0001 1 IN THE COURT OF COMMON PLEAS 2 CUYAHOGA COUNTY, OHIO 3 4 STEVEN BILTEKOFF et al., 5 6 Plaintiff, 7 8 vs. No. 07-616059 9 Hon. Michael P. Donnelly 10 THE CLEVELAND CLINIC FOUNDATION, 11 12 Defendant, 13 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 14 15 16 Deposition of ANTHONY SENAGORE, M.D. 17 Monday, October 22, 2007 18 9:00 a.m. 19 100 Michigan Street 20 Grand Rapids, Michigan 21 22 Before Melinda R. Womack, CSR3611 23 24 25 0002 1 APPEARANCES: 2 3 DAVID A. KULWICKI #0041106 4 Becker & Mishkind CO., L.P.A. 5 1660 West 2nd Street 6 Suite 660 7 Cleveland, Ohio 44113 8 Appearing on behalf of the Plaintiff. 9 10 RITA A. MAIMBOURG #0013161 11 Tucker Ellis & West L.L.P. 12 1150 Huntington Building 13 925 Euclid Avenue 14 Cleveland, Ohio 44115 15 Appearing on behalf of the Defendant. 16 17 18 19 20 21 22 23 24 25 0003 1 INDEX TO EXAMINATIONS 2 3 Witness Page 4 ANTHONY SENAGORE, M.D. 5 6 EXAMINATION BY MR. KULWICKI: 3 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0004 1 Grand Rapids, Michigan 2 Monday, October 22, 2007 3 About 9:00 a.m. 4 ANTHONY SENAGORE, M.D. 5 having first been duly sworn, was examined and 6 testified on his oath as follows: 7 EXAMINATION BY MR. KULWICKI: 8 Q. Okay. Good morning, Doctor Senagore. 9 Please state your full name and given us your current 10 home address. 11 A. Anthony Senagore, and home address is 2411 12 Santigo Avenue Southeast, Grand Rapids, Michigan. 13 Q. And, Doctor, we are here with respect to a 14 lawsuit that I brought on behalf of the Biltekoffs 15 against the Cleveland Clinic. Have you had the 16 opportunity to review Mr. Builtekoff's chart prior to 17 today's deposition? 18 A. I did, yes. 19 Q. And can you tell me what sections of that 20 chart you looked at? 21 A. I have the discharge summary and the order 22 sheet progress notes, imaging studies, operative note, 23 nurse's notes and EKG and pathology for that 24 hospitalization. 25 Q. Okay. Did you look at actual films or just 0005 1 reports of imaging studies? 2 A. Just reports. 3 Q. And with respect to the pathology, the same, 4 you looked at reports and not slides? 5 A. Correct. 6 Q. Doctor, this process that we're about to 7 undertake is called a deposition. Have you had a 8 deposition before? 9 A. Yes. 10 Q. And how many times? 11 A. A number, probably 30 or 40. 12 Q. Were those in a capacity as a treating 13 physician or as an expert witness? 14 A. Mostly as expert witness. 15 Q. And tell me with respect to your expert 16 witness work, have you done work both for the patient 17 or the plaintiff on one hand and the doctor or hospital 18 on the other hand? 19 A. Yes. 20 Q. Can you tell me how that work breaks down by 21 estimated percentage? 22 A. It's about 80 percent defense. 23 Q. Have you ever testified in a case involving 24 postop complications from laparoscopic colectomy? 25 A. I can't recall if I have or not, to be 0006 1 honest with you. 2 Q. We are obviously conducting this by 3 telephone and I appreciate you for accommodating me in 4 that regard. So far so good. Can you hear me? 5 A. Yes, no problem. 6 Q. Okay. Please if at any time you suspect 7 that you didn't hear my complete question or you know 8 you didn't hear my complete question, please tell me 9 that and I will restate it so that you're comfortable 10 that you've heard what I'm asking and we're 11 communicating appropriately. And likewise, if you 12 don't understand one of my questions because I've maybe 13 misused a medical term or it simply was just sloppy 14 English, stop me there as well and I will make every 15 effort to restate my questions to your satisfaction, 16 okay? 17 A. Fair enough. 18 Q. You're doing excellent in terms of answering 19 verbally and waiting for me to finish my question. 20 Please keep that up and I think we'll do just fine 21 here. 22 Tell me, Doctor, if you would, I 23 want to ask a little bit about your background and your 24 change, your recent change in employment status. When 25 was the last time that you were employed by the 0007 1 Cleveland Clinic. 2 A. I think it was April or May, 2005. 3 Q. And then you went to Toledo, is that 4 correct? 5 A. Correct. 6 Q. And tell me what that position was? 7 A. I was chairman of the department of surgery 8 at the University of Toledo. It was actually, 9 originally it was Medical College of Ohio, then the 10 name changed to Medical University, and then became 11 University of Toledo during my tenure there. 12 Q. And how long were you there for? 13 A. About 18 months. 14 Q. And tell me where you're at currently? 15 A. Spectrum Health in Grand Rapids, Michigan. 16 Q. I'm familiar with some other entities called 17 Spectrum Health. Is this a local Michigan corporation 18 or is it a national corporation, a regional? 19 A. Boy, it's a Michigan. I'm not sure what 20 their corporate status is. It's a Michigan not for 21 profit. 22 Q. Okay. And tell me what's your position 23 there? 24 A. I'm vice president of research and 25 education. 0008 1 Q. Are you currently practicing surgery? 2 A. Yes. 3 Q. And how often do you operate? 4 A. Once a week. 5 Q. In terms of your professional time, what 6 percentage is spent in active clinical or surgical 7 practice? 8 A. Probably about 35 percent right now. 9 Q. And tell me about the other 65 percent of 10 your professional time what are you doing? 11 A. Administration related to the research and 12 education programs at Spectrum. 13 Q. Without getting into any trade secrets, can 14 you give me some sort of overview of what that research 15 entails? 16 A. It's the whole mix from basic science 17 research through outcomes, health care related 18 research. 19 Q. What was it that you changed from the clinic 20 to the University of Toledo? 21 A. I was recruited to be chief of surgery 22 there. 23 Q. And likewise, why did you leave University 24 of Toledo for Spectrum Health? 25 A. It was a family decision to come back to the 0009 1 Grand Rapids area. 2 Q. In terms of your leaving the Cleveland 3 Clinic, was there any dissatisfaction with the clinical 4 scenario there? 5 A. No. It's a great situation. 6 Q. Do you remember Mr. Biltekoff in the sense 7 that you have a picture of him in your mind? 8 A. Not directly. Mostly it was from the 9 records. 10 Q. Why don't we, if we could, turn to the op 11 note from February 9, 2005, and I want to ask you a few 12 questions about surgery that you performed. 13 A. Okay. 14 Q. Tell me when you're ready. 15 A. Ready. 16 Q. Okay. Doctor, in terms of that surgery it 17 lists you as the attending, Doctor Hull as the other 18 physician, and I thought there was an assistant listed 19 but I'm not seeing that right now? 20 A. I'm sorry, what date are we talking about? 21 Q. February 9 of 2005. 22 A. No. I believe it's me as surgeon and Doctor 23 Bret Butler as first assistant. 24 Q. That's what I thought as well, but this 25 morning I made a copy myself, which I should never do. 0010 1 Oh, I'm sorry. I'm looking at the discharge summary. 2 Okay. Forgive me. Okay. I've got the op note. Very 3 good. Thank you for clarifying that. 4 A. Okay. 5 Q. Tell me if you can -- well, do you remember 6 this surgery, this particular surgery? 7 A. Not particularly, no. 8 Q. Okay. So your recollection of the events of 9 the surgery would be limited to what's set forth in 10 this op note, true? 11 A. Correct. 12 Q. And tell me what would Doctor Butler's role 13 typically be back in February of '05 with this type of 14 surgery? 15 A. He would have been holding the camera and 16 providing some retraction with an instrument. 17 Q. In terms of closing the patient at the 18 conclusion of the procedure, who would do that? 19 A. I would. 20 Q. You describe at the bottom of page one of 21 the op note the endo close was used to the right lower 22 quadrant fascia. Tell me what that means? 