Inadvertent liver resection

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toddlasher said:
www.pnj.com

Man dies after liver removed instead of spleen. It happens more often than you think. What to know

A Johns Hopkins study found a surgeon performs the wrong procedure on a patient 20 times a week and operates on the wrong body site 20 times a week.
www.pnj.com
Click to expand...

"According to medical records, the surgeon apparently did not realize his mistake at the time of the surgery and proceeded with labeling the removed liver specimen as a “spleen.”

After the procedure, Shaknovsky told Beverly Bryan, a nurse, the “spleen” was so diseased that it was four times bigger than usual and had “migrated” to the other side of Bill Bryan’s body.

The medical examiner determined Bill Bryan's liver was gone and his spleen was still in his body with a cyst attached to it, the attorney said."

This is insane.
 
I saw this last night. This part is ridiculous, but that's not even the right word (spleens don't migrate, not even in hysteria). I basically have no words for this. I mean, seriously. And his spleen only had a small cyst on autopsy. 😵‍💫

After the procedure, Shaknovsky told Beverly Bryan, a nurse, the “spleen” was so diseased that it was four times bigger than usual and had “migrated” to the other side of Bill Bryan’s body.
Click to expand...
 
At least hospital administration says they take patient safety seriously and offered up thoughts and prayers to the family. That’s nice of them, don’t you think? Are we sure this isn’t from The Onion?
 
Not sure if this is even believable. Journalists can write some wacky sensational things, particularly when their info comes from the family and the hospital can't comment because of HIPPA
 
Ashers said:
I saw this last night. This part is ridiculous, but that's not even the right word (spleens don't migrate, not even in hysteria). I basically have no words for this. I mean, seriously. And his spleen only had a small cyst on autopsy. 😵‍💫
Click to expand...
Maybe the spleen migrated illegally? Should have built an abdominal wall and made the stomach pay for it 😉
 
TheLoneWolf said:
Not sure if this is even believable. Journalists can write some wacky sensational things, particularly when their info comes from the family and the hospital can't comment because of HIPPA
Click to expand...
Probably surgeon injured or resected part of the liver and didn't realize it.

Hard to remove the whole thing
 
T-burglar said:
Imagine being the anesthesiologist and not giving that surgeon one warning that he’s operating on the wrong organ before tackling him.

Maybe there was no physician at the head of the bed.
Click to expand...
This was my thought.

The anatomy isn't even close to the same. Totally insane. How can a board certified surgeon do this by accident?
 
Last edited:
T-burglar said:
Imagine being the anesthesiologist and not giving that surgeon one warning that he’s operating on the wrong organ before tackling him.

Maybe there was no physician at the head of the bed.
Click to expand...

Why would it be the anesthesiologist's responsibility to make sure that the surgeon is taking out the correct organ?
 
GassYous said:
Why would it be the anesthesiologist's responsibility to make sure that the surgeon is taking out the correct organ?
Click to expand...


While I’m not a board certified surgeon I have spoken up in the past when I have noticed something was off. Like “hey just curious but I noticed my BP up here went from a MAP of 70 to 40, any reason for that?” Some surgeons aren’t the best at communication (let alone operating) and it’s my @$$ on the line also.
 
GassYous said:
Why would it be the anesthesiologist's responsibility to make sure that the surgeon is taking out the correct organ?
Click to expand...
It's not, but I would be saying something if I noticed the surgeon was working on the wrong organ. I typically watch substantial portions of an operation to see how it's going and anticipate problems.
 
www.pnj.com

Man dies after liver removed instead of spleen. It happens more often than you think. What to know

A Johns Hopkins study found a surgeon performs the wrong procedure on a patient 20 times a week and operates on the wrong body site 20 times a week.
www.pnj.com

Family discovers Dr. Shaknovsky operated on wrong part of another person's body​

As Zarzaur’s legal team began looking into Bill Bryan’s death, they discovered this was not the first time Shaknovsky had mistakenly operated on the wrong part of a person’s body.

In a previous wrong-site surgery in 2023, Zarzaur said Shaknovsky mistakenly removed a portion of a patient’s pancreas instead of performing the intended adrenal gland resection (cutting out tissue or part of an organ) at the same hospital.




This guy is fairly young, he graduated with his DO in 2009. It sounds like another Dr Death. Wouldn’t be surprised if drugs are involved.
 
