If the physician who signed this expert witness opinion is an academic, it sets a poor example for residents and trainees. The opinion is so vague and lacking in substance that it should be reviewed by the AUA, which has established guidelines for expert witness testimony. While it is unfortunate that the events of the case led to the death of the patient, it is challenging to reach any meaningful conclusion without knowing the details of the patient’s general condition and postoperative course. Poor outcomes can occur in complex cases despite appropriate care, but a clear breach of the standard of care must be demonstrated for a malpractice claim to be valid. This opinion fails to do so and instead appears to be more of a legal maneuver than a genuine medical evaluation.
Bear in mind that to get training to use the robot, you have to already be competent in that particular procedure laparoscopically. If you don't know how to do the procedure, you wouldn't get those privileges. The training for the robot is to learn how to do the procedure you already know how to do with a different instrument, the robot. Robotic training does not teach you how to do surgery, only how to use the robot to do the surgery. The length of training should not have a bearing in the case unless the injury was somehow caused by some malfunction or misuse of the robot or robotic instruments. I agree that they are trying to manufacture a case of negligence based on a bad outcome.
Thanks for the insights! Makes sense that learners aren't starting from scratch on the robot, just learning a new instrument for the surgery they already know how to do.
Whether done open, laparoscopically, or by robot, the fault in this case was a failure to rescue the patient from a complication (small bowel perforation) in time to avoid successive other complications...
As a Cardiac Anesthesiologist (30 years) and Chair/Medical Director of an Anesthesia group (5 years), I am of sound understanding of perioperative issues. To state the patient aspirated gastric contents during intubation lacks merit from the information given. It's very likely that the patient became progressively septic with progressive respiratory acidosis and ultimate respiratory failure (he had rapid response team/RRT attend to him). Accordingly, he likely was becoming more obtunded and unable to protect his airway as well. Due to the small bowel injury, an ileus with a small bowel obstruction likely developed, setting up the circumstances of gastro-duodenal contents to be retained/not drained (not sure an NG was in place). As such, the aspiration likely happened before/during/after the RRT further compromising his respiration. Further attendance respiratory acidosis likely occurred culminating in respiratory fatigue/failure and arrest. Further, his elder status likely contributed to a lack of respiratory reserve. The progressively worsening respiratory acidosis lead to a profound increase in the WOB (Work of Breathing) and attendant progressive increase in VO2 (Oxygen Consumption).
This is an unfortunate sequence of events because his deterioration could have been caught early post-op leading to prompt management and could have halted his deterioration.
Wise assessment, plaintiffs attorneys often try to make cases look like they stem from one egregious issue rather than the truth that there are usually multiple contributing factors (some modifiable and some not).
It seems there may be some documentation missing regarding the credentialing process. What's included shows "Step I" which concludes with stating the surgeon must operate under continuous proctoring. It then skips to a description of the requirements for proctors. What appears to be omitted are the steps that would lead to a surgeon operating independently (without which no surgeon would ever qualify as a proctor). Presumably there is a missing Step II or even more.
Good eye! The second page that included Step II got lost in the shuffle when I was uploading the documents. I edited the post and it is available above. Basically adds that once the surgeon has had 4 cases proctored, they can get independent privileges. Still seems a pretty low bar.
Credentialing for robotic surgery is extremely lax and really just a formality. It is treated as a tool that the surgeon ultimately takes responsibility for. The "8 hours" are typically an online certification course with the robot manufacturer. It is assumed however that you are not using a tool unless you are trained in it, which almost all urologists heavily use the robot in training now. My current hospital credentialing requested prior robotic case numbers in addition to the 8 hour course certificate, but I don't know that they had a minimum case load.
Unclear what this urologist's robotic surgery training was back in 2016. I agree with your review about the generic statement from the expert witness saying this was a bad outcome. I have seen very talented urologists perform successful robotic surgeries on patients who have complex abdominal surgical histories, so that is not a contraindication alone.