23 A. It's basically a device that is a long 24 needle with a grasping device to grab suture so you can 25 basically place the suture through the abdominal wall 0011 1 to be able to close the defect. 2 Q. It's my understanding that there were four 3 different trochar sites for this particular procedure, 4 is that correct? 5 A. Correct. 6 Q. And did you use the endo close for each of 7 those four holes? 8 A. No. Typically we only close ten millimeter 9 trochar or above. The two fives were not closed. In 10 fact, the five in the left lower quadrant was 11 incorporated in that incision in the left lower 12 quadrant, so it was closed like any regular incision. 13 The 12 in the right lower quadrant was closed with the 14 endo close, and then at the ten at the umbilicus I 15 placed a purse string at the start of the case and we 16 used that purse string suture to close the fascia at 17 the end. 18 Q. Tell me if you can which of those holes is 19 the one through which the hernia occurred. 20 A. It would be the right lower quadrant. 21 Q. Was that the 12 millimeter? 22 A. Correct. 23 Q. All right. And in terms of the risk of 24 hernia following a laparoscopy, does the risk go up 25 with the greater gauge trochar that you use? 0012 1 A. Yes. 2 Q. And tell me about the choice of a 12 3 millimeter. What was the reasoning behind that? 4 A. You need a 12 to accommodate the stapling 5 device. 6 Q. Can you use a smaller gauge and still 7 accommodate the stapling device? 8 A. No. 9 Q. I lost your answer. 10 A. No. 11 Q. Doctor, I read some of your writings here 12 and I can't quote you chapter and verse, but there is 13 an article that you wrote, I believe it was roughly 14 January of '04, the date's not really important, but 15 you talked about importance of closure in preventing 16 hernia and I want to ask you a little bit about that. 17 The article suggested that you had changed, prior to 18 that January '04 publication date you had changed the 19 manner in which you'd closed or that you closed lap, 20 lap entry sites in order to reduce the risk of hernia. 21 Does this -- am I making sense here? Do you know what 22 I'm talking about? 23 A. I'm not sure that I changed my technique. I 24 don't remember which article you're referring to, but I 25 mean my technique was pretty standard for an extended 0013 1 period of time. But I think that the -- if I, again, 2 I'm not sure which paper you're referring to, but my 3 teaching has always been to try to encourage people to 4 close those defects by one mechanism or another. 5 Q. Okay. And tell me what are the options? 6 A. There's just a variety of either suture 7 passing devices or clip devices that can be used. 8 Q. And tell me about why you chose the endo 9 close for this particularly, we're talking about the 12 10 millimeter site. 11 A. It's just an efficient way to do it. It's 12 an inexpensive piece of equipment. 13 Q. Was there anything, based on your review of 14 this operative note, was there anything unusual about 15 this procedure or Mr. Biltekoff's anatomy? 16 A. Nothing that appeared from the operative 17 record, no. 18 Q. Based on what we know, is the subsequent 19 clinical course in him developing a hernia, do you 20 think that there were things that were done during the 21 surgery that maybe could have been done differently 22 that would have prevented the hernia? 23 A. No. 24 Q. Okay. And is it your position that even in 25 the presence of appropriate care a patient can still 0014 1 develop a hernia after a laparoscopic procedure? 2 A. Correct. 3 Q. Okay. And maybe in terms of establishing 4 some language here so that I'm communicating with you 5 the way I hope to, what do you -- how do you 6 characterize the complication the Mr. Biltekoff 7 suffered? 8 A. I think that what he originally had was a 9 hematoma in the rectus muscle in proximity to that 12 10 millimeter trochar site, and it was the subsequent 11 expansion of the hematoma that disrupted that closure. 12 Q. All right. Let me ask you then some 13 questions about that. And I didn't hear you use the 14 term hernia at all. Did in fact Mr. Biltekoff's bowel 15 herniate into the trochar site? 16 A. Correct. 17 Q. Okay. And then he sustained necrosis of the 18 bowel, correct? 19 A. Correct. 20 Q. And then that portion of the bowel had to -- 21 why don't you describe what had to be done to treat the 22 necrotic bowel. 23 A. It had to be resected. And then he had the 24 abdominal cavity lavage, and then a stoma was placed to 25 divert the stool temporarily. 0015 1 Q. And I understand you weren't involved in 2 that procedure, correct? 3 A. Correct. 4 Q. Okay. Now with respect to this hematoma 5 formation, do you have an opinion as to what caused 6 that in his particular case following the February 9 7 procedure? 8 A. Specifically no, but in general when these 9 occur it's bleeding from blood vessels within the 10 muscle, the rectus sheath muscle. 11 Q. And what causes that? 12 A. Just disruption and stretch from the 13 procedure and sometimes the trochar. 14 Q. I think you stated that the hematoma was 15 within proximity of the 12 millimeter trochar site. 16 Tell me a little bit more about that. As opposed to 17 being inside the trochar site it was just merely 18 proximal to it? 19 A. No, proximity. So adjacent in the area. 20 Q. Okay. So as you go through the fascia, just 21 below that? 22 A. Yeah. That's where the muscle is, beneath 23 the fascia sheath, yep. 24 Q. Okay. And the expansion of the hematoma in 25 your opinion disrupted the closure, is that how you 0016 1 said that? 2 A. Correct. 3 Q. And what does that mean? 4 A. Just, I mean the suture has only a certain 5 amount of strength and as pressure builds up, the 6 suture can disrupt. 7 Q. So it actually compromised the suturing? 8 A. Or the suture pulled through the fascia. 9 It's almost impossible to know which one, but either 10 way, the defect reopened. 11 Q. Okay. And tell me physiologically how it is 12 that the bowel sort of migrates into that space? 13 A. The bowel has peristalsis so it's always 14 moving, and it sometimes it just happens to catch in a 15 space and then it just crawls one end over the other 16 because of the peristaltic contractions. 17 Q. Based on your review of this record, do you 18 have an opinion as to the date on which the bowel 19 became entrapped? 20 A. I think it probably herniated some time the 21 16th into the 17th, somewhere in there. 22 Q. And why do you say that? What facts lead 23 you to that conclusion? 24 A. Well, on our physical exam we noted the 25 hematoma early on and that really didn't change prior 0017 1 to that period of time. There was no increase in size 2 or really no change in his abdominal exam prior to that 3 period of time. Even with the upper GI series that was 4 performed I believe on the 16th he did not have a 5 complete bowel obstruction because contrast went all 6 the way through to the colon. 7 Q. Okay. Any other facts that support your 8 opinion that the herniation occurred some time in the 9 timeframe of the 16th or 17th? 10 A. I think that's the most important issue that 11 I just shared. 12 Q. Okay. I used the term entrapped and I just 13 kind of pulled that out of my own vocabulary. Is that, 14 in fact, what happens, the bowel gets entrapped in the 15 trochar site? 16 A. It protrudes through the defect, yes. 17 Q. Okay. With respect to this particular type 18 of surgery, the laparoscopic sigmoid colectomy, can you 19 give me some estimate of the number that you have 20 performed up until February of '05? 21 A. Oh, God, probably eight, nine hundred up to 22 that point in time. 23 Q. And despite your extensive experience with 24 it, was it considered at that time to be a rather new 25 technique? 