Averting complications of laparoscopy: Pearls from 5 patients
Ureter, bladder, small bowel, colon, vascular system—all are at risk of damage during operative laparoscopy
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<huc>Q.</huc>What is the only surgical procedure that is completely safe?
<huc>A.</huc>The surgical procedure that is not performed.
The unfortunate truth is that complications can occur during any operative procedure, despite our best efforts—and laparoscopy is no exception. Being vigilant for iatrogenic injuries, both during and after surgery, and ensuring that repairs are both thorough and timely, are two of our best weapons against major complications, along with meticulous technique and adequate experience.
This article features five cases that illustrate some of the most serious complications of laparoscopy—and how to prevent and manage them.
CASE 1: Surgical patient returns with signs of ureteral injury
A 42-year-old woman with a history of endometriosis undergoes laparoscopic hysterectomy and bilateral salpingo-oophorectomy. She is discharged 2 days later. Two days after that, she returns to the hospital complaining of fluid leaking from the vagina. She has no fever or any other significant complaint or physical findings other than abdominal tenderness, which is to be expected after surgery. A computed tomography (CT) scan with intravenous (IV) contrast reveals left ureteral obstruction near the bladder, with extravasation of contrast media into the abdominal cavity. Further investigation reveals a left ureteral transection.
Could this injury have been avoided? How should it be managed?
Postoperative diagnosis of ureteral injury can be challenging, in part because up to 50% of unilateral cases are asymptomatic. Be on the lookout for this complication in women who have undergone pelvic sidewall dissection or laparoscopic hysterectomy, such as the patient in the case just described. As the number of laparoscopic hysterectomies and retroperitoneal procedures has risen in recent years, so has the rate of ureteral injury, with an incidence of 0.3% to 2%.1,2
Ureteral injury can be caused by ligation, ischemia, resection, transection, crushing, or angulation. Three sites are particularly troublesome: the infundibulopelvic ligament, ovarian fossa, and ureteral tunnel.3,4 In Case 1, injury to the ureter was proximal to the bladder and probably occurred during transection of the uterosacral cardinal ligament complex.
What’s the best preventive strategy?
Meticulous technique is imperative to protect the ureters. This includes adequate visualization, intraperitoneal or retroperitoneal dissection, and early identification of the ureter. In a high-risk patient likely to have distorted anatomy due to severe endometriosis and fibrosis, retroperitoneal dissection of any adhesions or tumor and identification of the ureter are the best ways to avoid injury.
Intraperitoneal identification and dissection of the ureters can be enhanced by hydrodissection and resection of the affected peritoneum.3,4 To create a safe operating plane, make a small opening in the peritoneum below the ureter and inject 50 to 100 mL of lactated Ringer’s solution along the course of the ureter, which will displace it laterally.5
Although neither IV indigo carmine nor ureteral catheterization has been shown to reduce the risk of ureteral injury or identify ligation or thermal injury,3,6 both can help the surgeon identify intraoperative perforation of the ureter. Liberal use of cystoscopy with indigo carmine administration for identification of ureteral flow and ureteral catheterization can be used in potentially high-risk patients. If there is suspicion for devascularization or thermal injury, use prophylactic ureteral stents postoperatively for 2 to 4 weeks.
Don’t hesitate to consult a urologist
In Case 1, the surgeon sought immediate urologic consultation and the patient underwent laparotomy with ureteroneocystotomy without sequelae.
In general, management of ureteral injury depends on its severity and location, as well as the comfort level of the surgeon. Minor injuries are sometimes managed with cystoscopic stent placement, but more severe cases may require operative ureteral repair.
In cases like this one, where ureteral injury occurred in close proximity to the bladder, a ureteroneocystotomy is possible. However, in more cephalad injuries, there may be insufficient residual ureter to allow such a repair. In these cases, a Boari flap may be attempted to use bladder tissue to bridge the gap to the ureteral edge. Rarely, in high ureteral injuries, trans-ureteroureterostomy may be appropriate. This procedure carries the greatest risk, given that both kidneys are reliant on one ureter.
Is laparoscopic repair reasonable?
When surgical intervention is necessary, the choice between laparoscopy and laparotomy depends on the skill and comfort level of the surgeon and the availability of instruments and support team.6,7 That said, ureteral injury is usually treated via laparotomy.1 As operative laparoscopy becomes even more commonplace, reconstruction of the urinary system will increasingly be managed laparoscopically.
CASE 2: Postoperative symptoms lead to rehospitalization
A 35-year-old patient undergoes laparoscopic ovarian cystectomy and returns home the same day. She is readmitted 72 hours later because of lower abdominal tenderness, worsening nausea and vomiting, and urine-like drainage from her midline suprapubic trocar site. Analysis of the leaking fluid shows high creatinine levels consistent with urine. The patient has no fever and is hemodynamically stable. Examination reveals a moderately distended abdomen with decreased bowel sounds. Hematuria is evident on urine analysis.
Urologic consultation is obtained, and the patient undergoes simultaneous laparoscopy and cystoscopy, during which perforation of the bladder dome is discovered, apparently caused by the mid suprapubic trocar. The bladder is mobilized anteriorly, and both anterior and posterior aspects of the perforation are repaired in one layer laparoscopically.
After continuous drainage with a transurethral Foley catheter for 7 days, cystography shows complete healing of the bladder, and the Foley catheter is removed. The patient recovers completely.
