by Mr Paul Sutton
Introduction and incidence
Iatrogenic injuries — those unintentionally caused during medical treatment — are a recognised risk in abdominal and pelvic surgery. Even the most carefully planned and executed operations carry inherent risks. The abdomen and pelvis contain closely related structures which are anatomically variable, and frequently distorted by pathology, particularly in those patients with advanced malignancy, inflammatory bowel disease, or previous surgery.
Article by Mr Paul Sutton a Consultant Colorectal, Pelvic and Peritoneal Surgeon and Expert Witness at McCollum Consultants, this article explains how iatrogenic injuries occur, why many are accepted surgical risks rather than evidence of negligence, and what clinical and documentary features may indicate a breach of duty.
National data from the NHS and studies published in the UK surgical literature confirm these risks:
- Ureteric injury is reported in 0.3–1% of colorectal resections
- Inadvertent bowel injury can occur during laparoscopic procedures in up to 0.5% of cases.
- Vascular injuries, though rare, can be catastrophic and carry a risk of significant morbidity and mortality.
These injuries are often accepted complications when identified early and managed appropriately. However, in the context of an adverse outcome, particularly if the injury was missed, inappropriately handled, or inadequately consented for, questions of liability inevitably arise. For the legal teams handling such cases, understanding the distinction between recognised complications and avoidable harm is crucial.
Issues of consent
In the UK legal landscape, consent has evolved significantly following the landmark judgment in Montgomery v Lanarkshire Health Board [2015]. The ruling reaffirmed the shift from the Bolam test towards a patient-centred standard: patients must be informed of all material risks that a reasonable person in the patient’s position would likely attach significance to.
As a surgeon, this mandates a proactive, individualised approach to the consent process. As an example, when consenting a patient for an anterior resection, I must disclose the risks of iatrogenic injury to the bladder, ureter, bowel, or major vessels, however rare — especially if they may necessitate further intervention such as stoma formation or re-operation. A 0.5% risk of ureteric injury may be small, but if it results in a nephrostomy and loss of renal function, a court may consider the risk material and worthy of specific discussion.
This must be documented clearly in the consent form and correspondence from the outpatient clinic. A generic or incomplete consent form that omits serious or specific risks — particularly in high-risk or complex surgery — may well be seen as a breach of duty. Courts and legal professionals increasingly scrutinise the quality, not just the presence, of the documented consent. It is however feasible that an unexpected iatrogenic injury could occur which was not foreseen, and therefore not explicitly discussed as part of the consent process. This does not necessarily equate to a breach of duty.
Recognised Complications vs Negligence
Many iatrogenic injuries occur despite meticulous care and are recognised surgical complications. This is particularly true especially in hostile operative fields such as advanced malignancy, inflamed tissue, distorted anatomy, or extensive adhesions from previous operations. In cases of rectal cancer or diverticular disease, for instance, the inherent pathology may lead to anatomical variation which can make dissection hazardous, even in expert hands. The ureter may be displaced or obscured, and small bowel loops may be densely adhered. In such cases, injury may occur despite adequate pre-operative planning and meticulous surgical technique.
These events are reflected in national guidance and case studies. The Association of Coloproctology of Great Britain and Ireland (ACPGBI), along with the National Institute for Health and Care Excellence (NICE), outline many such injuries as recognised risks. When such complications are promptly recognised, appropriately treated, and disclosed, the care is generally considered to meet the expected standard. Lawyers reviewing such cases must be cautious not to conflate complication with breach.
Situations where breach of duty may apply
There are, however, clear areas where iatrogenic injury may reflect substandard care.
These include:
A) Inadequate Surgical Planning
Failure to properly assess and prepare for surgery can lead to avoidable injuries. For example, failing to obtain and/or review adequate preoperative imaging or not planning appropriately for challenges that may have been apparent from that imaging may constitute a breach. Multidisciplinary collaboration is a hallmark of modern surgical practice, and the absence of such planning, when clearly indicated, may also represent a breach.
B) Not Involving Other Specialists
In complex surgery where other anatomical systems are at risk, it may be negligent not to involve other relevant specialists. For example, continuing a difficult pelvic dissection in the presence of distorted ureteric anatomy without urological input can be unsafe. Intraoperative decisions must be made in the context of team-based care. Where appropriate multi-specialty assistance is not sought despite signs of difficulty, a question arises as to whether a reasonably competent surgeon would have escalated.
C) Not Asking for Help
One of the cultural shifts in modern surgery is a greater openness to intraoperative assistance. A solitary approach in a difficult case, particularly when other help is available but not requested, may be considered a breach. Junior surgeons operating whilst remotely supervised, particularly at night or in emergencies, must know when to escalate. Documentation of intraoperative findings and decision-making is key in defending or challenging these decisions.
D) Not Recognising the Injury
Failure to identify an injury — especially when there were clear intraoperative warning signs — can be indefensible. For instance, failing to check for ureteric integrity after a difficult pelvic dissection, or ignoring ongoing bleeding, may represent negligent care. Postoperatively, failing to detect a ureteric transection despite haematuria, abnormal drain output, or altered haemodynamics, may suggest a lack of appropriate vigilance. Similarly, missing a small bowel injury during adhesiolysis, especially if postoperative signs such as fever, tachycardia, or raised inflammatory markers are ignored, can lead to devastating outcomes for the patients which can be difficult to defend. The NHS Resolution’s 2020 report on learning from claims identified delay in recognising intraoperative injury and failure to escalate as recurring themes in high-value cases.
E) Failure to Salvage
Once an injury is identified, appropriate and timely management is crucial. For example, a bowel injury discovered intraoperatively must be repaired appropriately or resected. If a repair is performed under tension or in hostile conditions without consideration for diversion or resection, this may fall below the standard of care. If sepsis or leak is suspected postoperatively, returning to theatre promptly and early involvement of critical care teams is essential. In the face of a recognised injury, an inadequate response, whether due to inexperience, inadequate decision making, or system issues, could be viewed as a compounding breach, even if the original injury was within the bounds of accepted complications.
For injury lawyers, the focus in breach analysis should often be on recognition and response rather than the occurrence of injury. Operative notes, post-operative reviews, and escalation records are critical evidential documents.
The role of expert surgical evidence
In most iatrogenic injury claims, expert surgical opinion is essential to determine whether the actions taken were within the reasonable range of accepted surgical practice. An expert witness will evaluate:
- The quality and interpretation of pre-operative planning and imaging
- The conduct and documentation of the operation
- The timeliness of recognition and management of complications
- The adequacy of postoperative monitoring and escalation
Conclusion
Iatrogenic injury during abdominal and colorectal surgery remains a challenging area at the intersection of surgical risk and legal scrutiny. From the surgeon’s perspective, many such injuries are unavoidable, recognised complications of high-risk or complex surgery. However, the hallmarks of defensible care include a robust, individualised consent process, careful preoperative planning, seeking help when needed, timely recognition and management of complications, and clear and contemporaneous documentation.
For UK medical negligence lawyers, differentiating between an accepted complication and substandard care requires a nuanced understanding of the specific surgical scenario, taken in context of current surgical practice, clinical guidelines, and legal standards. It is important to discern whether the care provided met the standard expected of a reasonably competent practitioner in similar circumstances. Understanding the clinical realities, the standard of care, and acceptable variation in surgical practice is key to assessing liability in these complex and often emotive cases.