0018 1 A. No. It had been around for 14 years. 2 Q. Was its use as -- maybe you can help me out 3 here. Just struck me from some of the things that I 4 read about you and what you do that this was something 5 that, this type of surgery was something that you were 6 promoting over an open type of procedure because of 7 cost benefits and savings in terms of length of 8 hospital stay and that sort of thing, is that fair to 9 say? 10 A. Mostly because of decreased morbidity and 11 mortality, but cost benefits follow that. 12 Q. And were you part of any broader study that 13 went beyond your own practice with respect to this type 14 of procedure and its morbidity and mortality? 15 A. Not related to diverticular disease, but I 16 was part of a COST trial, which was the prospector 17 randomized trial on colon cancer. 18 Q. And you said COST, C-O-S-T? 19 A. Correct 20 Q. An what does that acronym stand for? 21 A. Good question. 22 Q. Okay. Can you tell me where the study was 23 published at? 24 A. I think one was in the New England Journal 25 of Medicine and a follow-up I think just came out in 0019 1 Annals of Surgery. 2 Q. And would these be in your CV? 3 A. They should be, yes. 4 Q. Okay. Do you have a current CV? 5 A. I do, yes. 6 Q. All right. I'm going, I'll ask for that and 7 we'll get it later. I appreciate maybe if you can give 8 a copy to attorney Maimbourg and I'll get in touch with 9 her and get that. 10 A. Okay. 11 Q. Thank you. In terms of complication rate 12 from this procedure, can you give me the overall 13 complication rate as a percentage of the eight or nine 14 hundred that you personally had experience performing? 15 A. Overall it's about nine percent. 16 Q. And how did that compare with an open 17 approach in your experience? 18 A. It's about a third. 19 Q. So 27 percent complication rate with the 20 open? 21 A. That would be typical in the U.S. 22 literature, yes. 23 Q. And with respect to the laparoscopic sigmoid 24 colectomy, what percentage of that nine percent would 25 be hernias? 0020 1 A. Vanishingly rare. The overall hernia rate 2 in our experience at trochar sites is less than one 3 percent. 4 Q. And let me try to understand that better. 5 One percent of the total or one percent of the nine 6 percent? 7 A. One percent of all the trochar sites. 8 Q. Okay. So if you did eight or nine hundred 9 of these you're talking about eight or nine patients 10 who had hernias? 11 A. Yeah. That presented later. In my 12 experience, no one presented immediately after surgery 13 like this aside from Mr. Biltekoff. 14 Q. And tell me what you mean then. I'm not 15 sure I follow that. Presented later. What do you 16 mean. 17 A. Year, year and a half later with a bulge at 18 one of the trochar sites. 19 Q. Okay. And what was the cause of the hernia 20 in those cases? 21 A. As it is with any hernia formation after 22 incision the failure primary healing of the closure. 23 Q. Um-hum. Was there anything about Mr. 24 Biltekoff, his anatomy, his personal behavior, you 25 know, that may have affected or led to or contributed 0021 1 to the expansion of the hematoma disrupting the closure 2 site in this particular case? 3 A. Not particularly, no. 4 Q. I know in some scenarios like orthopaedic 5 surgery smokers have a harder time healing. Did he 6 have anything like that, smoking or eating or 7 nutritional that may have contributed to this outcome? 8 A. I don't remember his body habitus, but 9 typically hematoma formation is really not directly 10 attributable to body habitus. 11 Q. Of the nine percent complication rate for 12 the laparoscopic procedure, can you give me some sense 13 about with other types of complications are involved? 14 A. Anastomotic leak runs around one, one and a 15 half percent. Then there's the risk of urinary tract 16 infection, atelectasis and some wound complications, 17 infection. 18 Q. Um-hum. In terms of obtaining Mr. 19 Biltekoff's informed consent would your practice at the 20 time have been to take him through a normal surgical 21 informed consent as opposed to doing the type of 22 informed consented that would be involved with say a 23 clinical trial or a controversial procedure? 24 MS. MAIMBOURG: I'm going to object 25 to that. I don't know what you mean. 0022 1 BY MR. KULWICKI: 2 Q. Did you understand the question, Doctor? 3 A. Not really, no. 4 Q. Okay. I have seen with clinical trials or 5 controversial procedures that physicians will take a 6 patient through a more extensive type of informed 7 consent. Have you ever done anything like that with 8 any type of new procedure or you know, unusual approach 9 to an old procedure? 10 A. When I've been involved in new procedures. 11 Q. Okay. And is there a terminology that you 12 use in terms of the type of informed consent that's 13 involved with that process? 14 A. No. When you're doing research projects 15 it's usually mandated by the the IRB in terms of what 16 is included in that discussion. 17 Q. And if I take your earlier discussion, I 18 would take it that this was not considered a new 19 procedure, nor was it part of any sort of clinical 20 study, is that true? 21 A. Correct. This is standard of care at that 22 time, 2005. 23 Q. Okay. Okay. Let me switch gears briefly 24 and talk about signs and symptoms of hernia following 25 laparoscopic sigmoid colectomy. Tell me what those 0023 1 are? 2 A. Of hernia would be a bulge. 3 Q. Okay. Anything else like pain or 4 obstruction or? 5 A. Well, not for just a simple hernia, no. 6 Those would imply a complicated hernia. 7 Q. And tell me what that term means, 8 complicated hernia? 9 A. Well, if it's an incarcerated hernia versus 10 a strangulated hernia then you would get, you would 11 progress from obstructive symptoms to maybe localized 12 pain to more diffuse abdominal pain. 13 Q. And are incarcerated and strangulated, are 14 those synonyms for one another or is incarcerated 15 without ischemia and strangulated is with ischemia? 16 A. Your latter definition is correct. 17 Q. And do the symptoms of incarcerated versus 18 strangulated, do they tend to fall on a spectrum in 19 terms of increasing pain and increasing symptomatology 20 with strangulation? 21 A. Yes. 22 Q. What about abdominal distention? Is that a 23 potential sign or symptom of an incarcerated or 24 strangulated bowel? 25 A. If there's obstruction. 0024 1 Q. I didn't get that fully. Could you say that 2 again? 3 A. If there is obstruction. 4 Q. Okay. Well then let me ask it that way. 5 Tell me what are the signs and symptoms of obstruction? 6 A. Abdominal distention, nausea and vomiting. 7 Q. Can a patient have a transient incarceration 8 of their bowel? 9 A. I suppose so, yes. 10 Q. And would that be marked by transience in 11 the signs and symptoms of incarceration? 12 A. Yes. 13 Q. Any can a patient have a transient 14 obstruction of their bowel? 15 A. In theory, yes. 16 Q. Was it his small bowel that was ultimately 17 incarcerated? 18 A. Yes. 19 Q. And in the physician's orders for this 20 particular case, there is a note that says the 21 anticipated discharge date is February 11, which would 22 be two days after the procedure. Is that a typical 23 recovery period? 24 A. Yes. 25 Q. And what about for an open procedure, what's 0025 1 the typical recovery period? 2 A. Typical length of stay would probably be six 3 to seven days. 4 Q. I think I read somewhere in your literature 5 that typical recovery period following a lap, 6 laparoscopic procedure is 3.3 days, and I can't cite 7 that to you, so don't take that as gospel, but I 8 thought that's what I read, which I thought was 9 interesting that here it was anticipated of two days. 10 Have you written somewhere that it's longer than two 11 days or has your recovery period come down in terms of 12 the length of stay because of the manner in which you 13 perform the procedure? 