure. As regard  the consequential blockade of bile, it is stated that this also is a phenomena whereby the Billo-enteric anastomosis gets obstructed after repair, this related to the nature of healing of the complainant and had nothing to do with the skill of the doctor.  It was explained that the level of Alkaline Phosphate was normal on 3-4-1997 i.e. a day before she was discharged from opposite party No.1-hospital on 4-4-1997.  It was denied that the opposite parties were liable for any medical negligence or deficiency in treatment of complainant No.1 or liable to pay any compensation for the same much less the compensation sought by the complainants
.
Issue Involved: Whether the CBD injury is a known complication of laparoscopic
cholecystectomy procedure or was it caused due to lack of care / negligence on the part of the operating surgeon (O.P. No.2) and his team?

Expert Opinion: The Board constituted by the DGHS after going through the entire record of the medical treatment gave their opinion as under:

“Summary:     Mrs. Talat Choudhary, 52 years Female was admitted on 25-3-1997 vide CR No. 495592 in Surgical Unit III AIIMS, New Delhi.  She was operated on 27-3-1997. Laparoscopic cholecystectomy was started which was converted to open cholecystectomy on detecting CBD injury (due to unclear anatomy) and Roux en Y Hepaticojejunostomy was done.  Post-operative stay was uneventful.  Tc 99m scan done on 3-4-1997 at AIIMS showed patent Hepaticojejunostomy.  Patient was discharged on 4-4-1997. Patient had persistently raised Serum Alk. Phosphate but Ultrasound abdomen & CT abdomen done at Patna on 10-6-1997 was not showing any evidence of biliary stasis.Patient was investigated at SGPGI, Lucknow, HIDA scan done on 4-7-1997 revealed evidence of stenosed biliary enteric anastomosis  for which Redo Surgery was done on 5-7-1997.  Patient was discharged on 23-7-1997.  Post-operative HIDA scan done on 18-8-1997 showed patent anastomosis.

Observations: Laparoscopic Cholecystectomy for Gall stone disease is a preferred mode of treatment.  CBD injury is a known complication of Laparoscopic as well as open Cholecystectomy.  Conversion to open Cholecystectomy upon suspicion/detection of CBD injury is a standard procedure as and when indicated.

On perusal of operative records of AIIMS, injury to the CBD in this patient was recognized intraoperatively and approximately laparoscopic procedure was converted to open procedure and remedial corrective measure in the form of Roux en Y Hepaticojejunostomy was performed which is a standard operative procedure for such complication.  Tc 99 m scan done on 3-4-1997 at AIIMS showed patent anastomosis. 
Conclusion: Committee is of the opinion that Laparoscopic Cholecystectomy was converted to open cholecystectomy and appropriate corrective measures (Hepaticojejunostomy) for the CBD injury were successfully taken.  At no stage any evidence of negligence is forthcoming on the perusal of relevant medical records made available to the committee.”

Held: On a consideration of the above noted authoritative opinions of the Medical experts and bearing in mind the legal position, there cannot be any denial of the position that the CBD injury is a well-known complication of the laparoscopic cholecystectomy procedure and frequency of such complications has increased with the advent of laparoscopic cholecystectomy.  It is much higher, say almost double or four times than in the case of open / conventional cholecystectomy.  Therefore it must be presumed that the incidence of CBD injury is a well-known risk when a patient undergoes a laparoscopic cholecystectomy procedure.  In other words, the same cannot be correlated as the act of negligence or carelessness on the part of the operating surgeon.  In a case where a patient has incidentally suffered CBD injury during the laparoscopic procedure cannot by itself be presumed to be a result of negligence in all such cases. However, that does not mean that a surgeon conducting the laparoscopic cholecystectomy procedure would be immune even if the CBD injury has been caused due to his negligence / lack of care in performing the said procedure.  In the case in hand, the complainants  are mostly harping upon the situation that the anatomy of the complainant No.1 was not fully and properly visualized before she was booked for laparoscopic cholecystectomy procedure for the removal of the stone from the gall bladder.  In other words, the complainants want to suggest that the operating surgeon has overlooked the said situation.  This argument does not cut much ice because in the present case, the complainants have failed to show that complainant No.1 had any abnormal / unusual anatomy on the face of which procedure of laparoscopic cholecystectomy was counter indicative or the operative surgeon should have gone only for conventional / open cholecystectomy procedure even to begin with. We therefore hold that no negligence can be attributable to the opposite parties on that count. As regards the procedure of laparoscopic cholecystectomy and the procedure adopted to correct the CBD injury, no fault can be found with the same as has been opined by the body of medical experts (supra).   Once it is shown that due medical protocol was followed, no case of medical negligence is made out against the opposite parties.

