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Failure to Document Surgery Correctly Results in Amputations

A female patient’s surgeon failed to disclose or record important details of gallbladder surgery with the result that as a result of his negligence, the patient required multiple amputations. A surgeon’s negligence in recording critical information about the outcome of a surgical procedure puts physicians asked to treat complications of the surgery in the dark and delays appropriate response to the symptoms.Failure to Document Surgery Correctly Results in Amputations - Altizer Law, PC

The Events

A general surgeon performed a laparoscopic procedure to remove the patient’s gallbladder. The surgeon did not reveal to the patient or her family that remnants of the gallbladder were left in the peritoneum and other surrounding tissues. The surgeon also neglected to include a note in the operative notes about the remnants. The surgeon’s failure to document the surgery correctly resulted in multiple amputations involving all of the plaintiff’s fingers and toes.

On the day after the surgery, the patient reported significant surgery-related symptoms. These included nausea, serious abdominal pain and general feelings of illness. These symptoms persisted throughout that day and the next day. On the second day after the surgery, after intensification of the symptoms, the patient (plaintiff) went to the hospital’s emergency room. The emergency room physician called the general surgeon to inquire about the surgery. The surgeon informed the emergency room physician that it had been a “normal procedure,” that it was “uneventful.” This corresponded to the documented report from the procedure. Simultaneously, the patient’s condition deteriorated seriously. As a result, she was airlifted to another facility.

On the following day, an open surgical procedure was performed. The surgical team reported the presence of approximately 3 liters of a bile-pus mixture. They also noted injury or damage to the bile duct and lacerations of the liver. They noted that the bile duct appeared to have “Endo-GIA staplers,” which were progressing into the liver ducts. They discovered that bile was streaming from the staple line. Due to a rapid drop in blood pressure during this procedure, the surgical team decided to terminate the surgery and resume at a later time.

Two days after the open exploratory procedure, another procedure was performed. At this point, the surgical team discovered a remaining piece of the gallbladder neck and part of the gallbladder that was left in its original place in the liver duct. During this procedure, the surgeons removed the remnants of the gallbladder that had been left in the first procedure. The amount of the gallbladder removed in the two surgeries was approximately the same (based on the pathology report for the first procedure).


The negligence of the general surgeon (first surgery) in failing to document or inform plaintiff of the remaining gallbladder segments were held to have directly caused the sepsis. The severely low blood pressure was held to be the cause of the reduced circulation, which was the cause of damage to the patient’s extremities. The final result of this outcome was partial amputation of all 10 of plaintiff’s fingers four months later and amputation of sections of all of the plaintiff’s toes two months after that.

One year after the first surgical procedure (gallbladder removal), a demand letter was sent to the general surgeon by the plaintiff and her legal team. Negotiations between the plaintiff’s legal team and the surgeon’s insurance company began. The matter was settled out of court 47 days after the demand letter was sent. This was prior to filing suit and before counsel was retained to defend the surgeon. The plaintiff received a financial settlement of $1,800,000.

In this case, the negligence of the general surgeon to follow standards of care and thoroughly document the details of the initial procedure, is medical malpractice that resulted in infection and loss of fingers and toes by the plaintiff.

Call Altizer Law, P.C.

If you or a loved one is injured or harmed due to the negligence or wrongdoing of a medical provider, you may be entitled to recover a financial award for your injuries and related costs. Call Altizer Law, P.C., to discuss the details of your matter and the merits of filing suit against the negligent medical provider. We will investigate the details of the injury and the events that caused the injury. If you retain us, we will carefully prepare a strong case and demand appropriate financial compensation for your hurts and harm. Bettina Altizer is a fierce and tenacious advocate for every client, to ensure that the largest possible settlement is obtained to help them move forward with their lives.