11148-2 Final

Case Study: Ureter Injury

Generally speaking, gynecologic surgery accounts for over 50% of all ureteral injuries resulting from operations. Hysterectomy of any type is usually a safe procedure, but any surgery has risks, such as blood loss, blood clots, infection, damage to surrounding organs, and reactions to anesthesia. Surgery involving the organs in the pelvis puts the surrounding organs at risk of injury as well.

Bladder, ureter, and bowel injuries are relatively common and known complications of hysterectomy, whether total abdominal, vaginal, laparoscopic, or laparoscopically-assisted. Injuries can be due to stapling/sutures, thermal injury, or aberrant anatomy. Subsequently, plaintiff claims of negligence as a result of these types of injuries are not uncommon in the realm of medical malpractice negligence. The following case study examines the visual strategy of the defense in an interesting case of ureteral injury after vaginal hysterectomy.

The female plaintiff presented to the defendant for a vaginal hysterectomy. There were no unusual findings and the procedure was without complication. At the conclusion of the procedure, a Foley was placed and the plaintiff was voiding well with clear urine. Postoperatively, the plaintiff complained of right-sided hip pain, but it was generally felt to be discomfort due to positioning. The plaintiff was discharged on the first postoperative day voiding well with clear urine. Two days later, the plaintiff returned to the defendant complaining of pain involving her right flank. She had a history of kidney stones, so she was sent for consultation. Two days postoperatively, a cystoscopy showed a right-sided ureteral obstruction with hydronephrosis. Ultimately, the plaintiff underwent a re-implantation of the ureter and insertion of the right-sided nephrostomy tube.

The plaintiff alleged that the defendant tied the ureter off with a suture during the vaginal hysterectomy procedure. The defense contended that the ureteral obstruction was caused by kinking of the ureter and/or by post-operative swelling of the surrounding tissues. While unfortunate, they argued that ureteral injury is a known complication of this procedure.

In order to visually present the defense strategy in court, the plan was to first orient the jury to the anatomy of the female pelvis involved in this case.


Female Pelvis

This gave the jury a frame of reference for the female anatomy as well as highlighting the spatial relationship between the uterus/ vagina, the bowel, and the ureter.

The next step in the visual strategy was to provide a visual reference of the plaintiff’s surgical procedure in order to help the defendant explain what he did during the procedure.


Total Vaginal Hysterectomy

The final portion of the visual strategy was to show the jury the likely mechanism of injury in this case. By showing how the closure of the vaginal cuff could put tension on the right side of the cuff, causing the right ureter to kink, blocking the flow of urine. It would also demonstrate how the swelling and inflammation of the surrounding tissues could contribute to the kinking and blockage.

Mechanism of Injury

The defense found these exhibits to be helpful in creating a baseline of medical knowledge for the jury and allowing their client and experts to explain their theories of alternative causation. Ultimately, the defense received a favorable outcome for their client in this case.

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Jennifer C. Webb, MS


Case Study: Spinal Accessory Nerve Transection

This unique case involved a female plaintiff with a history of right-sided shoulder and back pain. She presented to the defendant for evaluation of an enlarged, non-painful, right-sided posterior cervical lymph node, which she had noticed approximately 6 months earlier. The node was 1.5 x 1.5 cm and easily palpable along the border of the trapezius muscle; an ultrasound revealed it was negative for malignancy. The defendant biopsied and extracted the node but postoperatively the plaintiff had pain the area of the right tip of her shoulder near the deltoid. The incision healed well though and the plaintiff had normal shoulder and scapula movement, with good flexion and extension of her upper extremities bilaterally and symmetrically. Her pain waxed and waned, so she was referred to a neurologist as well as an orthopedist. She started PT and had less pain and no functional problems over time. Although the pain was lessened, it was still there, so the plaintiff was referred to a pain clinic, where doctors felt she could have new onset RSD, or a recurrence of old RSD.

Eight months postoperatively, the plaintiff presented to a new doctor at a joint center. He found that the plaintiff had difficulty in raising her right arm, both abduction and flexion, and she also had weakness of abduction of her right shoulder. She did, however, have full passive external rotation as well as internal rotation behind the back. There was no evidence of shoulder winging or pronation of the shoulder. The supraspinatus was atrophied, however, so there was concern for the suprascapular nerve. A month later, during a follow-up appointment, the plaintiff demonstrated Tinel’s sign over her upper shoulder distal to the incision site and winging of the scapula with significant atrophy of the dorsal shoulder. Spinal accessory nerve dysfunction was suspected, and the plaintiff was referred to a specialty clinic. There, doctors found that the spinal accessory nerve had been transected.

