Medico‐legal aspects of ureteric damage during abdominal hysterectomy

Sir, We write to express our dismay on reading Mr Brudenell’s article (Vol 103, December 1996)’ which tells us that judges are now to dictate details of operative technique, on the basis of the testimony of ‘expert’ witnesses. As fairly experienced pelvic surgeons, we find it difficult to recognise the picture that seems to have been portrayed by these ‘experts’. When bleeding arises from veins in the pelvis in the course of a pelvic dissection our first concern has always been to stop the bleeding. Of course we put in packs: of course we try to sutureligate only where we can see. Of course we are fearful of the nearby ureter. But all the time the blood keeps welling up and our first concern is to save life by stopping the bleeding. Now we are told that whenever the ureter is damaged, this is ips0 fact0 negligence and that res ipse loquitur; as if putting it all into dog-Latin somehow makes it any more true. There is now, it seems, a simple new equation: ureteric damage during pelvic surgery = E100,OOO in damages and lawyers’ fees. There is a sinister consequence of this equation. Imagine a pelvic surgeon faced with uncontrollable bleeding. Would he not be wiser to let the patient bleed to death, than try to stop the bleeding and thereby put the ureter at hazard? Sadly, it seems that a few of our colleagues feel obliged to testify that when anything goes wrong in an operation (so long as it has been done by somebody else) there must have been negligence. Surgeons who have considerable experience in operating in the pelvis are well aware that from time to time one can encounter tremendous bleeding from pelvic veins. The loss of blood can be life threatening. Putting in a pack may not stop the bleeding. The normal anatomical landmarks are obscured. Under these circumstances injury to the ureter surely does not necessarily imply negligence. Those with even more experience will admit that even when there is no unusual bleeding, and every care has been taken, it is still possible to injure a ureter. It has happened to each of us. We suspect that it has happened to these so-called ‘experts’. Why are they so eager to cast the first stone?