14 A. It would depend if you're talking mean or 15 median. 16 Q. Okay. 17 A. When we talk to the patient we usually 18 describe a median length of stay which would be about 2 19 to 2.5. And if you looked at the whole series, the 20 mean would be about 2.2, 2.3. 21 Q. Okay. 22 MS. MAIMBOURG: And Dave, just for 23 the record when I look at the order. 24 MR. KULWICKI: Yes. 25 MS. MAIMBOURG: I see an order on 0026 1 February 11 saying anticipate discharge tomorrow 2-12, 2 so I don't know where you saw that discharge was 3 anticipated 2-11. I might have missed it, but that was 4 the first note I saw. 5 MR. KULWICKI: Let's see here. 6 Yeah, it's on February 10, in the physician's orders at 7 7:00 a.m., and it's essentially the last note it says 8 anticipate discharge 2-11. 9 THE WITNESS: Yep. 10 MS. MAIMBOURG: Yeah. We found it. 11 MR. KULWICKI: Okay. 12 THE WITNESS: The reason for that 13 order was at that time we were doing discharge 14 planning. 15 BY MR. KULWICKI: 16 Q. Yes. 17 A. So it was a marker for the nurses to begin 18 discussions about anything that would be required at 19 home or necessary for a discharge. It didn't imply for 20 sure that you were going to be discharged. 21 Q. Doctor, with respect to postop complications 22 following laparoscopic procedures, does the surgeon and 23 the postop care team use the method of differential 24 diagnosis? 25 A. I'm not sure what you're asking. 0027 1 Q. Well, let me try to ask it a different way. 2 How do you define the term differential diagnosis? 3 A. Consideration of causation. 4 Q. And when a patient has an extended stay or 5 longer than usual stay and has signs or symptoms that 6 are not associated with the normal recovery, do you use 7 a differential to try to understand what's going on 8 with that patient? 9 A. Yes. 10 Q. And that's standard of care, correct, to use 11 a differential diagnosis? 12 A. Yes. 13 Q. Following laparoscopic procedures such as 14 this can you agree that the index of suspicion for 15 hernia should be high? 16 A. No. 17 Q. Why not? 18 A. Because in well over a thousand cases this 19 is the only acute one that I've seen. 20 Q. Do you typically use an NG tube in the 21 postop period for these patients? 22 A. I don't use NG tube for virtually any of my 23 patients. 24 Q. Why was it used here? 25 A. Because he had abdominal distention and 0028 1 nausea and vomiting. 2 Q. And what was the purpose of the NG tube? 3 A. To decompress the GI tract and relieve his 4 nausea. 5 Q. Doctor, what was in the differential in 6 terms of causes for the abdominal distention, nausea 7 and vomiting? 8 A. Given all of his findings, the working 9 diagnosis at that time was ileus probably secondary to 10 his hematoma in the abdominal wall. 11 Q. Is the formation of a hematoma after this 12 type of procedure unusual? 13 A. I guess it depends on how you define it. 14 It's less than one percent. 15 Q. And when I hematoma occurs following this 16 procedure, would you expect it to decrease in size over 17 successive postoperative days? 18 A. No. It would usually, you know, the handful 19 that I've seen, it would take a while for the blood to 20 be reabsorbed. 21 Q. Would you expect it to grow, though, in size 22 over successive postoperative days? 23 A. It could either stay stable or increase 24 depending if there's active bleeding or not. Sometimes 25 the clot brakes off and it bleeds secondarily. 0029 1 Q. Are there risks associated with a hematoma 2 following this type of procedure? 3 A. Well, the biggest risk would be infection 4 because blood is a good media for bacteria and there's 5 a chance that it wouldn't stop bleeding, it would need 6 surgical correction. 7 Q. And other than visually seeing the hematoma 8 expand through the surface or, you know, from 9 visualizing the belly, what would be other indicia of 10 the hematoma continuing to grow? 11 A. Well, it would eventually, you would feel a 12 bulge from it if it bled enough to push through, 13 usually stays beneath the fascia, so that would be a 14 late finding. More typical would be if he was bleeding 15 enough he would have a drop in hemoglobin or even if it 16 was vigorous enough he might drop his blood pressure. 17 Q. Tell me, what are the considerations for 18 surgical intervention in the face of a growing hematoma 19 following this type of procedure? 20 A. Really the only -- I've never had to do it, 21 but, you know, I guess the indications would be if 22 their vital signs are changing then you have to do 23 something to control the bleeding. More typically if 24 it was going to be a risk it would break through into 25 the abdominal cavity. And when there's no pressure to 0030 1 tamponade it, it would continue to bleed inside the 2 belly. 3 Q. And forgive me if I asked this, but can you 4 tell me why you believe Mr. Biltekoff's hematoma 5 continued to grow over the postoperative course? 6 A. Why it continued, only a hypothesis that 7 either the clot didn't hold or the clot broke off. 8 Q. Okay. Did he have any coagulopathies in 9 your review of the clinical picture that may have 10 caused or contributed to it? 11 A. I don't think so clinically, no. 12 Q. You used the term ileus earlier and I think 13 I know what that means but I probably ought to ask you 14 to define it. Can you tell me what you mean by that 15 term? 16 A. It's absence of effective peristalsis in the 17 GI tract. 18 Q. Are there certain clinical factors that 19 increase the risk of ileus in a post laparoscopic 20 surgery patient? 21 A. Not specific to a laparoscopic patient, no. 22 Q. In terms of that complication rate, the nine 23 percent complication rate for this type of procedure, 24 what percent of those are ileus? 25 A. Probably about a third of that. 0031 1 Q. Okay. Can we look at the progress notes, 2 and I want to ask you some questions about those. 3 A. Okay. 4 Q. Tell me when you have those ready. 5 A. I have them. 6 Q. The first one that I see is dated February 9 7 and it says postop. Is that your handwriting? 8 A. My signature, the bottom, it's the 9 handwriting of one of the residents. 10 Q. Okay. And then just so I get used to, the 11 very last thing there there's a diagonal line, a back 12 slash and then some initials, and then it looks like a 13 couple of numbers like zero two one. Is that the part 14 that you countersigned? 15 A. Yeah. It's 23711 was my pager number. 16 Q. Okay. And do you recognize who the resident 17 was that authored that note? 18 A. No, I don't. 19 Q. What does that signify that you 20 countersigned his or her note? 21 A. That, you know, basically I agreed with most 22 of the things that were said. 23 Q. Does it also signify that you were at 24 bedside and had conducted your own exam? 25 A. Yes. 0032 1 Q. All right. The next one, the next note I 2 see is February 10 of '05 and again it appears that you 3 countersigned a resident's note, is that correct? 4 A. Correct. 5 Q. Did you have a time that you normally 6 rounded on your postop patients? 7 A. Usually around between 6:30 and 7:30 in the 8 morning. 9 Q. Okay. And how many days a week in February 10 of '05 would you operate? 11 A. I mean my schedule time, if I wasn't out I 12 had blocked time on Wednesdays and then it would just 13 fit in from there. 14 Q. And did you typically operate a whole day? 15 A. It would be all day, Wednesday, yep. 16 Q. How many patients would you typically 17 operate on any day? 18 A. Four to six. 19 Q. And were they all laparoscopies? 20 A. Not necessarily. Probably majority 21 laparoscopic but not necessarily. I did the full gamut 22 of surgery. 23 Q. Was it all GI surgery? 