The plaintiff alleged that the defendant performed the node extraction negligently, resulting in the transection of the spinal accessory nerve. The defense contended that this is a known complication of this type of surgery and that the correct standard of care was met during and after the surgery.

The first step in the visual defense strategy was to familiarize the jury with the anatomy of the neck and the area of the lymph node extraction, including the course of the spinal accessory nerve along with the lymph nodes of the posterior triangle.


Posterior Triangle

Next, the defense sought to educate the jury on the defendant’s procedure, providing them with a step-by-step visual aid while the defendant explained the surgery in detail. This also allowed the jury to see the anatomy as the defendant saw it during the actual procedure.



A second panel showed the same steps in cross-section, giving the jury a more comprehensive understanding of the anatomy in the area of the surgery as well as the location and level of the surgery. This allowed the defendant to show the jury that the entire procedure took place superficial to the cervical fascia, whereas the spinal accessory nerve lies deep to this fascial layer.


The next step in the visual defense strategy was to show the known anatomical variations in the course of the spinal accessory nerve, compared to the defendant’s surgical field. This allowed the jury to see that in the normal anatomy of the spinal accessory nerve, it would be well beneath the cervical fascia, and therefore would not be injured by the extraction surgery. In contrast, it demonstrated that two anatomical variations in which the nerve could be injured is if the spinal accessory nerve is located directly beneath or above the lymph nodes of the posterior triangle where it would certainly be involved in the extraction. The exhibit showed another possible mechanism of injury to the spinal accessory nerve as adhesions, caused by an inflamed or enlarged node, which could manipulate the location of the nerve by pulling it more superficially towards the enlarged node and into the surgical field where it could sustain an injury.

Spinal Nerve

The last portion of the visual defense strategy was to highlight and enlarge the paragraph of the plaintiff’s informed consent for the procedure that outlined the potential for damage to deeper structures as well as the plaintiff’s signature indicating her understanding of these risks. A portion of the operative report was also highlighted and enlarged, in order to show the defendant’s summary of his discussion with the plaintiff regarding the risks of the procedure as well as the plaintiff’s acknowledgment of these risks and her decision to proceed with the surgery.

Informed Consent

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Russ Edwards, MS, CMI


Case Study: Anastomotic Leak

This case involved a middle-aged woman who was diagnosed with a villous adenoma in her cecum by laparoscopy and biopsy. During the subsequent laparoscopic hand-assisted hemicolectomy, the cecum was found to be attached to the omentum. There were no apparent complications.

Three days postoperatively, the plaintiff began feeling uncomfortable, but a CT showed no evidence of a leak. She was monitored for two more days and became increasingly ill. A barium enema at that time revealed an anastomotic leak, so she was returned to the OR for an exploratory laparotomy. When her abdomen was opened, several liters of dirty fluid were evacuated. The disrupted bowel was resected, fibrinous exudate was peeled from surfaces, and the abdomen was copiously irrigated. An ileostomy was created in the right lower quadrant. After a difficult postoperative course, complicated by sepsis and wound infection, the plaintiff was ultimately discharged about a month after her original hemicolectomy surgery.

The plaintiff alleged that the defendant failed to diagnose the anastomotic leak in a timely fashion. The defense contended that the plaintiff was properly managed throughout her hospital stay. She was appropriately evaluated for a leak and none was found, but when she continued to worsen a second evaluation was performed, at which time the leak was discovered and repaired. Anastomotic leak and sepsis are unfortunate but well-known complications of this procedure.

The first step in the visual defense strategy was to educate the jury on the original hemicolectomy procedure. A simple graphic explaining the plaintiff’s pre-operative and post-operative anatomy allowed the defendant to become a teacher and an expert in front of the jury.



Another exhibit was developed to help explain why free air seen in the immediate post-operative films was not diagnostic of an anastomotic leak. The illustration shows that free air is normally found in the abdomen after such laparoscopic surgery and is the result of insufflated air not being completely evacuated before closing. These residual air pockets are harmless and are absorbed by the body within a few days. Fluid seen in the inferior aspect of the abdomen was simply residual irrigant from the procedure.