Thanks for the comment! Interesting that most hospitals seem relatively lax on credentialing for these cases. I think the plaintiff was trying to argue that the hospital was negligent because they didn't require more. I wonder if we will slowly see the bar raised for proving competence with robotic cases.
We’ll see! Logically it wouldn’t make much sense but you never know how rules change due to legal issues. The risks to the robot are very similar to laparoscopic surgery (port placement being one of the biggest risk factors and then adhesion takedown like in this case) in general and I would argue the robot is much safer than pure laparoscopic surgery for the rest of the procedure due to the better visibility and controlled movements it provides. This case could very well have been worse with a pure lap approach (though not done anymore for prostatectomy bc this approach sucks so much). It wouldn’t make sense to me to have a more rigorous standard for robotics vs general laparoscopic surgery but lawyers may have their own reasons.
I can think of a highly respected urologist who would say this case should be done open if a patient has a complex surgical history. I can also think of several highly respected urologists that would do this robotic and have it go great. Interesting view into the tribulations with “expert witnesses”. Was the defense not able to call their own expert?
The other interesting thing is that open prostatectomies are no longer considered the standard of care and haven’t been for a while. It’s difficult to even find urologists confident in performing them nowadays because it’s so uncommon. I personally don’t do them and only assisted in 2 open prostates in training.
Hard to know without being there but adhesion takedown with small bowel injury is a fairly commonly discussed risk in abdominal surgery. Tough situation for everyone involved compounded by the fact that you need to operate on anywhere from 6-15 patients with prostate cancer to save one life…so this patient likely would not have benefitted from the surgery to begin with. Another reason why stakes are so high on prostate cancer surgery, most patients get the operation because they are healthy with lots of life left to protect and many of these patients won’t benefit from the surgery according to the data. So any complication like this is devastating. Tough all around.
Tough case especially in light of the NNT to save a life. The defense has not disclosed an expert yet. They usually consult an expert privately but don't bother to disclose their opinion unless they're going to trial. If they're working on a settlement it usually stays confidential. I'll update if they disclose one!
If the physician who signed this expert witness opinion is an academic, it sets a poor example for residents and trainees. The opinion is so vague and lacking in substance that it should be reviewed by the AUA, which has established guidelines for expert witness testimony. While it is unfortunate that the events of the case led to the death of the patient, it is challenging to reach any meaningful conclusion without knowing the details of the patient’s general condition and postoperative course. Poor outcomes can occur in complex cases despite appropriate care, but a clear breach of the standard of care must be demonstrated for a malpractice claim to be valid. This opinion fails to do so and instead appears to be more of a legal maneuver than a genuine medical evaluation.
Bear in mind that to get training to use the robot, you have to already be competent in that particular procedure laparoscopically. If you don't know how to do the procedure, you wouldn't get those privileges. The training for the robot is to learn how to do the procedure you already know how to do with a different instrument, the robot. Robotic training does not teach you how to do surgery, only how to use the robot to do the surgery. The length of training should not have a bearing in the case unless the injury was somehow caused by some malfunction or misuse of the robot or robotic instruments. I agree that they are trying to manufacture a case of negligence based on a bad outcome.
Thanks for the insights! Makes sense that learners aren't starting from scratch on the robot, just learning a new instrument for the surgery they already know how to do.
Whether done open, laparoscopically, or by robot, the fault in this case was a failure to rescue the patient from a complication (small bowel perforation) in time to avoid successive other complications...
Totally agree... a lot of the surgical lawsuits I see aren't so much centered around the complication, its how fast its identified and addressed.
As a Cardiac Anesthesiologist (30 years) and Chair/Medical Director of an Anesthesia group (5 years), I am of sound understanding of perioperative issues. To state the patient aspirated gastric contents during intubation lacks merit from the information given. It's very likely that the patient became progressively septic with progressive respiratory acidosis and ultimate respiratory failure (he had rapid response team/RRT attend to him). Accordingly, he likely was becoming more obtunded and unable to protect his airway as well. Due to the small bowel injury, an ileus with a small bowel obstruction likely developed, setting up the circumstances of gastro-duodenal contents to be retained/not drained (not sure an NG was in place). As such, the aspiration likely happened before/during/after the RRT further compromising his respiration. Further attendance respiratory acidosis likely occurred culminating in respiratory fatigue/failure and arrest. Further, his elder status likely contributed to a lack of respiratory reserve. The progressively worsening respiratory acidosis lead to a profound increase in the WOB (Work of Breathing) and attendant progressive increase in VO2 (Oxygen Consumption).
