How to avoid injury to bowel during laparoscopy
Be reluctant to perform laparoscopy in a patient known to have significant adhesions. Also, be aware of risk of injury at trocar entry and mindful of how you use energy devices.
IN THIS ARTICLE
The author reports no financial relationships relevant to this article.
CASE Postoperative abdominal pain. Is it gastroenteritis?
R.B., 35 years old, undergoes laparoscopic adhesiolysis for abdominal pain. Previously, she underwent exploratory laparotomy for a ruptured tubal pregnancy and, in separate operations, right oophorectomy via laparotomy for a ruptured corpus luteum cyst and diagnostic laparoscopy.
During the current surgery, extensive adhesions are observed, including interloop intestinal adhesions. The adhesions are lysed using monopolar scissors and a needle electrode, and R.B. is discharged home the same day.
Later that day and the next day, R.B. complains of abdominal pain that does not respond to prescribed analgesics, as well as nausea and vomiting. A nurse practitioner takes her call and prescribes a stronger analgesic, an antiemetic, and an antibiotic.
The following day, the patient’s husband telephones the treating gynecologist to report that his wife is still experiencing severe pain and nausea. He is told to bring her to the office, where she is described as having mild lower abdominal tenderness and mild rebound. An abdominal radiograph shows air-fluid levels and distended bowel. The gynecologist determines that the patient is experiencing gastroenteritis.
On postop day 3, R.B. continues to suffer from severe abdominal pain, nausea, and vomiting, and is unable to get out of bed. Her husband takes her to the emergency room at another hospital, where she is found to have diffuse peritonitis, absent bowel sounds, and:
- temperature, 101.8°F
- heart rate, 130/min
- respiratory rate, 24/min
- blood pressure, 90/60 mm Hg
- white blood cell (WBC) count, 21.5 × 103/μL
- x-ray showing free air.
A general surgeon performs an exploratory laparotomy and finds foul-smelling abdominal fluid, 200 to 300 mL of pus, and a 1-cm perforation of the sigmoid colon. He performs sigmoid colon resection and a left-colon colostomy. A second laparotomy is necessary to drain a subphrenic abscess.
Four months later, the colostomy is taken down and bowel continuity is established.
Subsequently, the patient experiences episodes of gaseous and fecal incontinence, which are thought to be secondary to nerve damage. A ventral hernia is also diagnosed.
Could this outcome have been avoided?
No physician would wish a major complication of surgery upon any patient. Yet, sometimes, preventive efforts fall short of the goal or the physician is slow to suspect injury when the patient experiences postoperative abdominal pain and other symptoms. Intestinal injury may not be common during laparoscopy, but it is certainly not rare. And the longer diagnosis is delayed, the greater the risk of sepsis, even death.
Recognizing the limitations of laparoscopic surgery is a first step toward reducing the complication rate. 1,2 The ability to determine when laparotomy would better serve the patient’s interests is also critical, and prompt diagnosis and repair of any complication that does occur will ensure and speed the patient’s recovery.
The most serious complications associated with diagnostic and operative laparoscopy are major vessel and intestinal injuries. Both types of injury significantly raise the risk of mortality, which ranges from 2% to 23%. 3,4 The overall risk of injury to the gastrointestinal tract averages 1.6 to 2.0 for every 1,000 cases. The risk of major vessel injury averages 0.5 for every 1,000 cases. 5-9
In an earlier article for OBG Management, I reviewed vascular injury during laparoscopy. 10 In Part 1 of this article, I focus on ways to avoid intestinal injury.In Part 2 , I outline strategies to identify it in a timely manner when it does occur.
10 ways to lower the risk of intestinal injury
- Avoid laparoscopy when severe adhesions are anticipated—such as when the patient has a history of multiple laparotomies, or when significant adhesions have been documented.
- Be aware that laparoscopy carries additional risks beyond those of the primary surgical procedure, owing to factors peculiar to endoscopic technique and instrumentation.
- Consider open laparoscopy or insert the primary trocar at an alternative location, such as the left upper quadrant, when the patient has a history of laparotomy.
- Avoid blunt dissection for anything other than mild (filmy) adhesions. Sharp dissection associated with hydrodissection is the safest method of adhesiolysis. Clear visualization of the operative site is the sine qua non for precise dissection.
- Avoid monopolar electrosurgical devices for laparoscopic surgery whenever possible. Also remember that bipolar and ultrasonic devices can cause thermal injury by heat conduction as well as by direct application. Laser energy will continue beyond the target unless provision is made to absorb the residual energy.
- At the conclusion of any laparoscopic procedure, especially after adhesiolysis or bowel dissection, inspect the intestines and include the details in the operative report.
- After any laparoscopic procedure, if the patient does not improve steadily, the first presumptive diagnosis to be excluded is injury secondary to the procedure or technique.
- The major symptom of intestinal perforation is abdominal pain, which does not ease without increasing quantities of analgesics.
- Investigate any bowel injury thoroughly to determine viability at the site of injury. Whenever possible, repair all injuries intraoperatively.