Before/After Surgery

The last portion of the visual defense strategy aimed to explain to the jury the normal movement of bowel contents compared to what is seen during ileus and gastrogaffin enema. This illustrated the defense theory that the contrast material pushed the fecal material back up the colon, with the increased back pressure causing the anastomosis to rupture and leak.

Bowel Exhibit

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Russ Edwards, MS, CMI


Case Study: Cholecystectomy (Bile Duct Injury)

This case involved middle-aged male who presented with multiple gallstones in the gallbladder, one of which was lodged in the gallbladder neck. The defendant performed a laparoscopic cholecystectomy on 10/23/06. Upon visualization of the surgical field, the defendant encountered multiple adhesions, which required tedious dissection. After decompression of the tense gallbladder, the defendant dissected the cystic duct and artery out of the surrounding tissue. An intraoperative cholangiogram revealed a dilated common bile duct and short cystic duct. The defendant then transected what he believed to be the cystic duct but during dissection of the gallbladder from the hepatic bed, he discovered a structure leaking bile into the surgical field. A cholangiogram at that point revealed that the cystic duct had been divided at its junction with the common hepatic duct, resulting in an approximately 3 cm defect in the common hepatic duct.

After multiple consults, the defendant elected to discontinue the procedure and prepare the patient for transfer to another area hospital for repair. A cholangiocatheter was left within the common hepatic duct and a drain was placed in the area of the injury. The trocar sites were closed and the patient was prepared for transfer.

The plaintiff alleged that the procedure was performed negligently, resulting in an injured bile duct. The defense contends that while unfortunate, bile duct injury is a known complication of this procedure, especially in the presence of adhesions. The injury was recognized immediately and plans for repair were made promptly.

The first step in the visual defense strategy was to educate the jury on the normal biliary anatomy. A simple graphic showing the ‘textbook appearance’ allowed the jury to see and easily understand the anatomy to be discussed during the trial. An overlay image enabled them to better appreciate what the surgeon actually saw upon entering the abdomen, showing that the anatomy is obscured by a sheet of connective tissue and fat – the lesser omentum.


Biliary Anatomy 2

The next exhibit drew the jury into the surgical field in question, showing the normal anatomy in order to compare it to the plaintiff’s anatomy. This clearly outlined the plaintiff’s abnormal anatomy – a short cystic duct that was tethered to the common hepatic duct. A similar image allowed the defense to present the defendant’s surgical view of the plaintiff’s anatomy intraoperatively. This was crucial to the defense by allowing the jury to understand how – although the defendant performed the procedure within the standard of care by dissecting the hepatoduodenal ligament in order to expose the cystic duct and artery – he was unable to appreciate the variation in the plaintiff’s anatomy and subsequently injured the hepatic duct.


Gallbladder 2

A full-color artist’s interpretation of the anatomy seen on plaintiff’s intraoperative cholangiogram allowed the jury to understand what was seen on this film.


Cholangiogram 2

Lastly, a surgical series enabled the jury to see what the defendant did during the plaintiff’s procedure, showing that it was done within the standard of care, and unfortunately, the plaintiff’s anatomical variation resulted in the injury.


Cholecystectomy 2

The visual exhibits used in this case enabled the defense to present the defendant’s story from his point of view and in a very realistic manner. The client felt that they definitely contributed to a defense win in this case!

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Jennifer C. Webb, MS


Case Study: Porcelain v. PFM Crowns

This case involved a female patient who presented for evaluation of a chipped tooth. The defendant recommended veneers on teeth #8 and #9. She prepared the patient’s teeth by grinding down and performing root canals on #8 and #9, but after completion of the root canals, the defendant opted to crown the teeth rather than place veneers.The patient returned to the defendant practice about five years later because tooth #9 had broken off. She was evaluated by another defendant doctor who referred the patient to an oral surgeon for extraction of tooth #9. The oral surgeon extracted tooth #9 shortly after. The patient subsequently underwent a series of bone grafts for dental implants.

The plaintiff alleged that the first defendant doctor was negligent in her preparation of the patient’s teeth for veneers and/or crowns and over-ground teeth #8 and #9. They further allege that the defendant was negligent in placing full porcelain crowns. The defense contended that the dental procedures were done within the standard of care and that the defendant placed porcelain-fused-to-metal (PFM) crowns, not full porcelain ones.

