Surender Singh s/o Jagdish Singh And Another (administrators of the estate of Narindar Kaur d/o Sarwan Singh) v Li Man Kay and Others

• Judge: Lai Siu Chiu J
• Judgment Date: 22 July 2009
• Neutral Citation: [2009] SGHC 168
• Defendant Counsel: Edwin Tong, Mak Wei Munn and Kristy Tan (Allen & Gledhill LLP),Rebecca Chew, Kelvin Poon and Loke Pei-Shan (Rajah & Tann LLP)
• Published date: 27 August 2009
• Subject Matter: Medical negligence,Tort,Evidence,Negligence,Proof of evidence,Onus of proof
• Citation: [2009] SGHC 168
• Court: High Court (Singapore)
• Plaintiff Counsel: Palaniappan Sundararaj and Shankar A.S. (Straits Law Practice LLC)
• Year: 2009

22 July 2009 Judgment reserved.

Lai Siu Chiu J:

Introduction

The parties in this action

1 This action arose from the tragic death of one Narindar Kaur d/o Sarwan Singh, aged 33 years (the “Deceased”), on 16 February 2005, mere hours after undergoing a surgical procedure, termed Left Hand Assisted Laparoscopic Donor Nephrectomy (“HALDN”), to remove her left kidney for donation to her husband, Surender Singh s/o Jagdish Singh (the “first plaintiff”), who was suffering from end-stage renal failure. Minda Kour d/o Hendar Singh (the “second plaintiff”) is the Deceased’s mother. Where relevant in this judgment, the first and second plaintiffs will be collectively referred to as “the plaintiffs”.

2 The HALDN procedure was performed at the National University Hospital of Singapore (“NUH”) by Dr Li Man Kay (“Dr Li”) who is the first defendant. Dr Li was assisted by Dr Consigliere David Terence (“Dr Consigliere”) who is the second defendant. Dr Li was the head of the renal transplant team of the Ministry of Health from 2001 to August 2008. He is an urologist and renal transplant surgeon by training and is in private practice. He is also a visiting consultant for urology at NUH and the Singapore General Hospital (“SGH”).

3 Dr Consigliere is presently a senior consultant and the head of the Department of Urology at NUH which is the third defendant in this case. Where necessary, Dr Li and Dr Consigliere will be referred to collectively as “the two doctors” and the two doctors and NUH will be referred to collectively as “the three defendants”.

The nature of this action

4 The Deceased left behind as dependents, her husband (viz the first plaintiff) and three young children who are aged 14, 13 and 6 years. The plaintiffs are the co-administrators of the Deceased’s estate and brought this claim on behalf of and for the Deceased’s dependents, on the basis of negligence and/or breach of contract against Dr Li, Dr Consigliere and NUH, pursuant to ss 20 and 21 of the Civil Law Act (Cap 43, 1999 Ed).

Background facts

5 Before I set out the events surrounding the Deceased’s HALDN procedure on 16 February 2005, it would be necessary to first explain the renal anatomy and the HALDN procedure, for a better understanding of what transpired.

The renal anatomy

6 Counsel for the two doctors Edwin Tong (“Mr Tong”) had very helpfully provided the court at the commencement of the trial with three diagrams depicting the renal anatomy. These are reproduced in Annex A and should be viewed together with the description set out below.

7 The renal system comprises of two kidneys (viz the left and the right kidney), two ureters (left and right), a single bladder and a single urethra. The kidneys are highly vascularised organs receiving approximately 20% of the human body’s resting cardiac output. The organs regulate the volume and concentration of fluids in the human body by producing urine which removes, inter alia, waste products from the blood.

8 The HALDN procedure involved the Deceased’s left kidney and the focus will therefore be on the left side of the renal anatomy. The left kidney is connected to three central systems. In the first connection, the bladder is connected to the left kidney via the left ureter. In the second connection, the left kidney is connected to the aorta via the left renal artery. The aorta, the largest artery in the human body, brings oxygenated blood to all parts of the body. The left renal artery supplies the left kidney with blood and oxygen directly from the aorta. In the third connection, the left kidney is connected to the inferior vena cava via the left renal vein. The inferior vena cava returns blood to the heart from the lower part of the body. The left renal vein drains the left kidney. Simply put, blood flows from the left kidney through the left renal vein to the heart via the inferior vena cava, after waste products have been removed. The left renal artery and the left renal vein are major blood vessels connected to the left kidney. Typically the renal artery branches out from the aorta in a single vessel which then divides into two branches (creating a “Y” shape) that pass into the kidney. The left renal vein, which branches out from the inferior vena cava, may have two or three branches, but these may or may not pass into the left kidney. Apart from the renal artery and the renal vein, smaller blood vessels surround the renal bed, the tissues around the renal artery, the renal vein and the kidney itself.

