The Expert: Dr. George Plonk, a vascular surgeon based in North Carolina, testifies for the defense concerning the procedure at issue.
Giving testimony to support the defense in a medical malpractice trial out of Fulton County Georgia, Dr. George Plonk, a board-certified vascular surgeon, addresses the issue of whether severing the hypoglossal nerve (the cranial nerve supplying the tongue) during a carotid endarterectomy constitutes negligence. A carotid endarterectomy is an operation during which atherosclerotic plaques are stripped from the internal lining of the carotid artery (which supplies the brain) in order to prevent pieces of the plaque from breaking off and entering the brain.
The plaintiff in this case suffered partial paralysis of the tongue when his hypoglossal nerve on one side was transected in the course of the procedure. The surgeon recognized the injury and attempted an immediate repair, which the plaintiff also claimed was performed improperly, although the issue of repair is not addressed in this clip.
The expert establishes immediately his belief that transection of the hypoglossal nerve is a known and accepted complication occurring during carotid artery surgery due to its proximity to or location within the operative site, and that avoidance of such is problematic given the variations in anatomical norms as well as anomalies of positioning of this nerve. He uses the example of the complication of stroke occurring during endarterectomy. This is an operation performed on the carotid artery to prevent stroke, and surgeons take maximal precautions to prevent this complication from occurring, yet it still occurs in 1-2% of cases. Other cranial nerves that can be injured during this procedure include the mandibular branch of the facial nerve, as well as the vagus nerve in the neck. These can be injured by traction placed in gaining exposure, heat injury from proximity of the nerves to the cauterizing instrument, and from actual transection, as in this case. Plonk explains that there is a 5-15% chance of symptomatic injury to one of these nerves during carotid endarterectomy. If all injuries, symptomatic as well as asymptomatic, were considered, the incidence of cranial nerve injury may be as high as 25%. For this reason, it is important when performing bilateral carotid endarterectomies that the possibility that one side may have had a cranial nerve injury, subclinically affecting the vocal cords, be ruled out prior to attempting to operate on the opposite side.
Plonk plainly states that it is not part of the standard of care for the surgeon to identify the hypoglossal nerve when operating on the carotid artery. In describing the anatomy, he says that, in many cases, the nerve will be higher than the operative site. It is not only unnecessary, he says, but can be damaging to identify this nerve when it is already well out of the way. Anatomic variation could bring it into the operative field, in which case it must be defined and retracted out of the way. This principle of not searching for the hypoglossal nerve applies even when a mass is being removed or reoperation is performed in the face of significant adhesion formation. In contrast, the expert does consistently identify the vagus nerve which “is always in harm’s way” during this operation.
Plonk elaborates that there are times when damage to the hypoglossal nerve could be considered malpractice, such as when one operates while on drugs or alcohol, operating on the wrong side, or when a surgeon is emphasizing speed of operation over safety. There can also be technical intraoperative mistakes that could be considered malpractice, but this would require extensive knowledge of what exactly was done during the procedure.
Ultimately, the doctor states that, given his own training and experience as a vascular surgeon performing carotid endarterectomy, he does not feel that the defendant was in violation of the standard of care. The testimony was convincing, as the jury returned a verdict for the defense.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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