24 A. It was all colorectal, yes. 25 Q. Okay. And Doctor, what are the signs or 0033 1 symptoms of ileus? 2 A. Abdominal distention, nausea and vomiting. 3 Q. Are hypoactive bowel sounds a sign or 4 symptom of anything? 5 A. No. I haven't listened to bowel sounds in 6 20 years. 7 Q. Is increased or decreased gas a sign or 8 symptom of anything in a postop patient? 9 A. Gas where? 10 Q. I guess just passing of gas. I'm looking at 11 a note here, February 11, '05. It looks like it's not 12 timed to second note on that page, it was February 11 13 note and it says patient ambulatory complaining of gas 14 and bloating to abdomen. Is that significant in any 15 respect? 16 A. No. After anesthesia you could expect that. 17 Q. Okay. 18 A. That was actually a nurse's note. 19 Q. Yeah, I see that. It doesn't appear that 20 you countersigned any of the notes on February 11, is 21 that correct or am I missing something? 22 A. No. Looks like I didn't sign that, no. 23 Actually I think I was gone because I belive that 24 that's Doctor Delaney's note on the 11th. 25 Q. Okay. 0034 1 A. And he was covering for me. 2 Q. Was he an attending at the time? 3 A. Correct. 4 Q. And what was his name? 5 A. Conor Delaney. 6 Q. And do you know where you were? 7 A. I suspect that was about the timeframe that 8 the Cleveland Clinic colorectal course usually occurs 9 in Florida, so I was probably on my way down there. 10 Q. And how long does that course last? 11 A. It lasted a week for various things. 12 Q. Can you tell from the record when you first 13 were involved again with this patient after February 10 14 either by phone or in person? 15 A. Actually looks like I signed the note on the 16 14th. 17 Q. Yeah, I see that. Does that mean you were 18 there in person? 19 A. I hope so. 20 Q. Okay. Well, let me just clarify that so our 21 record is clear. You would not give anyone authority 22 over the phone to countersign your signature? 23 A. I would challenge them to be able to do 24 that. 25 Q. Okay. And the impression on that date, on 0035 1 the 14th, it says ileus plus minus. Can you tell me 2 what that says? 3 A. Oh, gastroparesis. 4 Q. And what does that mean? 5 A. It's impaired emptying of the stomach. It 6 would not apply in this case. That was from my intern. 7 Q. Okay. There is some noting off to the 8 right. It says plan and there's something slash ice. 9 And then if you continue along that line there's some 10 writing over in the margin. Is that your handwriting? 11 A. The note from the intern is NG vomits again 12 and my note is yes, now, meaning put the NG tube in 13 now. 14 Q. Is an NG tube used to treat ileus? 15 A. Yes. 16 Q. And how does that work? 17 A. Decompresses the bowel. 18 Q. Tell me about treatment of ileus. Is it, is 19 it reversible? 20 A. It reverses on its own. We don't have any 21 agent to reverse it. 22 Q. Does it ever lead to more complications 23 besides the obstruction? 24 A. Patients with ileus are at risk for other 25 complications, mostly pulmonary. 0036 1 Q. How long does postop ileus typically last? 2 A. Well, it can range from three to seven days. 3 It's less frequent with laparoscopic than open, but 4 when it occurs it still can last three to seven days. 5 Q. Is there a way to test to determine whether 6 in fact your impression of ileus is in fact grounded in 7 good science? 8 A. At this stage no, you would just observe 9 them clinically. 10 Q. With respect to the nurse's notes can you 11 tell me why it is that the nurse's notes appear in the 12 physician's progress notes? 13 A. I really don't know. They don't 14 consistently go there. I was actually kind of amazed 15 to see them. 16 Q. I had deposed a couple of nurses in this 17 case and I believe it was in this case that I was told, 18 and it may have been another case that I had against 19 the clinic, I'm not sure, that part of the practice to 20 assist the physicians in keeping abreast of the nurse's 21 observations is to have a nurse one time during a day 22 or a shift, I can't remember which, make a note, sort 23 of a summary note in the physician's progress notes. 24 Were you aware of any practice like that? 25 A. No. 0037 1 Q. Is ileus painful? 2 A. It can be with distention. 3 Q. Does ileus cause or contribute to hematoma 4 formation? 5 A. No. Be more likely the reverse. 6 Q. Just flipping through here, I'm not seeing 7 after the February 14 visit where you countersigned 8 there. I'm not seeing anymore of your counter 9 signature. 10 A. Correct. 11 Q. Can you tell me if you see him again between 12 February 14 and February 17? 13 A. No. I don't think I'm back until later than 14 that. 15 MS. MAIMBOURG: Dave, he doesn't 16 have any progress notes but there is an order he signed 17 on the 15th. 18 MR. KULWICKI: I was going to get to 19 that. Thank you for pointing that out. 20 THE WITNESS: I think I probably 21 left early on the 15th. 22 BY MR. KULWICKI: 23 Q. Okay. Let's go ahead and turn to the 24 orders. And just give me an overview, Doctor, in terms 25 of your practice back in February of '05 when you had, 0038 1 you know, residents there with you and you would round 2 in the morning, I assume the residents would see the 3 patients throughout the course of the day, true? 4 A. Correct. 5 Q. And when you rounded would you typically 6 author orders yourself or would you have the resident 7 do it or was it a mix? 8 A. Mix, just whoever, whoever had the chart 9 first. 10 Q. Okay. I'm not a hundred percent familiar 11 with your signature but it seems to me in flipping 12 through your orders that the first one I see that you 13 yourself authored was on February 14. Is that correct 14 or did I miss some? 15 A. 14, no, that was mine. 16 Q. Okay. And do you see any before then? 17 A. Don't think so, no. 18 Q. Tell me what you wrote on the 14th? 19 A. 14th, NG to low intermittent suction. MPO, 20 gastrograph and enema today. 21 Q. The gastrograph, is that the same thing as a 22 barium enema? 23 A. Different contrast materials, water soluble. 24 Q. And what was the purpose for that order? 25 A. To rule out anastomotic leak. 0039 1 Q. Is it fair to say that as of the 14th you 2 were not thinking of bowel incarceration or 3 strangulation? 4 A. In a hernia, no. 5 Q. If you had been, would you have ordered a CT 6 scan? 7 A. It was purely hypothetical because I didn't 8 think that fit with the clinical picture. 9 Q. But in terms of bowel strangulation or 10 hernia is on your differential, is that how you rule it 11 out is with a CT scan? 12 A. It might be one way. I would look more on 13 physical exam for findings that made me think of that. 14 Q. Okay. And Doctor, if you could, just 15 flipping through the orders, can you tell me when's the 16 next order that it appears you authored? 17 A. Next one I wrote was on the 15th. 18 Q. And tell me what you wrote at that time? 19 A. Full liquid diet. 20 Q. Okay. And is that the last order that you 21 wrote before he went back to surgery on the 17th? 22 A. It appears so, yes. 23 Q. Okay. You've had a chance to go through 24 these records and, you know, I don't want to catch you 25 cold here and I want to make sure you have a chance to 0040 1 answer accurately. Are you comfortable that that's the 2 case? 3 A. Yeah. I don't believe I wrote an order 4 after that. 5 Q. Okay. When you were not present and doing 6 rounds, was it Doctor Delaney who covered for you 7 between February 9 and February 17 or were there other 8 attendings that covered for you? 9 A. You know, I don't know the days of the week. 10 It might have been that Doctor Delaney just rounded 11 because that was a weekend. 12 Q. Uh-huh. 13 A. And usually the person on-call would round 14 for the group. 