What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?

A 128 Million Dollar Question

Rajshri M. Gartland, MD, MPH; Jordan P. Bloom, MD, MPH; Zhi Ven Fong, MD, MPH; Courtney DeRoo, BS; Kathy Dwyer, MSN, RN; Gene Quinn, MD, MPH; Keith Lillemoe, MD, FACS; Elizabeth Mort, MD, MPHy


Annals of Surgery. 2019;269(5):785-791. 

In This Article

Abstract and Introduction


Objective: We aimed to study the contributing factors and costs of malpractice claims involving the surgical management of benign biliary disease given the emotional, physical, and financial toll of these claims on patients, providers, and the healthcare system.

Summary Background Data: Cholecystectomy complications carry significant morbidity and rank among the leading sources of surgical malpractice claims.

Methods: Using the CRICO Strategies' Comparative Benchmarking System database, representing approximately 30% of all paid and unpaid malpractice claims in the United States, 4081 closed claims filed against general surgeons from 1995 to 2015 were reviewed to isolate 745 cholecystectomy-related claims. A multivariable model was used to determine factors associated with claim outcome.

Results: The most common associated complications included bile duct injury (n = 397), bowel perforation (n = 96), and hemorrhage (n = 78). Bile duct injuries were recognized intraoperatively only 19% of the time and required biliary reconstruction surgery 77% of the time. The total cost for all claims over the study period was over $128 M and the median time from event to case close was over 3 years. 40% of claims resulted in patient payout; of these, most claims were settled out of court and the median cost per claim was $264,650. For the 60% of claims not resulting in patient payout, most cases were denied, dropped, or dismissed, yet still averaged over $15,000 per claim in legal and administrative fees. On multivariable analysis, bile duct injury, bowel perforation, and high clinical severity were associated with patient payout, while a resident or fellow being named in a claim was negatively associated with patient payout (P < 0.05).

Conclusion: Cholecystectomy-related claims are costly and time-consuming. Strategies that reduce the risk and aid in recognition of cholecystectomy complications, as well as advance support of patients and families after poor outcomes, may improve clinical care and reduce claim burden.


Every year, up to 1.2 million laparoscopic cholecystectomies (CCY) are performed in the United States (US) for gallstone disease.[1] CCY is one of the most commonly performed operations in the US and is by and large considered a safe procedure with most patients discharged on the same day postoperatively. However, major morbidity still occurs in 5% of cases,[2] with a serious complication being a bile duct injury (BDI) that can lead to long-term disability[3–5] and reduced survival.[6–9] The unexpected nature of these morbid complications likely explains the high medical malpractice claim rate associated with CCY-related injuries,[10] and BDIs in particular.[11,12]

Despite moving along the laparoscopic CCY learning curve in the last 3 decades, the incidence of BDI-related malpractice claims following laparoscopic CCY has not decreased.[11] These claims bear an incredible burden on patients; in addition to enduring the harm event associated with the claim, most patients are not ultimately compensated. When a claim does result in a payout to a patient, for every dollar spent on compensation, approximately 54 cents is spent on administrative costs and legal fees.[13] For surgeons, involvement in a claim is strongly related to burnout, depression, and suicidal ideation.[14] Additionally, the perceived threat of malpractice claims, highest for surgeons among all medical specialties,[15] perpetuates the practice of defensive medicine and risk aversion which imposes a significant financial burden on the healthcare system.[16]

To mitigate the physical, emotional, and financial impact that these malpractice claims have on both patients and physicians, including trainees, we must better understand the nature of malpractice claims after CCY. Most large malpractice databases, including the National Practitioner Database, are limited by a lack of detailed clinical information and inclusion of only paid malpractice cases, therefore missing claims that are either denied, dropped, dismissed, or successfully defended in court. This study represents the largest review of both paid and unpaid cholecystectomy closed claims using a deeply-coded malpractice claims database, and aims to describe the costs and contributing factors of these claims as well as assess factors associated with patient payout.