GassYous said:
Why would it be the anesthesiologist's responsibility to make sure that the surgeon is taking out the correct organ?
Click to expand...

Probably by the time it happened things were already crashing and burning. Thjs isn't going to be a slow ooze. They said that much in thr article: that it turned into a blood bath. And particularly in a hand assisted laparoscopic case you don't always get the best view of what the surgeon is doing on the screens.
 
Sounds like a mixture of plaintiff attorney press release nonsense, and actual malpractice.

Maybe a lobe of a giant liver was peeking over by the spleen and the surgeon injured it. No way the liver was removed. It's a ridiculous story.
 
T-burglar said:
Imagine being the anesthesiologist and not giving that surgeon one warning that he’s operating on the wrong organ before tackling him.

Maybe there was no physician at the head of the bed.
Click to expand...

The anesthesiologist correcting the surgeons anatomical knowledge should never be the last step before disaster.
 
pgg said:
Sounds like a mixture of plaintiff attorney press release nonsense, and actual malpractice.

Maybe a lobe of a giant liver was peeking over by the spleen and the surgeon injured it. No way the liver was removed. It's a ridiculous story.
Click to expand...
Agree it seems impossible.

There is this quote but it’s info from the plaintiffs attorney.

“The medical examiner determined Bill Bryan's liver was gone and his spleen was still in his body with a cyst attached to it, the attorney said”
 
toddlasher said:
Agree it seems impossible.

There is this quote but it’s info from the plaintiffs attorney.

“The medical examiner determined Bill Bryan's liver was gone and his spleen was still in his body with a cyst attached to it, the attorney said”
Click to expand...

It's amazing how malpractice attorneys can know so little about basic medicine. So who knows what amount of this is factual.

Need to see the actual autopsy report.
 
T-burglar said:
Imagine being the anesthesiologist and not giving that surgeon one warning that he’s operating on the wrong organ before tackling him.

Maybe there was no physician at the head of the bed.
Click to expand...

That’s why you don’t see any anesthesiologist names in the suit… was prob an “independent” crNa… somehow the nurses always get out of it.
 
coffeebythelake said:
It's amazing how malpractice attorneys can know so little about basic medicine. So who knows what amount of this is factual.

Need to see the actual autopsy report.
Click to expand...
It seems like this actually did happen - but the fact that most of the info so far is coming from a plaintiff's attorney makes it at least questionable. He went as far as to release a video "PSA" to warn the public about the surgeon.
 
Agast said:
www.pnj.com

Man dies after liver removed instead of spleen. It happens more often than you think. What to know

A Johns Hopkins study found a surgeon performs the wrong procedure on a patient 20 times a week and operates on the wrong body site 20 times a week.
www.pnj.com

Family discovers Dr. Shaknovsky operated on wrong part of another person's body​

As Zarzaur’s legal team began looking into Bill Bryan’s death, they discovered this was not the first time Shaknovsky had mistakenly operated on the wrong part of a person’s body.

In a previous wrong-site surgery in 2023, Zarzaur said Shaknovsky mistakenly removed a portion of a patient’s pancreas instead of performing the intended adrenal gland resection (cutting out tissue or part of an organ) at the same hospital.




This guy is fairly young, he graduated with his DO in 2009. It sounds like another Dr Death. Wouldn’t be surprised if drugs are involved.
Click to expand...
www.dallasobserver.com

Dr. Death is One of the Biggest Podcasts to Come Out of Dallas. It's Also Terrifying.

The final episode of what is perhaps the biggest podcast to have ever come out of Dallas is now out. Since dropping its first episode Sept. 4, Dr. Death has had more than four million listeners and racked up more than 21,000 five-star ratings on iTunes. But despite the rave...
www.dallasobserver.com www.dallasobserver.com

I don’t put anything past any doctor any more

There was another batch of crazy botched surgeries, I think some were a Us surgeon who also worked abroad
 
My friend once watched 2 VA doctors doing a colon resection for cancer, when they were feeling around the abdomen for spread, came across a “mystery” lump in the pelvis - it was the uterus. It took them a while to figure it out. You don’t come across those as often at the VA to be fair.
 
Stellar Mudd said:
www.dallasobserver.com

Dr. Death is One of the Biggest Podcasts to Come Out of Dallas. It's Also Terrifying.