15 Q. Was it the case with every hospitalized 16 postop patient that a physician would see them on 17 rounds every day? 18 A. Yes. 19 Q. An attending physician? 20 A. Yes, almost certainly, yes. 21 Q. Okay. Doctor, do you have an opinion to a 22 reasonable degree of medical probability as to when Mr. 23 Biltekoff's bowel became ischemic? 24 A. I think probably some time late, late on 25 the -- probably on the 17th. Either very late on the 0041 1 16th or some time early on the 17th. 2 Q. And we talked earlier and I think I used the 3 term entrapped and I think you said that you thought 4 that's when the bowel became entrapped. Do you think 5 that it became entrapped and ischemic all at once? 6 A. I think it progressed quickly, yes. 7 Q. Okay. And when do you believe the bowel 8 became necrotic? 9 A. I guess that's all the same thing in my 10 mind. Once it becomes ischemic then it can break down, 11 so it's all part of the spectrum. 12 Q. How long does it take from bowel ischemia to 13 bowel necrosis? 14 A. Could be as short as three hours, typically 15 not longer than six. 16 Q. Is bowel strangulation a medical emergency? 17 A. Yes, you would want to intervene for that. 18 Q. Is there a way to determine by signs or 19 symptoms the difference between necrosis and 20 strangulation? 21 A. Not really, no. 22 Q. Is there a point in time when the pain goes 23 away? 24 A. No, because the mechanism just changes. If 25 it's in the intestine, pain is initially in the bowel 0042 1 and the inflammation that it causes and then if it 2 becomes ischemic and disrupts, then it would cause the 3 same thing from the leakage. So typically pain doesn't 4 really defervesce. 5 Q. Is there such a thing as a partial 6 obstruction of the small bowel? 7 A. Yes. 8 Q. And what are the signs or symptoms of that? 9 A. Abdominal distention and nausea and 10 vomiting. 11 Q. Is dehydration associated with obstruction 12 of the small bowel? 13 A. If the fluids are not replaced. 14 Q. And how does that occur? 15 A. There's loss of fluid into the bowel and 16 then if the patient isn't drinking, they don't replace 17 that loss. 18 Q. What does the wound of a postop laparoscopy 19 patient typically look like? 20 A. Typically you see the little incision. 21 Q. I'm sorry, you cut out. 22 A. Typically you see the little, small incision 23 with the Band Aid on it. 24 Q. Is swelling, edema, hematoma, and redness 25 abnormal? 0043 1 A. The hematoma is unusual but we knew he had a 2 hematoma early on in his course. 3 Q. How about swelling, edema and redness? 4 A. That would all be because of the hematoma. 5 Q. I'm sort of getting a feel here for your 6 assessment as things went along here. At some point in 7 Mr. Biltekoff's stay somebody drew a circle around the 8 hematoma. Do you remember reading that? 9 A. No, I don't. 10 Q. Is that something that the nursing staff is 11 trained to do? 12 A. I have no idea. 13 Q. Is it something that you use from time to 14 time to keep an eye on hematoma formation or redness 15 and swelling to make sure it's not getting worse? 16 A. Not for hematoma, no. 17 Q. Okay. Well, is it something that you ever 18 do, draw a circle on someone's belly for purposes of 19 ongoing assessment? 20 A. Only if I think that there's a cellulitis. 21 Q. On February 11, the day of Mr. Biltekoff's 22 expected discharge, a nurse charged that there is 23 swelling that continued to swell outside of the marked 24 area as well as pain and abdominal distention. What 25 would be in the differential for that type of clinical 0044 1 picture? 2 A. What we considered it to be was the 3 hematoma. It would not be unexpected that the blood 4 would continue to dissect in the tissue and typically 5 the bruising can extend all the way down the thigh. 6 Q. Wouldn't it have been prudent to investigate 7 the bowel status prior to February 17 through CT 8 imaging? 9 A. No. 10 Q. Why not? 11 A. Because I didn't think it was prudent. 12 Q. Under what circumstances is CT imaging 13 appropriate to investigate the bowel status of a 14 patient postop laparoscopy patient who's having issues 15 with nausea, vomiting, distention, a drop in their 16 hematocrit, blood pressure decrease, a stay beyond 17 what's expected, dehydration, need for an NG tube, 18 under all of those clinical factors when is a CT scan 19 indicated? 20 A. I think you have a lot in your question. 21 You should break that up because some of those things 22 did not occur. 23 Q. Okay. All right. Well let me just try to 24 make it simpler then. When is CT imaging indicated in 25 a postop laparoscopy patients. 0045 1 A. If you're expecting an intraabdominal 2 abscess. 3 Q. If bowel strangulation is in your 4 differential, what sort of testing is indicated? 5 A. That would be suspected clinically and you 6 might not need any test at all. You might just move on 7 to laparotomy. 8 Q. Okay. And would that be if you could 9 actually palpate the bulging bowel? 10 A. Yeah, if he had a tender bulge that we were 11 impressed with then we would have acted on that 12 physical finding alone. 13 Q. Did he ever develop that in his course? 14 A. I think very late on the 17th, but certainly 15 not on the 14th or 15th. 16 Q. Okay. Is it your belief that he had an 17 ileus? 18 A. Yes. 19 Q. And then subsequently developed the 20 herniation? 21 A. Correct. 22 Q. Okay. And you said something earlier, don't 23 let me misstate this, but was it your belief that the 24 hematoma may have contributed to the ileus? 25 A. Yes. 0046 1 Q. How did that happen? 2 A. Blood if it gets in the peritoneal cavity is 3 a cause of ileus. 4 Q. Doctor, if you would kindly look at the labs 5 on February 11th? 6 A. I don't have the labs. 7 MS. MAIMBOURG: I have them. It's 8 going to a minute for him to probably to get the right 9 date. What particular labs are you looking at? 10 MR. KULWICKI: I want to have him 11 look at the HH and from February 10 to February 11. 12 THE WITNESS: Okay. 13 BY MR. KULWICKI: 14 Q. It shows the hemoglobin dropping from the 15 10th to the 11th from 10.6 to 8.5 and the hematocrit 16 dropping from 32.6 to 26 on the 11th. 17 A. Correct. 18 Q. What's the significance of that, if any? 19 A. That his hemoglobin dropped. 20 Q. And what's the potential, what's in the 21 differential for that change? 22 A. There is no differential. We thought it was 23 due to the hematoma. 24 Q. The fact that it's changing -- well, first 25 of all, do you agree that that reflects a change? 0047 1 A. Yes. 2 Q. And is that reflective of ongoing bleeding? 3 A. No. It's probably a combination of acute 4 blood loss plus resuscitation. 5 Q. So dilution through fluid? 6 A. Correct. 7 Q. Would you agree that as of February 13 Mr. 8 Biltekoff was beginning to show signs of dehydration 9 and after that point in time required fluid volume 10 replacement? 11 A. Yeah. It was consistent with his ileus that 12 we had to replace his NG tube losses. 13 Q. On February 15 it's noted that Mr. Biltekoff 14 was febrile and was experiencing crackles in his lower 15 lobes. 16 A. I'm not sure where you see that. 17 MS. MAIMBOURG: It's the progress. 18 THE WITNESS: On the 15th? 19 BY MR. KULWICKI: 20 Q. Yes. 21 A. Oh, I see. Yeah. Okay. 10:20 p.m. 22 Q. And what do you believe is the cause of 23 that? 24 A. Probably ileus. 25 Q. Tell me how ileus can cause those findings? 0048 1 A. Collapse of the small air sac, the alveolae 2 lead to release of chemicals that cause fever response. 3 Q. How about with respect to the lung sounds? 4 A. Will be the same thing, that the lungs are 5 partially collapsed so you hear rattling when you 6 listen. 7 Q. In retrospect if CT imaging had been done 8 some time between February 14 and February 16 when -- 9 or 17, whatever that timeframe is where you believe 10 that his bowel became entrapped or strangulated, 11 between those dates, the 14th and 16th or 17th, what do 12 you think imaging would likely have shown? 