First, the defense sought to educate the jury on the anatomy of normal dentition. By showing the normal number and type of teeth, where they are located in the mouth, and the anatomy of an actual tooth, the defense set the stage for the jury to understand the plaintiff’s problems and the issues of this case.


Normal Dentition

The next exhibit was designed to help the jury understand what is done during a root canal. A base image showed a normal tooth, with overlays showing the removal of the center pulp of the tooth, as well as the final root canal filling it in.


Root Canal

Root Canal overlay

Root Canal overlay 2

The next part of the visual defense strategy utilized illustrations designed to match the first exhibit, explaining normal dentition, in order to explain the patient’s dentition when she first presented with a chipped tooth. Overlays showed the defendant’s root canal and filling preparation, as well as the crowns that the defendant placed.



Dentition overlay

Dentition overlay 2

In order to help the jury understand a key issue of the case, porcelain-fused-to-metal (PFM) crowns, the next exhibit sought to educate the jury on what makes up a PFM crown, what preparation they require, and how they look in the mouth.


PFM Crowns

PFM Crowns overlay

Similarly, the next part of the visual defense strategy involved an exhibit explaining the same concepts with full porcelain crowns. This allowed the jury to see that the preparation for a PFM and a full porcelain crown is the same, with the same amount of tooth removed for PFM crowns and full porcelain ones.


Full Porcelain Crowns

Full Porcelain Crowns overlay

Lastly, the defense sought to show the jury how a porcelain crown with a line of margin can appear to look like a fracture in an xray.


Fracture vs. Line of Margin

This case utilized visual exhibits to walk the jury through complex and confusing dental anatomy in order to help them understand the subtle nuances of the case.


Case Study: Gastric Bypass

This case involved a morbidly obese woman who underwent a vertical banded gastroplasty with Roux-en-Y.  The procedure was performed through an open incision because the patient was undergoing a cholecystectomy and a ventral hernia repair during the same surgery.  The bypass was uneventful, a gastrostomy tube was placed, and there were no apparent complications to any of the procedures.

Postoperatively the patient experienced abdominal pain, and although a Gastrografin study three days after the procedure showed no clear indication of extravasation, a CT the following day showed a large fluid collection surrounding the spleen, which was felt to be blood.  She was returned to the ER on post-op day 9 for repair of wound dehiscence and evacuation of an infected hematoma.

Intraoperatively, after the hematoma was evacuated, and bleeding was noted from the gastric pouch as well as the spleen.  The bleeding was controlled and there was otherwise no evidence of abscesses or foul-smelling fluid.  Further dissection did reveal a relatively fresh enterotomy on the end of the Roux limb, and this was easily repaired with suture.  Unfortunately, the spleen continued to bleed from the hilum area so a splenectomy had to be performed due to the patient’s developing coagulopathy.  At the conclusion of the procedure when the retractors were removed, a liver laceration became apparent.  It was packed, drains were placed, and the patient was closed.

The plaintiff alleged that the defendant injured the bowel during the initial gastric bypass procedure, resulting in peritonitis and the complications that ensued.  The defense contended that the gastric bypass was performed within the standard of care and without incident.  The defense opined that the patient’s bowel perforation and bleeding were delayed complications, which are relatively common.  Further, while the patient did have an infected hematoma, there was no sign of true peritonitis from bowel contents spillage.

The first goal of the defense visual strategy was to explain the principle behind performing a vertical banded gastroplasty with Roux-en-Y bypass, showing how it aids the patient in losing weight and to show the anatomy involved in this surgery.


Roux-En-Y Gastric Bypass


With the next exhibit, the defense explained the mechanics of this surgery, in order to show how the anastomoses were oversewn during this procedure making it very unlikely that there was a leak after the initial procedure.




Then next step of the visual defense strategy was to show the jury the relative locations of the roux-en-Y surgery compared to the intra-abdominal hematoma by showing them a postoperative view as well as interpreting the postoperative films.




The defense then chose to visually explain wound dehiscence in order to show how this tissue breakdown can, and often is, caused by infection in the skin and/or subcutaneous tissue.


Lastly, the defense sought to visually explain how a splenic hematoma, like the one that this patient developed, would break down and dissipate over time.

