The document discusses medicolegal aspects of head and neck endocrine surgery. It notes that the most common reasons for litigation related to thyroid surgery are vocal cord paralysis and recurrent laryngeal nerve injury. For parathyroid surgery, failure to document maneuvers to preserve the parathyroids or measure intraoperative parathyroid hormone can make malpractice suits difficult to defend. The document emphasizes the importance of obtaining proper informed consent, documenting surgical notes and postoperative care, using accepted surgical techniques, and referring cases that exceed a surgeon's expertise.

1. MEDICOLEGAL ASPECTS OF
HEAD AND NECK
ENDOCRINE SURGERY
D r U t k a l M i s h r a
A s s i s t a n t P r o f e s s o r , A I I M S B h o p a l
15/09/2021

2. LEGAL BASIS
• The legal basis of a malpractice suit rests on four
components.
• The essence of the case is usually the question “Did
the surgeon deviate from the standard of care?”
• The legal doctrine most commonly used by plaintiffs in
malpractice cases involving RLN injury is “res ipsa
loquitur”
The surgeon has entered into a relationship obligating
provision of care to the patient.
The surgeon violated the
“standard of care.”
The “substandard care” resulted in injury
to the patient.
This resulted in compensable damages to
the patient

3. Statistics of Medical negligence cases filled in various consumer
courts in India
https://www.researchgate.net/publication/335868242_Duty_to_ensure_quality_d
esign_and_safety_of_IOL_Manufacturer_Dealer_or_Treating_Doctor

4. THYROIDECTOMY
• The most common reason for litigation was vocal cord paralysis 51%
• Of those, 43% of cases (n = 12) were due to unilateral recurrent laryngeal nerve ( RLN) injury,
• and 39% (n = 11) were due to bilateral RLN injury.
• Of thyroidectomy-related claims, 11% went to trial and a third resulted in an indemnity
payment.
• 2nd – Spinal accessory nerve injury
• 3rd – Hypocalcaemia
• The most common nontechnical cause for malpractice suits related to the thyroid is the delayed
diagnosis of cancer.
• In USA standard of care for thyroid related procedures is defined by ATA guidelines.
Swonke ML, Shakibai N, Chaaban MR. Medical Malpractice Trends in Thyroidectomies among General
Surgeons and Otolaryngologists. OTO Open. 2020 May 13;4(2):2473974X20921141. doi:
10.1177/2473974X20921141. PMID: 32435722; PMCID: PMC7223205.

5. RLN
• Rates of permanent injury to the recurrent laryngeal nerve - 1%
• Identification of RLN in its entire course - is less likely to result in nerve injury and
represents the standard of care
• Preoperative laryngoscopy.
• Intraoperative recurrent laryngeal nerve monitoring

6. Malpractice Claims and the Parathyroid Glands
• Permanent hypoparathyroidism alone is rarely a reason for a malpractice suit.
• Failure to mention the parathyroids and maneuvers to preserve them in the operative
notes of a patient who ends up with permanent hypoparathyroidism is a difficult case
to defend.
• Parathyroid adenoma surgery –
Preoperative imaging,
Intraoperative parathyroid hormone (IOPTH) measurement.

7. CASE EXAMPLES
• https://mega.nz/file /ThpUHBRb#mlx4rDdimS8 tsjNpLe_2lK8crIoiKPRtauggqmjQzyg
• https://mega.nz/file /Wk4mDR5Q#1-zz2eEp-8jHIKQcNS3u7oOlIjbU6BkBlzSHcit3erw
• https://mega.nz/file /e5piUJCA#EhyOIvLGhIu637vLL4z95ikwzgctSli2OLiObLWkQhM

8. Points to note
• Lack of informed consent was cited in most number of malpractice suits.
• Frequently, the patients did not know their operating physicians.
• Although, most of the surgeons had a pre-operative discussion with their patients and
relatives, only rarely is this discussion documented.
• Official recommendations for obtaining informed consent for elective procedures -
more than 24 hours prior to the procedure.
• Wrong technique used for treatment is the next frequent complaint followed by
complications of the operations.
Bastia BK. Litigation suits in otorhinolaryngology - Areas of concern. Indian J Otolaryngol Head Neck Surg.
2006 Oct;58(4):370-3. doi: 10.1007/BF03049598. PMID: 23120351; PMCID: PMC3450379.

