A surgeon has apologised to a patient after removing the wrong part of the man’s lung during surgery.
A decision released by the Health and Disability Commissioner (HDC) today found that the doctor breached the man’s rights by failing to provide services with reasonable care and skill and failing to obtain the patient’s informed consent.
The patient, a man in his 60s at the time, had a family history of cancer and arranged for a routine screening at a hospital for his own lung health in July 2020.
He was diagnosed with adenocarcinoma, a type of lung cancer that forms in the bronchial glands.
It was recommended he undergo surgery to have a tumour on his lower left lung removed.
The doctor performing the surgery was a senior cardiothoracic surgeon with “many years’ experience”.
He told the HDC he had completed “almost 300 video-assisted thoracoscopic surgery (VATS) lobectomies”.
A VATS lobectomy is a minimally invasive surgical procedure where, with the help of a tiny camera, a lobe of the lung is removed using small incisions.
The surgery
On September 11 2020, the patient underwent his first surgery. It was found that both of the man’s upper and lower lobes appeared emphysematous, and an enlarged lymph node was taken for biopsy.
What was believed to be the left lower lobe of the lung was removed and sent to the medical laboratory for testing.
In the days following, the man appeared to recover well – until he became “feverish” on day five. A chest X-ray found the “abnormal presence” of air and fluid in the man’s chest, and he underwent a CT scan the next day.
On the day of the scan, a pathologist told the surgeon that no tumour had been found on the removed part of the lung.
When the CT scan results came back, it was revealed the upper left lobe had been removed instead of the lower left lobe and that there was a loss of blood supply to the remaining part of his lung.
According to the doctor, he explained the “conundrum” to the patient and informed him a “re-exploration” was required. He said he would relay the findings to him and apologised for exposing him to a second surgery.
He said he wasn’t entirely aware of what had gone wrong at the time.
“It was hard to imagine how an upper lobe lung could be mistaken for a lower lobe, which I believed I had taken out, having done all standard checks.”
The man underwent a second surgery to remove the remaining part of his lung, which the patient consented to.
In his complaint, however, the patient alleged he was not fully informed and claimed he wasn’t told the wrong part of his lung had been removed until after the second surgery was complete.
He said there had been no mention of a “conundrum” about cancer being found and no “re-exploration” or “relay of findings”.
“Instead, he told me that ‘the blood supply to the rest of the left lung was compromised’, and it [the remainder of the lung] needed to be removed in a second operation.
“At no time before the second operation was I told that an error had been made during the first operation,” he said.
“At that point, I believed I was consenting to removal of the lung with the upper lobe in place, still under the impression that the first operation had removed the lower lobe and the cancer.”
The man said his wife was the one who told him about the error.
According to the report, Health NZ said the surgeon acknowledged that the ultimate cause for the second operation was not discussed with the patient, “although the removal of the incorrect lobe of the lung was considered/suspected at that time”. This was confirmed in the surgery.
When the HDC asked what went wrong in the first surgery, the doctor said he believed the lung had rotated 180 degrees on itself, “unbeknownst to anyone of us during the procedure”. He described it as a “very rare phenomenon”.
The doctor said the lung likely flipped while it was inflated and deflated early in the surgery. This process is usually done once or twice to ensure the correct airway is being divided.
The lung’s rotation resulted in the wrong part appearing on the screen used to operate.
The doctor disagreed with an independent adviser’s advice that the error was caused by disorientation or an error of judgement on his part. He claimed to be “fully aware” that the planned procedure was a lower lobectomy and proceeded to remove the lobe visible on the right side of the fissure (which was the left lower lobe).
The doctor said neither he nor anyone else in the operating room knew that the lung had rotated.
“I had planned for a left lower lobectomy and proceeded to remove the lobe that was visible to my right. I removed this lobe thinking that this was the lower lobe,” he said.
“This was the error that was made, as it was not known at the time that the lung had rotated 180 degrees … This was an inadvertent error.
“The rare event of torsion of the lung was not recognised by me or anyone else at the time. I removed the lower part of the rotated left lung.”
The patient told the HDC that since the surgery, he had not been able to return to many of his daily activities because of “significant pain” when using his left hand.
The man’s cancer returned and was now on the right lower lobe of his only remaining lung.
Commissioner’s decision
The commissioner found the doctor had breached the patient’s right to services with reasonable care and skill.
“I am nevertheless critical that [the doctor] did not identify that he was removing the left upper lobe instead of the left lower lobe of the lung, including with reference to the available anatomic markers, namely the inferior pulmonary vein.
“I also note that [the doctor] has accepted that this should not have happened, regardless of how it occurred.”
The doctor was also found to have breached the patient’s right to informed consent about the surgery.
“[The patient] should have been given an explanation that removal of the incorrect lobe was a possible explanation for the absence of cancer within the resected lobe and the compromised circulation evident on the CT scan.
“I am critical that this did not occur.”
Since the incident, the doctor has continued to perform surgeries and now uses ink to mark the lobe that is intended to be removed.
The commissioner recommended the doctor provide a formal written apology to the man – which has since been delivered.
It was also recommended that he audit other procedures he performed over the last six months to ensure no similar incidents occur and receive further education on documentation.