Hematoma Dissipation

The visual exhibits used in this case helped the defense to simplify some very complex anatomy and surgical technique in order to clearly explain how these complications occurred in the absence of negligence.

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI


Case Study: Retained Foreign Body

The female plaintiff presented to the defendant with abdominal pain and after a sonogram indicated a pelvic mass, the defendant performed an exploratory laparotomy. Intraoperatively, as the defendant entered the abdominal cavity, he used moistened lap pads to position the small bowel up and away from the operative site. The incision was held open with an adjustable retractor in order to expose the pelvic organs. The defendant found a large complex left ovarian mass totally replacing the ovarian tissue, which necessitated a left salping- oophorectomy. He irrigated and checked the pelvis, removed the self-retaining retractor and lap pads, and closed the wound. The procedure took only half an hour and just before closure, the nursing staff performed the surgical count for all instruments, sponges, and needles. Both the circulating and scrub nurse indicated that the surgical count was correct twice and the defendant was notified of this.

Postoperatively the patient did well, although she did experience an elevated temperature and some left sided pain. Tests revealed no abnormalities, but she was started on antibiotic therapy before she was discharged home on post-op day 7. She did well initially, but a little over a month after the surgery, the patient developed an infection in her incision. The wound was cleaned and she was treated with oral antibiotics and she improved.

Two months later however, she returned with purulence and foul smelling drainage from her wound. An exploratory laparotomy revealed a subcutaneous abscess that extended into the peritoneal cavity. The abscess contained two retained lap pads. Unfortunately the patient had a stormy postoperative course with a perforation, fistula, and another abscess.

The plaintiff alleged that the defendant was negligent in leaving two lap pads inside of her during the initial surgery. The defendant contends that he performed a reasonable inspection prior to the closure of the peritoneum. The nurses reported a ‘good count’ to him and recorded correct count in the chart.

The first step in the visual defense strategy was to help the jury to understand the surgical field and the anatomy that the defendant encountered in this patient in order to explain how this mistake could have happened in the absence of negligence. These images allowed the defense to explain why lap pads were used during this surgery as well as how those pads changed in appearance during the course of the surgery. An overlay showed the jury how, as the pads soaked up body fluid and became matted to the intestines during the course of the surgery, they became indistinguishable from the surrounding tissue.


Lap Pad


Lap Pad overlay


Similarly, the next series of images designed for this case sought to explain to the jury how these lap pads migrated into the intestines during the course of the surgery and were not immediately apparent to the surgeon when he inspected the field before closure.


Foreign Body Migration


Foreign Body Migration 2


Foreign Body Migration overlay


Another area of liability in this case was the fact that the retained lab pads were later found in the right lower quadrant, which was not the area in which the defense contended that they disappeared. The last part of the visual defense strategy for this case was to explain to the jury the concept of foreign body migration and to show how gravity and patient movement caused the pads to move downward in the body.


Foreign Body Migration 3


—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI


Case Study: Lumbar Nerve Root Compression

This case involved a 19-year-old male patient who had a history of low back pain for about a year and was reporting severe, constant, and aching lower back pain of 8-9 on a scale of 10, as well as radicular right leg pain, decreased sensation on the right, difficulty straightening his right leg making it difficult to walk. An MRI showed a rather large L5-S1 herniated disc on the right side with severe degenerative disc disease.

The defendant performed an L5-S1 decompression with posterior lumbar interbody fusion and placement of a TraXis cage. Infuse and autograft were used to complete the interbody fusion. Intraoperatively, the defendant found that the patient had severe degenerative disc disease with a large right paracentral disc herniation, with the disc acting like a broad-based disc bulge with some components of hard and soft disc. There were no significant sequestered or extruded fragments, however.

Postoperatively, the patient initially reported an improvement in his leg pain and less discomfort in his lower back. Within a month, however, he was complaining of significant ongoing pain and was also displaying significant narcotic seeking behavior. The defendant began tapering the patient’s narcotics and prescribed him physical therapy. The patient continued to complain of rather significant lower back pain, however. A diagnostic x-ray showed that the grafts and hardware were in good position, although a CT myelogram done three months later did show some ectopic bone formation in the spinal canal in the area of the diskectomy, but the nerve root appeared to be above the level of the bony spur. The patient continued to complain of back pain and diagnostic studies continued to show no evidence of disc herniation or nerve root impingement and an EMG showed normal sensory nerve conduction.

