Case Study

Known Complications in Surgery

Sachhikant Tripathi  v. Dr. Vikash Singh, Revision Petition No. 1858 OF 2018 decided by the NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION  NEW DELHI on 11.11.2019

Facts: The complainant, Sachhikant Tripathi, alleged that he underwent operation for removal of gall bladder stone, it was performed by OP in his private clinic at Ara, the patient did not get sufficient relief and he was suffering continuous abdominal pain, hence, approached the OP-doctor. Few blood tests and ultrasonography (USG) of abdomen were performed. The investigations revealed jaundice to the patient  and a stone was still present in the abdomen. Therefore,  the OP- doctor without issuing any referral letter, advised the patient to consult Dr. Manoj Kumar at Patna, who performed second operation and thereafter the patient became normal, and that the OP-doctor failed to remove the gall stone during the first operation and it was  a clear case of deficiency in service and unethical practice on the part of the OP-doctor.

Defence: The patient came to OP with severe abdominal pain and after investigations, it was diagnosed as a case of gall bladder stone. The OP-doctor performed laparoscopic cholecystectomy i.e. removal of gall bladder. However, the stone in Common Bile Duct (CBD) was not evident during operation. After a week, the patient experienced pain in abdomen and the USG report revealed a stone in CBD. Therefore, for proper removal of CBD stone, OP- doctor advised endoscopic retrograde cholangiopancreatography (ERCP) and referred the patient to   Dr.Manoj Kumar at Patna. He removed CBD stone by ERCP.

Observations: Admittedly, there was no dispute that patient was diagnosed as a case of gall bladder stone. Therefore, the OP- doctor performed laparoscopic cholecystectomy, but subsequently after 10 days CBD stone was found by doing USG. Therefore,  OP referred the patient to Dr. Manoj Kumar at Patna who removed the CBD stone by ERCP procedure In our considered view,  ERCP was proper and accepted procedure for removal of CBD stone.   The gall stones are most commonly seen in the gall bladder and rarely found in the biliary ductal  system. (Bellay and Loves Surgery, the Surgical Pathology by Ackerman). As per the medical text  Stones in common bile duct is known as  Choledocholithiasis, is one of the complications of cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of cholelithiasis.  Common bile duct (CBD) stones are seen in approximately 7%-12% of patients who undergo cholecystectomy for symptomatic cholelithiasis and are a common indication for referral to a biliary endoscopist. They vary in size ranging from rather small (approximately 1-2 mm) to very large (> 3 cm). Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) and basket or balloon extraction are well established therapeutic procedures for the management of CBD stones. It is estimated that nearly 85%-95% of all CBD stones can be managed effectively by these conventional endoscopic methods.

Held: In the instant case, OP- doctor performed laparoscopic cholecystectomy i.e. gall bladder was removed with gall stone. In our view the District Forum wrongly came to  conclusion that “how within 10 days” another stone of 1.09 mm” was formed in the abdomen of the complainant.  The District Forum, on presumption held that while removing the stone possibly, Dr. Vikash Singh applied pressure on stone and it broke and it left into the abdomen of the Complainant. It should be borne in mind that the CBD stone means a stone in common bile duct. In the instant case the CBD stone (1.09 cm) was diagnosed week after the laparoscopic cholecystectomy, diagnosis was made  due to increased bilirubin level and USG study.

Complainant failed to establish  negligence against  OP- doctor. Complainant’s case is neither supported by any expert opinion nor by any medical literature. The OP-doctor followed the accepted line of treatment and we do not find any fault or imperfection in performing laparoscopic cholecystectomy. When the CBD stone was found after a week, which could be managed effectively by the conventional endoscopic method (ERCP).

Accordingly, the patient who referred to an expert at Patna, who recorded CBD stone by ERCP. Thus, referring the patient for ERCP was not a wrong decision of OP. The gall bladder and the common bile duct are distinctively different to each other. In the obtaining facts and the available evidence on record, it is not feasible to attribute negligence / deficiency (i) in diagnosing stones in the gall bladder or (ii) in performing the laparoscopic cholecystectomy for removal of the gall bladder or (iii) in thereafter diagnosing stone in the common bile duct on the basis of a subsequent ultrasonography or (iv) in advising the patient for endoscopic retrograde cholangiopancreatography by another doctor (who evidently had the wherewithal therefor, and who successfully undertook endoscopic retrograde cholangiopancreatography and removal of stone in the common bile duct), and it is difficult to conclusively establish medical negligence / deficiency in service on the respondent doctor. The revision petition fails.

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