9 Urine, the filtered product containing inter alia, waste materials excreted from the left kidney passes down the left ureter and collects in the bladder. It is passed out from the bladder and the body via the urethra.

10 To remove the left kidney from the donor, all the different tissues attached to the three central systems in [8] must be dissected from the left kidney. Once the dissection of these tissues (which include the left renal artery and the left renal vein) are done, the tissues are secured using a variety of means including clips known as Hem-o-lok clips. Once clipped, the tissues are then transected. The left kidney will then be transplanted into the recipient. As the tissues are usually embedded with other tissues (such as the colon, the spleen and fatty tissues) that have to be first moved, cauterised or removed from the left kidney, the surgeon’s task of identifying and freeing the tissues is challenging. I turn next to the HALDN procedure.

The HALDN procedure

11 Laparoscopic donor nephrectomy is a type of keyhole surgery performed on a kidney donor to remove one of the donor’s kidneys for transplantation into a recipient. HALDN is one method of keyhole surgery. In HALDN, three abdominal incisions are made by the first surgeon at the start of the surgery. The first incision, of about 7 cm, is made around the patient’s navel for the insertion of the hand port. The hand port allows the first surgeon to insert and use his hand in the patient’s renal bed area during the surgery and also to remove the detached kidney at the end of the surgery.

12 After this first 7cm incision, two smaller abdominal incisions, of about 10mm, are made for two 10mm ports. An endoscopic camera is inserted through one port while laparoscopic surgical instruments are inserted through the other port. The endoscopic camera is operated by the second surgeon. The camera captures images of the renal bed. These images are magnified and displayed on two television monitors on either side of the operating table. The positioning of the television monitors ensures that both the first and the second surgeons are able to see the images which are displayed about 1m from each of them. With such a set up, one advantage of laparoscopic donor nephrectomy (and HALDN) is that unlike standard open surgery (where the surgeons have the best and perhaps only view of the surgical site), everyone in the operating room can see the images on the two television monitors.

13 Where surgery is for the removal of the left kidney, the first surgeon, relying on visualisation from the endoscopic camera, will proceed to dissect and transect the left ureter, the left renal artery, the left renal vein and the surrounding blood vessels. Each of these vessels will first be secured and then dissected. If the donor’s renal artery is cut before branching, there will be a single arterial vessel on the graft side (ie, the side where the kidney is to be removed for implantation) for anastomosis (ie, connection) in the recipient. The portion of the renal artery on the graft side must be of a sufficient length for anastomosis. On the other hand, if the renal artery is cut after branching, there will then be two arterial vessels on the graft side for anastomosis in the recipient. Obviously, anastomosis in the recipient would be easier if the arterial vessel is cut before branching, since only one vessel is involved. The challenge however is to identify a sufficient length of the renal artery or renal vein from the proximal end (viz the portion of the vein or artery that comes out of the inferior vena cava or the aorta) before branching occurs, to secure the vessel before transection. Following transection of the left renal vein and artery, the kidney is then removed through the hand port.

14 The major vessels (which include the renal artery and the renal vein) are secured and transected only after the smaller vessels have themselves been secured and transected. The reason for this order is that once the renal artery is clamped, blood will not flow into the kidney any more. The moment the renal artery is clamped, arterial circulation is interrupted and that starts what is called the warm ischemic time. At this stage, the kidney is live but is deprived of blood. The warm ischemic time ends with the commencement of cold perfusion (which involves the flushing of the extracted kidney with a special iced solution) of the extracted kidney to prepare it for transplantation into the recipient. The warm ischemic time, which is always measured and monitored closely in transplants, should be as short as possible as it affects the quality of the extracted kidney for transplantation.

15 The portion of the renal artery and the renal vein on the graft side of the extracted kidney would then be left free for anastomosis with the recipient’s renal artery and renal vein. Upon anastomosis, the flow of blood through the transplanted kidney starts again. Suction is frequently applied to the renal bed to remove remnant blood which may collect. This ensures visibility of any active bleeding sites.

16 After the kidney is removed, mopping, flushing and suction are performed to clean the renal bed of blood and haemoserous fluid. The renal bed and the abdominal cavity are then checked to ensure that there are no bleeding sites and that haemostasis (viz the process by which bleeding stops) is first achieved, before the three surgical incisions in [11] and [12] are closed.

Hem-o-Lok...