In any case, the complainant No.1 was discharged from the hospital on 4-4-1997, in a satisfactory condition and she did not revert back to the said hospital for consultation about the subsequent problems, which she had to face, may be for the reason that the complainants had lost faith in the treatment given by the opposite parties.  On that count also, it is not possible to fix any liability on the opposite parties.  The complaint being devoid of any merits is accordingly dismissed, leaving the parties to bear their own costs.

Original Petition No. 114 of 1999 decided on 9th November, 2012 by the National Consumer Disputes Redressal Commission New Delhi.

Facts:  In February, 1997, the complainant had complaint of pain in her abdomen and after consultation with local doctors and radiological and other investigations, she was diagnosed as having stones in the Gall Bladder and was advised surgery for the same.  Going by the high reputation of opposite party No.1 - All India Institute of Medical Sciences, the complainants approached the said hospital in March 1997 and was advised to undergo laparoscopic cholecystectomy, which would normally require hospitalization of 3-4 days in all. On 25-3-1997, the complainant No.1 was admitted in AIIMS in the private ward of AIIMS after paying the requisite charges and laparoscopic cholecystectomy was conducted on her in the morning of 27-3-1997 by opposite party No. 2 - Surgeon.   From the discharge summary received by the complainant, it was revealed that some injury was caused to the bile duct during laparoscopic procedure and to repair the same, the abdomen of the complainant No.1 was opened and false excuse was given for covering up the said mistake, which was caused due to the negligence and carelessness of opposite party No.2 and other assisting doctors.  It was alleged that not only was the injury to the bile duct caused but it was not repaired promptly and properly, which resulted into further complications.  After her discharge from the opposite party No.1-hospital, the complainant No.1 consulted other doctors at Delhi, Patna and Lucknow who tried to treat the complainant No.1 through medicines at a huge cost.   Even then, the level of Alkaline Phosphate increased in the body of complainant No.1 as was found after Nuclear Medicine test at Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow (for short ‘SGPGIMS’) and it was found that there was blockade in the body of the complainant No.1, which prevented free passage of bile and raised alkaline phosphate which was due to the faulty repair of the bile duct injury.  Despite taking treatment at various medical centers, there was not much improvement in the condition of complainant No.1 and she was advised to undergo second surgery, which could pose a risk to her life.  It was alleged that due to residual defect / disability, the family life of the complainant had also been ruined and the complainants were unable to perform their duties and pursue their social and political activities and claimed a compensation of  `30,58,923.

Defence: It was not denied that the laparoscopic cholecystectomy was conducted by opposite party No.2 on the complainant No.1 at opposite party No.1-hospital and that during the course of the procedure an injury was occasioned to the bile duct of complainant No.1.  However, it was sought to be explained that the alleged injury (defect) is incidental and commonly accepted phenomena to such surgeries, which was assented to by complainant No.2 and therefore, no liability can be enfastened on the opposite parties.  The opposite party No.2 operated complainant No.1 with utmost care and ability and that while removing the stones from the gall bladder through laparoscopic procedure the surgeon encountered with a situation when it became eminent for him to convert the laparoscopic procedure into open / conventional cholecystectomy procedure. As regard  the consequential blockade of bile, it is stated that this also is a phenomena whereby the Billo-enteric anastomosis gets obstructed after repair, this related to the nature of healing of the complainant and had nothing to do with the skill of the doctor.  It was explained that the level of Alkaline Phosphate was normal on 3-4-1997 i.e. a day before she was discharged from opposite party No.1-hospital on 4-4-1997.  It was denied that the opposite parties were liable for any medical negligence or deficiency in treatment of complainant No.1 or liable to pay any compensation for the same much less the compensation sought by the complainants.

Issue Involved: Whether the CBD injury is a known complication of laparoscopic cholecystectomy procedure or was it caused due to lack of care / negligence on the part of the operating surgeon (O.P. No.2) and his team?