The final episode of what is perhaps the biggest podcast to have ever come out of Dallas is now out. Since dropping its first episode Sept. 4, Dr. Death has had more than four million listeners and racked up more than 21,000 five-star ratings on iTunes. But despite the rave...
www.dallasobserver.com www.dallasobserver.com

I don’t put anything past any doctor any more

There was another batch of crazy botched surgeries, I think some were a Us surgeon who also worked abroad
Click to expand...

Paolo Macchiarini - Wikipedia

en.m.wikipedia.org en.m.wikipedia.org
 
Op note and autopsy from: x.com

The op note sounds reasonable enough, but something doesn't add up...
 

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"Makary said that at many medical centers, patient safety procedures have long been in place to prevent never events, including mandatory "timeouts" in the operating room before operations begin to make sure medical records and surgical plans match the patient on the table," according to the Johns Hopkins article in ScienceDaily.“


I bet the “timeout” was perfect.
 
banister said:
Op note and autopsy from: x.com

The op note sounds reasonable enough, but something doesn't add up...
Click to expand...

Something doesn’t add up is an understatement. First off, the patient showed up with splenomegally and a drop in HCT per the notes with a question of underlying malignancy. I still can’t wrap my head around how this guy did a complete liver resection and didn’t realize it. The spleen is a fairly thin walled “bag of blood” per my anatomy professor. The liver is a large organ with a grossly different appearance, location and blood supply, never mind the biliary drainage. It appears per the pathology report this surgeon did remove either all of or the majority of this guy’s liver. Also this guy’s liver appears from the pathology report to be enlarged as well.
 
centdoc said:
That’s why you don’t see any anesthesiologist names in the suit… was prob an “independent” crNa… somehow the nurses always get out of it.
Click to expand...

It’s because nurses are the caring, warm hearted back bone of the American healthcare system. Literally everyone has a friend or family member who is a nurse. Nurses won’t be found guilty/liable in all but the most obvious/egregious of circumstances. More often than not the plaintiff and their attorneys just come across as callous for naming “that sweet girl that took care of mee-maw when she broke her hip.” The average juror doesn’t understand the difference between a cRNa and a RN.
 
nimbus said:
"Makary said that at many medical centers, patient safety procedures have long been in place to prevent never events, including mandatory "timeouts" in the operating room before operations begin to make sure medical records and surgical plans match the patient on the table," according to the Johns Hopkins article in ScienceDaily.“


I bet the “timeout” was perfect.
Click to expand...
Well of course it was. Just like when there's a retained sponge or instrument - "but the count was correct".
 
A bunch of things struck me after reading op report:

1. They were ready for a potential disaster. Patient was lined up and products were ordered. Yet the assistant listed was the scrub tech? Were all the PAs helping the ortho bro flip three total joint room?

2. Extensive discussion about spleen dissection. Is looking at hilum and then all hell breaks loose. So, for a couple hours he is picking away and doesn’t notice that he is actually looking at the liver?
 
GassYous said:
Why would it be the anesthesiologist's responsibility to make sure that the surgeon is taking out the correct organ?
Click to expand...
That would still be an argument by plaintiff lawyer in trial. Complaint would read something like:

“Dr. —— anesthesiologist had a duty to inform surgeon of removal of wrong organ. Dr —— failed to stop procedure and surgeon from removing wrong organ.”

It would need to be defended.
 
jwk said:
Well of course it was. Just like when there's a retained sponge or instrument - "but the count was correct".
Click to expand...
Clearly another pre-procedure timeout is necessary, with introductions.

And a debrief. Everyone can introduce themselves again, because who can remember all the traveler RN names?
 
gasmd98 said:
A bunch of things struck me after reading op report:

1. They were ready for a potential disaster. Patient was lined up and products were ordered. Yet the assistant listed was the scrub tech? Were all the PAs helping the ortho bro flip three total joint room?

2. Extensive discussion about spleen dissection. Is looking at hilum and then all hell breaks loose. So, for a couple hours he is picking away and doesn’t notice that he is actually looking at the liver?
Click to expand...

Maybe the surgeon had a REPUTATION. Anesthesiologist prepared based on this reputation.
 
TheLoneWolf said:
Yes I thought the same thing. Possible situs inversus
Click to expand...

Which should have been picked up by radiology. Easily. You know this patient got all kinds of scans on arrival in addition to the MRI.

This is my world. Trauma and splenectomies and liver resections. This is unfathomable.
 
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