General surgery expert witness opines on injury during hiatal hernia repair surgery

A general surgery expert witness opines on vagus nerve injury during a hiatal hernia repair surgery. This case takes place in Maine and involves a male patient who underwent laparoscopic hiatal hernia repair with fundoplication. She had previously been diagnosed with Barrett’s disease (Barrett’s Mucosa). Within a few days following the surgery, he was experiencing severe pain. His surgeon told him that there was nothing wrong with him. However, the patient’s symptoms persisted. His primary care physician wrote notes to the surgeon suggesting something was wrong but the surgeon responded that it was just stress or that he was not eating properly. A year later, and after living in severe pain and unable to eat, the patient was diagnosed with vagus nerve injury from the surgery. In fact, the surgeon wrote about severing the right vagus nerve in his operative report: “I entered the transparent pars flaccid on each side of the hepatic branch of the vagus nerve and divided the peritoneum along the anterior dilated hiatus. I got into an easy blunt dissection plane between the hernia sac and the mediastinal structures. I carried the dissection posteriorly along the left and right crura, exposing the union of the two posteriorly. I freed the fundus from the left crural attachments using the Harmonic scalpel ended up sacrificing at least 2-3 superior short gastric vessels. The hernia sac stripped from the mediastinal easily with side open exposure of the esophagus and a prominent left vagus nerve trunk anteriorly. I circumferentially mobilized well up the mediastinum. I then excised and discarded the transparent hernia sac; initially I thought it was associated with the angle of his fat pad that was generous. I began dissecting through that and then realized that the mobile stomach was rotating from the lesser curve over to the angle of his side and I stopped dissection; I stopped this just before taking the prominent left gastric vessels but realized that I had taken the right vagus nerve.” The surgeon never told the patient that he severed the right vagus nerve nor did he inform his primary care physician. The patient ultimately required a gastrectomy.

Question(s) For Expert Witness

1. How often do you perform this type of procedure?

2. What measures should be taken to prevent damage to vagus nerve during this surgery?

3. Given the patient's symptoms and the intraoperative complications, should the surgeon has dismissed the patient's complaints?

Expert Witness Response

I repair hiatal and paraesophageal hernias commonly in my practice - on average, 3-4 per month. Vagal nerve injury is a serious complication of the examination, and meticulous surgical technique involving mobilization of the appropriate structures and proper identification of critical anatomy is important. The nerve should have been identified intraoperatively. It is never appropriate to dismiss a patient's complaint of severe discomfort, especially when the PCP is also concerned.

This expert is a board certified general surgeon with additional fellowship training in minimally invasive surgical techniques. He trained at the University of California Davis School of Medicine for residency and at Johns Hopkins for fellowship. He is the Director of a surgical hernia center at one of the nations most prestigious university medical centers in Maryland.