The Board was notified of a malpractice settlement regarding the treatment of a 76-year-old woman.
On 02/14/2012, a woman was evaluated by a urology regarding a renal lesion that had been found on a CT scan. The urologist ordered a CT scan which was performed on 11/28/2012 and which revealed no no significant change in size of the 0.9 cm lesion located on the upper pole of the right kidney. The lesion had a slightly thickened and irregular enhancing wall. There was a small ventral wall hernia. The urologist documented the renal lesion as being complex and enhancing with no significant enlargement. It was around 1 cm in diameter and was not causing the patient any symptoms. The urologist recommended a biopsy.
On 01/24/2013, the patient underwent a right renal biopsy. Pathology revealed probable clear cell renal cell carcinoma Fuhrman grade 2.
On 01/30/2013, the urologist documented that he discussed the risks and benefits with the patient regarding surgery. The urologist offered a hand assisted approach to allow for repair of the patient’s hernia. The patient gave consent for the procedure.
On 04/17/2013, the patient was admitted for right nephrectomy via hand assisted laparoscopy. Per the anesthesia record, the anesthesia start time was 1:51 p.m. and surgery start time was 2:26 p.m. The surgery end time was 5:54 p.m. The urologist’s operative note documented adhesions and significant bleeding he initially thought was due to injury of the inferior vena cava. The patient received two packed red blood cell transfusions and the operation was converted to an open procedure.
At 3:00 p.m., the anesthesia record stated that the blood pressure was 60/30.
At 3:47 p.m., a general surgeon was consulted and arrived in the operating room. The surgeon noted that there was bleeding along the anterolateral edge of the patient’s duodenum and pancreas. The portal vein, common bile duct, and hepatic artery were transected. The urologist stated that he proceeded with a radical nephrectomy prior to liver vascular repair to avoid further liver vascular damage. Per the general surgeon’s note, hepatic warm ischemia time was one hour and fifteen minutes. After the nephrectomy was completed, the hepatic artery, portal vein, and common bile duct were repaired, including graft replacement.
At 5:30 a.m. on 04/18/2013, the urologist dictated his operative report.
On 04/18/2013, the patient was taken back to surgery after sanguineous fluid was found in the drain output. The general surgeon’s intraoperative findings included 1500 ml of intra-abdominal blood along with bleeding from a gonadal vessel and from the insertion of the renal vein on the vena cava. The family requested DNR status for the patient. The patient subsequently died.
The Board judged urologist’s conduct to be below the minimum standard of competence given failure to use proper surgical technique with correct tissue transection/ligation, failure to timely convert to an open procedure, and failure to consider hepatic artery and portal vein repair prior to proceeding with the performance of the nephrectomy.
The Board ordered the urologist to be reprimanded.
Date: November 2016
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
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