Expert Opinion: The Board constituted by the DGHS after going through the entire record of the medical treatment gave their opinion as under:

“Summary:     Mrs. Talat Choudhary, 52 years Female was admitted on 25-3-1997 vide CR No. 495592 in Surgical Unit III AIIMS, New Delhi.  She was operated on 27-3-1997. Laparoscopic cholecystectomy was started which was converted to open cholecystectomy on detecting CBD injury (due to unclear anatomy) and Roux en Y Hepaticojejunostomy was done.  Post-operative stay was uneventful.  Tc 99m scan done on 3-4-1997 at AIIMS showed patent Hepaticojejunostomy.  Patient was discharged on 4-4-1997. Patient had persistently raised Serum Alk. Phosphate but Ultrasound abdomen & CT abdomen done at Patna on 10-6-1997 was not showing any evidence of biliary stasis.Patient was investigated at SGPGI, Lucknow, HIDA scan done on 4-7-1997 revealed evidence of stenosed biliary enteric anastomosis  for which Redo Surgery was done on 5-7-1997.  Patient was discharged on 23-7-1997.  Post-operative HIDA scan done on 18-8-1997 showed patent anastomosis.

Observations: Laparoscopic Cholecystectomy for Gall stone disease is a preferred mode of treatment.  CBD injury is a known complication of Laparoscopic as well as open Cholecystectomy.  Conversion to open Cholecystectomy upon suspicion/detection of CBD injury is a standard procedure as and when indicated.

On perusal of operative records of AIIMS, injury to the CBD in this patient was recognized intraoperatively and approximately laparoscopic procedure was converted to open procedure and remedial corrective measure in the form of Roux en Y Hepaticojejunostomy was performed which is a standard operative procedure for such complication.  Tc 99 m scan done on 3-4-1997 at AIIMS showed patent anastomosis.
 

Conclusion: Committee is of the opinion that Laparoscopic Cholecystectomy was converted to open cholecystectomy and appropriate corrective measures (Hepaticojejunostomy) for the CBD injury were successfully taken.  At no stage any evidence of negligence is forthcoming on the perusal of relevant medical records made available to the committee.”

Held: On a consideration of the above noted authoritative opinions of the Medical experts and bearing in mind the legal position, there cannot be any denial of the position that the CBD injury is a well-known complication of the laparoscopic cholecystectomy procedure and frequency of such complications has increased with the advent of laparoscopic cholecystectomy.  It is much higher, say almost double or four times than in the case of open / conventional cholecystectomy.  Therefore it must be presumed that the incidence of CBD injury is a well-known risk when a patient undergoes a laparoscopic cholecystectomy procedure.  In other words, the same cannot be correlated as the act of negligence or carelessness on the part of the operating surgeon.  In a case where a patient has incidentally suffered CBD injury during the laparoscopic procedure cannot by itself be presumed to be a result of negligence in all such cases. However, that does not mean that a surgeon conducting the laparoscopic cholecystectomy procedure would be immune even if the CBD injury has been caused due to his negligence / lack of care in performing the said procedure.  In the case in hand, the complainants  are mostly harping upon the situation that the anatomy of the complainant No.1 was not fully and properly visualized before she was booked for laparoscopic cholecystectomy procedure for the removal of the stone from the gall bladder.  In other words, the complainants want to suggest that the operating surgeon has overlooked the said situation.  This argument does not cut much ice because in the present case, the complainants have failed to show that complainant No.1 had any abnormal / unusual anatomy on the face of which procedure of laparoscopic cholecystectomy was counter indicative or the operative surgeon should have gone only for conventional / open cholecystectomy procedure even to begin with. We therefore hold that no negligence can be attributable to the opposite parties on that count. As regards the procedure of laparoscopic cholecystectomy and the procedure adopted to correct the CBD injury, no fault can be found with the same as has been opined by the body of medical experts (supra).   Once it is shown that due medical protocol was followed, no case of medical negligence is made out against the opposite parties.

In any case, the complainant No.1 was discharged from the hospital on 4-4-1997, in a satisfactory condition and she did not revert back to the said hospital for consultation about the subsequent problems, which she had to face, may be for the reason that the complainants had lost faith in the treatment given by the opposite parties.  On that count also, it is not possible to fix any liability on the opposite parties.  The complaint being devoid of any merits is accordingly dismissed, leaving the parties to bear their own costs.

 

 
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