This is an unfortunate sequence of events because his deterioration could have been caught early post-op leading to prompt management and could have halted his deterioration.
Wise assessment, plaintiffs attorneys often try to make cases look like they stem from one egregious issue rather than the truth that there are usually multiple contributing factors (some modifiable and some not).
It seems there may be some documentation missing regarding the credentialing process. What's included shows "Step I" which concludes with stating the surgeon must operate under continuous proctoring. It then skips to a description of the requirements for proctors. What appears to be omitted are the steps that would lead to a surgeon operating independently (without which no surgeon would ever qualify as a proctor). Presumably there is a missing Step II or even more.
Good eye! The second page that included Step II got lost in the shuffle when I was uploading the documents. I edited the post and it is available above. Basically adds that once the surgeon has had 4 cases proctored, they can get independent privileges. Still seems a pretty low bar.
Credentialing for robotic surgery is extremely lax and really just a formality. It is treated as a tool that the surgeon ultimately takes responsibility for. The "8 hours" are typically an online certification course with the robot manufacturer. It is assumed however that you are not using a tool unless you are trained in it, which almost all urologists heavily use the robot in training now. My current hospital credentialing requested prior robotic case numbers in addition to the 8 hour course certificate, but I don't know that they had a minimum case load.
Unclear what this urologist's robotic surgery training was back in 2016. I agree with your review about the generic statement from the expert witness saying this was a bad outcome. I have seen very talented urologists perform successful robotic surgeries on patients who have complex abdominal surgical histories, so that is not a contraindication alone.
Thanks for the comment! Interesting that most hospitals seem relatively lax on credentialing for these cases. I think the plaintiff was trying to argue that the hospital was negligent because they didn't require more. I wonder if we will slowly see the bar raised for proving competence with robotic cases.
We’ll see! Logically it wouldn’t make much sense but you never know how rules change due to legal issues. The risks to the robot are very similar to laparoscopic surgery (port placement being one of the biggest risk factors and then adhesion takedown like in this case) in general and I would argue the robot is much safer than pure laparoscopic surgery for the rest of the procedure due to the better visibility and controlled movements it provides. This case could very well have been worse with a pure lap approach (though not done anymore for prostatectomy bc this approach sucks so much). It wouldn’t make sense to me to have a more rigorous standard for robotics vs general laparoscopic surgery but lawyers may have their own reasons.
I can think of a highly respected urologist who would say this case should be done open if a patient has a complex surgical history. I can also think of several highly respected urologists that would do this robotic and have it go great. Interesting view into the tribulations with “expert witnesses”. Was the defense not able to call their own expert?
The other interesting thing is that open prostatectomies are no longer considered the standard of care and haven’t been for a while. It’s difficult to even find urologists confident in performing them nowadays because it’s so uncommon. I personally don’t do them and only assisted in 2 open prostates in training.
Hard to know without being there but adhesion takedown with small bowel injury is a fairly commonly discussed risk in abdominal surgery. Tough situation for everyone involved compounded by the fact that you need to operate on anywhere from 6-15 patients with prostate cancer to save one life…so this patient likely would not have benefitted from the surgery to begin with. Another reason why stakes are so high on prostate cancer surgery, most patients get the operation because they are healthy with lots of life left to protect and many of these patients won’t benefit from the surgery according to the data. So any complication like this is devastating. Tough all around.
Tough case especially in light of the NNT to save a life. The defense has not disclosed an expert yet. They usually consult an expert privately but don't bother to disclose their opinion unless they're going to trial. If they're working on a settlement it usually stays confidential. I'll update if they disclose one!