The plaintiff alleged that the BMP that the defendant used during surgery caused ectopic bone growth and that this bone growth pushed on the nerve roots, causing the plaintiff’s continued lower back and leg pain. The defense contended that the ectopic bone growth was not pushing on the nerve and that the pain the plaintiff was experiencing was from his previous pathology.

The first goal of the defense visual strategy was to allow the jury to see the normal anatomy of the lumbosacral nerve roots and to show how they exit the foramen at L5-S1. This could then be used in conjunction with a second board for comparison against the plaintiff’s preoperative and postoperative anatomy, in order to show how his nerve roots exited at that level before and after the defendant’s procedure. These exhibits were designed for side-by-side use in order to clearly show that preoperatively the plaintiff’s S1 nerve root was compressed by his bulging L5-S1 disc; the L5 nerve root was not directly compressed. Postoperatively, however, both the S1 and L5 nerve roots were decompressed and remained so, unaffected by the ectopic bone growth in the spinal canal, with the L5 nerve root exiting above the growth and the S1 nerve root exiting below the growth. Color-coding of the L4 and L5 nerve roots helped to focus the jury’s attention on the path of these 2 pairs of nerves.


Lumbosacral Nerve Roots


Lumbosacral Nerve Roots 2


The next exhibit went in to further detail to show the preoperative condition of the plaintiff’s lumbosacral spine, showing his large disc herniation and severe degenerative disc disease, as well as the postoperative condition of the plaintiff’s lumbosacral spine, showing the decompression and benign ectopic bone growth.


Preoperative Lumbosacral


Post-operative Lumbosacral


Next, the defense visual strategy tackled the development of the ectopic bone growth in the plaintiff’s spinal canal. This exhibit first showed the plaintiff’s initial post-operative condition, showing the placement of Pro Osteon, BMP sponge, Bone autograft, and the TraXis cage with BMP sponge in order to show that at the conclusion of the procedure, there was no graft material in the spinal canal and neither the L5 nor the S1 nerve roots were compressed. An overlay showed that by several months after the procedure, the ectopic bone growth was extruding into the spinal canal, but it was below and above the L5 and S1 nerve roots, respectively, and not compressing either root.


Preoperative condition


Preoperative condition overlay


Lastly, in order to reinforce the defense contention that the post-operative condition showed no impingement on either the L5 or the S1 nerve roots on the right, the next exhibit showed the jury the pre-operative films compared to the post-operative films, using overlays to explain what is seen on these films.


Post-op Films


Post-op Films


The visual exhibits created for this case served to simplify and clearly outline the defense’s case in the setting of complex anatomy, pathology, and surgical technique and were instrumental in obtaining a defense verdict.

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI


Case Study: Total Hip Replacement

This case involved a 45-year-old woman who had undergone a transvaginal tape suspension (TVT) and rectocele repair in February 2004. Postoperatively she complained of left groin pain and tests revealed a small cortical cyst in the left femoral head so she was sent for an orthopedic evaluation. Her EMG was normal and physical therapy had good results. She returned three months later, however, with marked left groin tenderness and a palpable mass in the region. She underwent two left hip intra-articular blocks and reported relief of pain. A neurologist evaluated her and found no neurologic cause. Seven months after the original procedure, however, she was in severe pain again. She underwent hip arthroscopy in October, with steroid injection, and she reported that she was pain-free at the follow-up appointment.
She was complaining of left hip pain by December again, however, so a second arthroscopic procedure was performed in March. At that time, the plaintiff’s anterior labrum was found to be hyperplastic and edematous, so a cartilaginous flap on the femoral head, as well as the anterior labrum, were reduced. Although she reported no pain at her follow-up appointment, the plaintiff presented again in April complaining of groin pain and increased hip irritability on passive range of motion.

The plaintiff underwent a total hip replacement in July and had excellent response and elimination of hip pain. The groin pain, however, returned in early 2006. She described it as extending from the femoral pulse region to the knee and posterior. Half of her sling was removed in May and her pain was totally relieved until August, when it returned again. Further testing revealed degenerative disc disease, so the plaintiff underwent an L4 nerve block, which relieved her pain for about three days. In March 2007, her TVT was again revised and no undo inflammation or obtrusion was noted intraoperatively. A segment of mesh was resected in November, but her left groin pain continued and she received a series of pudendal nerve injections through September 2008. The plaintiff ultimately underwent a pudendal nerve entrapment release in September 2008. She continues to be treated for chronic regional pain syndrome.