Vesical injury sometimes occurs in patients who have a history of laparotomy, a full bladder at the time of surgery, or displaced anatomy due to pelvic adhesions.11 Although bladder injury is rare, laparoscopy increases the risk. Trocars, uterine manipulators, and blunt instruments can perforate or lacerate the bladder, and energy devices can cause thermal injury. The risk of bladder injury increases during laparoscopic hysterectomy.
Be vigilant about trocar placement and dissection techniques
Accessory trocars can injure a full bladder. Injury can also occur when distorted anatomy from a previous pelvic operation obscures bladder boundaries, making insertion of the midline trocar potentially perilous (FIGURE 1). The Veress needle and Rubin’s cannula can perforate the bladder.11-13 And in the anterior cul-de-sac, adhesiolysis, deep coagulation, laser ablation, or sharp excision of endometriosis implants can predispose a patient to bladder injury.
In women with severe endometriosis, lower-segment myoma, or a history of cesarean section, the bladder is vulnerable to laceration when blunt dissection is used during laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH). A vesical injury also can occur at the time of laparoscopic bladder-neck suspension upon entry into, and dissection of, the space of Retzius.
FIGURE 1 A bladder at risk
In this patient with a previous cesarean section, the bladder is adherent to the anterior abdominal wall. Needle mapping in the conventional midline trocar position indicates that the trocar must be relocated to avoid bladder injury.
Intraoperative findings that suggest bladder injury include air in the urinary catheter, hematuria, trocar site drainage of urine, or indigo carmine leakage. Postoperative signs and symptoms include leaking from incisional sites, a mass in the abdominal wall, and abdominal swelling.
Liberal use of cystoscopy or distension of the bladder with 300 to 500 mL of normal saline is recommended whenever there is a suspicion of bladder injury, especially during laparoscopic hysterectomy or LAVH. When a trocar causes the injury, look for both entry and exit punctures, both of which should be treated.
No matter how much care is taken, some bladder injuries, such as vesicovaginal fistulae, become apparent only postoperatively. More rarely, peritonitis or pseudoascites herald the injury. Retrograde cystography may aid identification.
Treatment of bladder injuries
Small perforations recognized intraoperatively may be conservatively managed by postoperative bladder drainage for 5 to 7 days. Most other bladder injuries require prompt intervention. For example, trocar injury to the bladder dome requires one- or two-layer closure followed by 5 to 7 days of urinary drainage. (Both closing and healing are promoted by drainage.)
CASE 3: Postop pain, tachycardia
A 41-year-old obese woman undergoes laparoscopic cystectomy for an 8-cm left ovarian mass. The abdomen is entered on the second attempt with a long Veress needle. The umbilical trocar is reinserted “several” times because of difficulty opening the peritoneum with the tip of the trocar sheath. The surgical procedure is completed within 2 hours, and the patient is discharged 23 hours later.
The next day, she experiences increasing abdominal pain and presents to the emergency room. Upon admission she reports intermittent chills, but denies nausea and vomiting. She is in mild distress, pale and tachycardic, with a temperature of 96.4°, pulse of 117, respiration rate of 20, blood pressure of 106/64 mm Hg, and oxygen saturation of 92%. She also has a diffusely tender abdomen but normal blood work. Abdominal and chest x-rays show a large right subphrenic air-fluid level that is consistent with free intraperitoneal air, unsurprising given her recent surgery. Bibasilar atelectasis and consolidation are noted on the initial chest x-ray.
During observation over the next 2 days, she remains afebrile and tachycardic, but her shortness of breath becomes progressively worse. Neither spiral CT nor lower-extremity Doppler suggests pulmonary embolism or deep venous thrombosis. Supplemental oxygen, aggressive pain management, albuterol, ipratropium, and acetylcysteine are initiated after pulmonary consultation.
The patient tolerates a regular diet on postoperative day 3 and has a bowel movement on day 5. However, the same day she begins vomiting and reports worsening abdominal pain. CT imaging of the abdomen and pelvis reveals free air in the abdomen and loculated fluid with air bubbles suspicious for intra-abdominal infection and perforated bowel.
Exploratory laparotomy reveals diffuse feculent peritonitis, as well as food particles and contrast media. There is a perforation in the antimesenteric side of the ileum approximately 1.5 feet proximal to the ileocecal valve. This perforation measures approximately 1 cm in diameter and is freely spilling intestinal contents. Small bowel resection is performed to treat the perforation.
Following the surgery, the patient recovers slowly.
Could the bowel perforation have been detected sooner?
Intestinal tract injury is a serious complication, particularly with postoperative diagnosis.15 Damage can occur during insertion of the Veress needle or trocar when the bowel is immobilized by adhesions, or during enterolysis.16 Unrecognized thermal injury can cause delayed bowel injury.
Small-bowel damage often occurs during uncontrolled insertion of the Veress needle or primary umbilical trocar. It also may result from sharp dissection or thermal injury.17,18 Abrasions and lacerations can occur if traction is exerted on the bowel using serrated graspers. When adhesions are dense and tissue planes poorly defined, the risk of laceration due to energy sources or sharp dissection increases.
Be cautious during bowel manipulation. Avoid blunt dissection. Be especially careful when the small bowel is adherent to the anterior abdominal wall (FIGURE 2A), particularly during evaluation of patients with a history of bowel resection, exploratory laparotomy for trauma-related peritonitis, or tumor debulking.