13 MS. MAIMBOURG: I'm going to object 14 to that. First of all, he said that he thought the 15 bowel may have become entrapped on the 16th or the 16 17th. I think he said late 16th. You're now backing 17 it up to the 14th. And this is just my suggestion, you 18 want to take a day at a time? 19 MR. KULWICKI: Well, what I'm trying 20 to do is I didn't mean to misstate that. I think you 21 may have misheard me. What I was saying is I was 22 trying to pick two endpoints, and the first endpoint is 23 the 14th and the second endpoint is late on the 16th or 24 the 17th when Doctor Senagore believes the bowel became 25 entrapped for the first time. 0049 1 BY MR. KULWICKI: 2 Q. Between those two end points do you have an 3 opinion as to what CT imaging of the abdomen likely 4 would have shown? 5 A. Likely would have shown the hematoma on the 6 abdominal sidewall. 7 Q. Do you have an opinion as to what it likely 8 would have shown in terms of the size of the hematoma? 9 A. No. I mean it would have just shown what we 10 were appreciating clinically. 11 Q. And then from that point in time when you 12 believe that the entrapment began, whether it was late 13 on the 16th or early on the 17th, had imaging been 14 done, CT imaging been done during that timeframe what 15 do you think that likely would have shown? 16 A. On which date now? 17 Q. I think your earlier testimony was that some 18 time late on the 16th or early on the 17th is when you 19 think the entrapment occurred or the incarceration 20 occurred. And what I'm asking is from that point on 21 forward to the time of surgery, if CT imaging had been 22 performed, what do you think it likely would have 23 shown? 24 A. Well, I think it was done on the 17th, so 25 you know, at that point some time that day it would 0050 1 have shown the bowel depending on what time you did it. 2 Q. And what would it have shown about the 3 bowel? 4 A. It would have just shown the bowel entrapped 5 in the hernia sac and obstructing. 6 Q. And in terms of the 16th and 17th, just to 7 clarify, you did not see the patient on those days, is 8 that correct? 9 A. Correct. 10 Q. Okay. 11 MR. KULWICKI: I may be done but I 12 want to put you on hold for a second and talk with my 13 nurse and look at my notes. I may have five minutes 14 here so why don't we take a five, ten-minute break. 15 I'll come back and then I'll wrap up in five or ten 16 minutes. 17 MS. MAIMBOURG: Are you going to 18 hang up or just put us on hold? 19 MR. KULWICKI: I'll just put you on 20 hold. 21 (Whereupon a brief pause was held 22 In the proceedings). 23 BY MR. KULWICKI: 24 Q. Doctor, we just took a ten or so minute 25 break. Is there any questions that I've asked so far 0051 1 that you wish that you had had a better opportunity to 2 expound upon or that you can state more accurately? 3 A. No. I believe I was accurate on my 4 comments. 5 Q. Okay. And for the record, Nurse Michelle 6 Mahon is no longer on the line. I had her just hang up 7 so I can finish up. 8 But Doctor, with respect to ileus, 9 is there a phenomenon related to anesthesia whereby 10 ileus occurs? 11 A. Well it's multifactorial. I'm not sure it's 12 directly related to anesthesia. There's some component 13 primarily due to narcotics. 14 Q. Okay. And is that type of ileus that's 15 related to anesthesia, does that typically have a 16 duration that should not last beyond the first postop 17 day? 18 A. No, not true. 19 Q. Tell me in your opinion how long ileus 20 related to anesthesia can persist? 21 A. There's no such thing as anesthesia related 22 ileus. There's postoperative ileus after laparotomy 23 that's multifactorial, and as I alluded to, it can last 24 anywhere from three to seven, sometimes ten days. 25 Q. And when you say multifactorial, is one of 0052 1 the potential factors the anesthesia that's used? 2 A. Can be, yes. 3 Q. And what are the other potential factors? 4 A. Inflammatory response, pain response, 5 narcotics that are given after surgery, and lack of 6 ambulation are probably the most common causes. 7 Q. Now, can you have ileus related to 8 obstruction as well? 9 A. Well, I guess it depends how you describe 10 it. Typically in our jargon we would not call those 11 the same things. Ileus implies impaired motility. 12 Obstruction is a different phenomenon, although in some 13 textbooks they use the word interchangeably, which I 14 think is inaccurate? 15 Q. With respect to the hematoma formation that 16 was at issue in this case, is it the case that that 17 type of hematoma can grow internally as well as 18 externally? 19 A. In theory it could, yes. 20 Q. And I'm just trying to feature in my mind 21 how that would disrupt the sutures. Can you describe 22 the type of sutures that you use for this procedure? 23 A. I can't recall exactly. Usually I use 24 Vicryl so it's a resorbable suture. It's just a 25 pressure phenomenon, really. There's a certain amount 0053 1 of tensile strength that a suture will hold and there's 2 a certain amount of tensile strength that the fascia 3 will hold, particularly on the inside because the 4 abdominal wall on that level, the thickest layer is 5 above the muscle and the thinnest layer is posterior. 6 So if it's bleeding in the muscle there would be less 7 strength underneath it and that might be the place that 8 would open first, and then over time it would disrupt 9 the anterior closure. 10 Q. So it doesn't actually eat away at the 11 sutures or decrease their tensile strength? 12 A. I don't believe so, no. And I don't think 13 there was enough time here for infection to set up. I 14 think it was if anything it was mostly a pressure 15 phenomenon. 16 Q. And again, trying to understand this better, 17 is it your belief that the pressure caused the sutures 18 to tear lose from the skin into which they were sewn? 19 A. Into the fascia. I can't say it with 20 certainty if it was the suture that broke under the 21 pressure or that the fascia tore through. Functionally 22 they end up the same way. 23 Q. Was there any report made of this particular 24 complication in the literature? 25 A. No. I mean it's so infrequent that no one 0054 1 really writes about it. 2 Q. Well I'm talking about his case in 3 particular. I know sometimes things that are extremely 4 rare or unusual, physicians will sometimes report on 5 them as case reports. Was there a case report prepared 6 regarding Mr. Biltekoff? 7 A. Not that I'm aware of, no. 8 Q. Do you have any specific recollection of 9 discussions with the surgeons who investigated that 10 suture line when they reopened him back up in terms of 11 their discussion of what they found? 12 A. No. 13 Q. Can distention from an ileus cause 14 disruption of sutures? 15 A. It can. 16 Q. So it's not so much the hematoma, the ileus 17 that's the concern, it's the distention and the 18 pressure caused from the distention that's the concern, 19 right? 20 A. Of which now, I'm sorry? 21 Q. I'm just trying to understand mechanically 22 what happens here. And my question is, it's not 23 necessarily the ileus or the hematoma that is the 24 concern, it's the distention that they cause that's the 25 concern in terms of loosening the sutures? 0055 1 A. Well I think they're not synonymous. I 2 think that in my mind in this case it was the pressure 3 caused by the hematoma that resulted in the hernia to 4 form. 5 Q. Yeah. 6 A. And the ileus was not a component. 7 Sometimes in midline incisions the ileus can disrupt 8 the midline wound, but I don't think that played a role 9 here. 10 Q. Is that because of the distention from an 11 ileus tends to be in a different place than the 12 distention from a hematoma? 