The plaintiff alleged that the hip replacement was unnecessary since she had nerve injury following her TVT procedure. The defense contends that the plaintiff had a hip pathology and that the presentation and the resolution of her hip after replacement show that the surgery was necessary and effective. While groin symptoms are common in hip disease, in this case the pain was apparently related to something else, but still lead to surgical resolution of her hip symptoms.

The first visual exhibit in this case was designed to educate the jury on the anatomy of the hip in order to explain the anatomical relationships in that region and to show how pathology in one area could cause pain in another.


Nerves of the Left Hip


A key part of the visual defense strategy was to explain the plaintiff’s pre-operative hip pathology, and the next exhibit did this by comparing the plaintiff’s anatomy to normal.   An accompanying exhibit showed the anatomy that was encountered during her hip arthroscopy as well as what was done during that procedure.


Hip: Arthroscopy


Hip: Arthroscopy 2


The final set of exhibits used reconstructed film views from the plaintiff’s actual CT studies in order to give the jury a more clear view of her exact preoperative anatomy. This allowed the defense to show the extent of the pathologic condition of her hip at the time of the hip replacement and to explain to the jury why the hip replacement was in fact necessary.


Hip: Total Hip Replacement


Hip: Total Hip Replacement 2


Hip Scans


The visual defense strategy in this case was designed to give the jury a more clear understanding of the plaintiff’s hip pathology in order to explain that the damages alleged in this case—an unnecessary hip replacement—were not valid. By reconstructing the plaintiff’s films and using them in conjunction with artistic interpretations of the pathology that they showed, the defense was able to successfully explain that, not only did the plaintiff have a definite hip pathology, but also that the pathology necessitated surgical repair.

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI


Case Study: Carpal Tunnel Syndrome

This case involved a patient who underwent an endoscopic carpal tunnel surgery. During the procedure, the patient’s hand was dropped during transfer. Postoperatively he experienced transient neuropraxia.

The plaintiff alleged that the neuropraxia was caused by the hand being dropped during transfer.

The defense in this case hinged on the jury’s ability to understand the anatomy of the carpal tunnel so that they could also understand how the neuropraxia could have occurred independent of the hand drop. The first visual exhibit gave the jury a basic overview of the anatomy of the hand, specifically the nervous anatomy and the anatomy of carpal tunnel. 


Hand Anatomy


The defense’s next focus was to teach the jury about this endoscopic procedure. The first exhibit in this effort was aimed at walking the jury through the steps of the surgery anatomically, showing the placement of the instruments, how they are used to relieve the patient’s symptomatology, and also the relationships between the instruments and the relevant anatomy.


Surgery 1


Surgery 2


The next exhibit sought to give the jury a closer view of what this procedure looks like from an external perspective so that they could understand how the surgeon and assistant must manipulate the patient’s hand and wrist in order to perform this surgery.


Carpal Tunnel Procedure


Then an exhibit was used to explain the sequence of events and incident that occurred during this procedure, as well as what was done after the incident. This allowed the jury to see that the defendant had turned away from the patient to obtain the hand holder device when the patient’s hand slipped. The PA then held the patient’s fingertips and palm to elevate them after the incident.


Positioning of Arm


Sequence of Events 1


Sequence of Events 2


Sequence of Events 3


The defense used the next several visual exhibits to focus the jury’s attention on how the median nerve can become compressed within the carpal tunnel, showing that carpal tunnel syndrome itself causes nerve compression. These exhibits demonstrated how nerve compression can also occur with the insertion of the cannula, and ultimately how this nerve compression is relieved during surgery. Importantly, the last exhibit also simply demonstrated to the jury how pressure on the median nerve is increased with wrist extension alone.


Nerve Compression 1


Nerve Compression 2


Pressure Increase


Overall we designed the visual defense strategy in this case to fully educate the jury on the anatomy and steps involved in this procedure so that they could understand how this transient injury could have occurred in the absence of negligence on the defendant’s part. By introducing the jury to multiple views of the procedure as well as using simple diagrams to explain key points of the case, the defense was able to help the jury visually navigate the confusing anatomy and understand that although a mistake was made, it may not have been the cause of the negative outcome.

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI


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