9. SURGEON–PATIENT RELATIONSHIP
• Patients must be willing to place so much trust in their surgeons that they are willing
to risk disfigurement and potentially permanent disability or even death at the hands of
the surgeon.
• A successful surgeon-patient relationship therefore requires a deep level of trust -
developed in a relatively short period of time of the preoperative visits.
• Surgeon must take this opportunity to teach patients regarding the anatomy, nature of
disease, treatment options, complications and quality of life.
Bastia BK. Litigation suits in otorhinolaryngology - Areas of concern. Indian J Otolaryngol Head Neck Surg.
2006 Oct;58(4):370-3. doi: 10.1007/BF03049598. PMID: 23120351; PMCID: PMC3450379.

10. INFORMED CONSENT
• In the current era of shared decision making, surgeons must approach the informed
consent process as a means of educating the patient on his/her condition so that the
patient can participate in the decision about whether to have surgery or not.
• Consent is explicit i.e. both person-specific, and procedure-specific.
• All the relevant information of the disease and treatment needs to be informed to the
patient.
• All significant and material risks are to be disclosed.
• The patient should also be informed about other alternative treatments available and
the consequence of no treatment at all.
• The entire conversation should be documented and signed by the patient or his
representative in presence of witness.
Bastia BK. Litigation suits in otorhinolaryngology - Areas of concern. Indian J Otolaryngol Head Neck Surg.
2006 Oct;58(4):370-3. doi: 10.1007/BF03049598. PMID: 23120351; PMCID: PMC3450379.

11. TECHNIQUES USED FOR TREATMENT
• A surgeon should try continuously to improve medical knowledge and skills.
• A surgeon should use one of the accepted methods prevailing at that time in medical
world.
• However, if there are two or more accepted views on a particular point, a surgeon is
free to accept any one depending upon his skill and expertise.
Bastia BK. Litigation suits in otorhinolaryngology - Areas of concern. Indian J Otolaryngol Head Neck Surg.
2006 Oct;58(4):370-3. doi: 10.1007/BF03049598. PMID: 23120351; PMCID: PMC3450379.

12. POST OP CARE
• It is accepted in the court of law that every operation has certain risk and known
complications which are sometimes beyond the control of the surgeon.
• The surgeon can not be held responsible for this natural phenomenon.
• But, if the surgeon is aware of the post-operative complications and does not attend
when it occurs, it is negligence.
• The operating surgeon is responsible for the postoperative care of the patient.
• A surgeon, after operation can not, without patient’s consent, hand over a patient to
some other doctor having lower qualification to take post-operative care.
• The surgeon is responsible for determining when the patient should be discharged
from the hospital.
Bastia BK. Litigation suits in otorhinolaryngology - Areas of concern. Indian J Otolaryngol Head Neck Surg.
2006 Oct;58(4):370-3. doi: 10.1007/BF03049598. PMID: 23120351; PMCID: PMC3450379.

13. OPERATIVE NOTES
• It has to be legible and comprehensive.
• It should include diagrams, if this explains the procedure.
• It must contain
– The names of the surgeon, assistants and the anesthetist who conducted the procedure.
– The indication for the operation
– Name of the procedure.
– Description of the position of the patient.
– Describe the site, shape and length of the incision and the structures that were divided to obtain access.
– The pathology needs to be described as seen in the operating field.
– The exact procedure should be described step by step.
– Any special procedure done or any special instruments used should also be documented.
– The method used for closure needs to be mentioned.
– Instructions regarding postoperative care are an important part of the note and must be clearly written.
– Any complications that may follow must be documented clearly.
– At the end of the operating note, the surgeon must sign it with his name and date.
• Like all the medical records, the operating note has to be preserved for at least three years.

14. TO REFER
• It is a basic duty of the doctor to handle only those cases which are within the limit of
his skill, knowledge and experience.
• He must take into consideration the availability of equipments, staff, medicine and
other circumstances also.
• Once a patient is under his care, it is negligence to leave the treatment halfway
especially when patient's condition is deteriorating.
• If a doctor finds on preliminary examination that, the case is beyond his capacity, it is
better to refer it to the consultant or a hospital at the earliest after giving primary
treatments only.

15. TAKE HOME MESSAGE
• Good communication
• Obtaining appropriate informed consent for treatment
• Keeping accurate and appropriate medical records

16. THANK YOU