13 A. Well, because the wound is much smaller here 14 it's really not enough force to bring to bear locally. 15 In a long midline incision because it's a much longer 16 incision and it's the part that feels the central 17 pressure from significant abdominal distention that 18 it's a bigger risk with a vertical midline incision. 19 And that does correlate with dehiscence and hernia and 20 all of those wound complications. 21 Q. Okay. With respect to diagnosing a bowel 22 obstruction, can you have bowel obstruction or partial 23 bowel obstruction that's not apparent by simply looking 24 at the patient? 25 A. Yes. 0056 1 Q. And can you have bowel obstruction that can 2 be missed on CT imaging? 3 A. Well, I mean if you have a complete bowel 4 obstruction, usually CT will identify that, much like 5 small bowel series will identify a complete bowel 6 obstruction, but partial might be a tough call. 7 Q. If there's a discrepancy between imaging and 8 clinical signs and symptoms that point to a bowel 9 obstruction, does that warrant further investigation? 10 A. No. Clinical judgement would dictate where 11 to go next. 12 Q. And what are the options that a physician 13 has if the imaging isn't reflective of a partial 14 obstruction or a complete obstruction yet symptoms are 15 consistent with an obstruction, what's in your arsenal 16 to try to ferret out what's going on? 17 A. Well in the absence of defining a complete 18 bowel obstruction, then we might not do anymore 19 diagnostic studies. We might just watch the patient 20 and wait for it to resolve on its own, and the odds are 21 very good that that will happen. 22 Q. Short of improvement, are there other 23 diagnostic modalities available to you to try to 24 determine whether there's an obstruction? 25 A. Aside from CT scan and small bowel series, 0057 1 not that I'm aware of. 2 Q. And you use the term small bowel series. Is 3 that the same thing as the water soluble enema? 4 A. No. This would be contrast from above. 5 Q. Okay. And that wasn't done with this 6 particular patient? 7 A. It was done actually. 8 Q. It was? 9 A. Yeah. Completed on the 16th and showed 10 contrast -- no evidence of -- it was read as consistent 11 with bowel obstruction, but the contrast went through. 12 And, in fact, an x-ray, I believe, on the 16th or 13 actually the morning of the 17th actually show no 14 contrast in the small bowel but contrast in the colon 15 which would be consistent with small bowel obstruction 16 and/or ileus. 17 Q. Do you have the physician who ordered that 18 study or are you looking at the report? 19 A. I'm just looking at the report. I don't 20 know who ordered it. 21 MR. KULWICKI: Doctor. Thank you 22 very much for your time and good luck with your new 23 venture, and counsel can advise you with respect to 24 your right to review this and sign off on it and I very 25 much appreciate your patience, Doctor? 0058 1 THE WITNESS: Thank you. 2 MS. MAIMBOURG: Dave, we're going to 3 have him read it. 4 MR. KULWICKI: Take whatever time 5 you need. We're no rush, obviously. 6 (Deposition concluded at 10:50 a.m.). 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0059 1 CERTIFICATE OF NOTARY 2 3 STATE OF MICHIGAN ) 4 ) SS 5 COUNTY OF OAKLAND ) 6 I, Melinda R. Womack, Certified Shorthand 7 Reporter, a Notary Public in and for the above county 8 and state, do hereby certify that the above deposition 9 was taken before me at the time and place hereinbefore 10 set forth; that the witness was by me first duly sworn 11 to testify to the truth, and nothing but the truth, 12 that the foregoing questions asked and answers made by 13 the witness were duly recorded by me stenographically 14 and reduced to computer transcription; that this is a 15 true, full and correct transcript of my stenographic 16 notes so taken; and that I am not related to, nor of 17 counsel to either party nor interested in the event of 18 this cause. 19 20 21 ___________________________ 22 Melinda R. Womack, CSR3611 23 Notary Public, 24 Oakland County, Michigan 25 My Commission expires: 6-22-11 0060 1 CAPTION 2 The Deposition of ANTHONY SENAGORE, M.D., taken 3 in the matter, on the date, and at the time and 4 place set out on the title page hereof. 5 It was requested that the deposition be taken 6 by the reporter and that same be reduced to 7 typewritten form. 8 It was agreed by and between counsel and the 9 parties that the Deponent will read and sign the 10 transcript of said deposition. 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 0061 1 CERTIFICATE 2 STATE OF : 3 COUNTY/CITY OF : 4 Before me, this day, personally appeared, 5 ANTHONY SENAGORE, M.D., who, being duly sworn, states that the 6 foregoing transcript of his/her Deposition, taken in the 7 matter, on the date, and at the time and place set out 8 on the title page hereof, constitutes a true and accurate 9 transcript of said deposition. 10 _________________________ 11 ANTHONY SENAGORE, M.D. 12 13 SUBSCRIBED and SWORN to before me this 14 _______day of_________________, 2006 in the 15 jurisdiction aforesaid. 16 17 _____________________ ________________________ 18 My Commission Expires Notary Public 19 20 *If no changes need to be made on the following two pages, 21 place a check here ____, and return only this signed page.* 22 23 24 25 0062 1 DEPOSITION ERRATA SHEET 2 RE: SetDepo, Inc. 3 File No. 15058 4 Case Caption: STEVEN BILTEKOFF et al. 5 vs. THE CLEVELAND CLINIC FOUNDATION 6 Deponent: ANTHONY SENAGORE, M.D. 7 Deposition Date: October 22, 2007 8 To the Reporter: 9 I have read the entire transcript of my Deposition taken 10 in the captioned matter or the same has been read to me. 11 I request that the following changes be entered upon the 12 record for the reasons indicated. I have signed my name to 13 the Errata Sheet and the appropriate Certificate and 14 authorize you to attach both to the original transcript. 15 16 Page No._____Line No._____Change to:________________________ 17 ____________________________________________________________ 18 Reason for change:__________________________________________ 19 Page No._____Line No._____Change to:________________________ 20 ____________________________________________________________ 21 Reason for change:__________________________________________ 22 Page No._____Line No._____Change to:________________________ 23 ____________________________________________________________ 24 Reason for change:__________________________________________ 25 0063 1 Deposition of ANTHONY SENAGORE, M.D. 2 Page No._____Line No._____Change to:________________________ 3 ____________________________________________________________ 4 Reason for change:__________________________________________ 5 Page No._____Line No._____Change to:________________________ 6 ____________________________________________________________ 7 Reason for change:__________________________________________ 8 Page No._____Line No._____Change to:________________________ 9 ____________________________________________________________ 10 Reason for change:__________________________________________ 11 Page No._____Line No._____Change to:________________________ 12 ____________________________________________________________ 13 Reason for change:__________________________________________ 14 Page No._____Line No._____Change to:________________________ 15 ____________________________________________________________ 16 Reason for change:__________________________________________ 17 Page No._____Line No._____Change to:________________________ 18 ____________________________________________________________ 19 Reason for change:__________________________________________ 20 21 SIGNATURE:__________________________________DATE:___________ 22 ANTHONY SENAGORE, M.D. 23 24 25