- After intestinal perforation, the risk of sepsis is high. Look for early signs such as tachycardia, subnormal body temperature, depressed WBC count, and the appearance of immature white cell elements.
Familiarity with intestinal and pelvic anatomy can prevent surgical injury
A thorough familiarity with pelvic anatomy is important to avoid injury at trocar entry, but it is even more critical in regard to operative injury. The small intestine spreads diffusely throughout the abdomen beneath the anterior abdominal wall. It lies beneath the umbilicus and anterior midline, whereas the large bowel is located at the periphery. The sigmoid colon swings left to right before joining the rectum anterior to the presacral space. The sigmoid junction with the descending colon lies well to the left of the midline, and the cecum lies at the pelvic brim to the right of midline.
In some women, the intestines droop into the pelvis and cover the adnexa, making adhesions between these structures highly likely following dissection in the vicinity of the tubes and ovaries.
Depending on the degree of redundancy of the mesentery of the cecum or sigmoid colon, these structures may droop into the pelvis and cover the adnexa. Therefore, adhesions are likely to develop between the large or small intestine, or both, and the adnexa following dissection in the vicinity of or immediately over the tubes and ovaries. Knowing the normal anatomic relationships is vital for restorative surgery.
When severe adhesions involve the large intestine, it is critical to know the anatomy of the retroperitoneum and be skilled enough to gain safe entry and to dissect that space to safely separate the adnexa when they are densely adhered to the pelvic sidewall in the area of the obturator fossa.
As laparoscopy evolves, the injury rate rises
Over the past 40 years, laparoscopy has evolved from an uncommonly utilized diagnostic tool to a minimally invasive alternative to laparotomy for even the most difficult and complex operations, reaching a high point with robotic laparoscopy. As this technology has developed, serious complications—to some degree, unique to laparoscopy—have increased. In the future, as less skilled surgeons perform a greater percentage of laparoscopic surgeries, a still greater number of complications will arise.
The frequency of intestinal perforation is not great relative to the total number of laparoscopic procedures performed. The TABLE lists several series totaling more than 380,000 laparoscopic operations. The risk of reported bowel perforation ranged from 0.6 to 6 for every 1,000 procedures, with a mean risk of 2.4 for every 1,000. However, these data are inconclusive because the total number of laparoscopic operations performed in the United States is not accurately known. Nor is the precise number of complications associated with these procedures known—specifically, the number of intestinal perforations—as no law requires them to be reported.
Research surveys are unreliable in many cases. In addition, the relative expertise of the surgeon is impossible to quantify. For example, although a surgeon may have many years of operative experience, it is unclear whether this always translates into skill or comfort with laparoscopic procedures. And, when a resident scrubs in with a faculty surgeon, any data collected fail to reflect which part of the surgery was performed by the resident and which by the fully trained gynecologist.
These unknown variables are important in terms of risk, surgical complications, and outcomes. Surgical skill is the greatest unknown factor in any outcome study of any surgical procedure.
Studies of complications reveal: Gastrointestinal injury is no rare event during laparoscopic surgery
Study (year; country)
Brown et al (1978; UK) 16
Soderstrom (1993; US) 17
Bateman et al (1996; US) 18
Champault et al (1996; France) 15
Saidi et al (1996; US) 19
Jansen et al (1997; Netherlands) 5
Harkki-Siren et al (1997; Finland) 8
Harkki-Siren et al (1997; Finland) 7
Chapron et al (1998; France) 6
Chapron et al (1999; France) 9
Gordts et al (2001; France) 20
Bhoyrul et al (2001; US) 13
Wang et al (2001; Taiwan) 21
Sharp et al (2002; US) 14
Brosens et al (2003; Belgium) 22
* 80 open laparoscopy procedures; 30 closed laparoscopy procedures
† Limited to trocar injuries
‡ Laparoscopic hysterectomy
§ All trocar injuries obtained through Food and Drug Administration reports
** Limited to optical access trocars
Classifying intestinal injuries
As in the case of major vessel injury, intestinal injury sustained during laparoscopy can be classified as either:
- Injury secondary to the approach. This category refers to entry complications associated with creation of the pneumoperitoneum and insertion of primary and secondary trocars.
- Injury secondary to the procedure or operation. This type of injury occurs as a result of manipulation with various devices during laparoscopy. The devices may include probes, forceps, scissors, or energy devices such as laser, electrosurgical, and ultrasonic instruments.
How trocar injury happens
Several studies have demonstrated that abdominal adhesions place any patient into a high-risk category for trocar injury to the intestines. Patients who have undergone multiple laparotomies, like the patient in the case that opened this article, are more likely to have severe adhesions and fall into the highest risk category for bowel perforation. 11 It is impossible to predict with any degree of accuracy whether the intestine is adherent to the entry site.
Pneumoperitoneum can be protective
Creation of a pneumoperitoneum creates a cushion of gas between the intestines and the anterior abdominal wall (provided the intestines are not adherent to the abdominal wall). Manufacturers of disposable trocars with a retractable shield recommend creating an adequate pneumoperitoneum so that the “safety shield” deploys quickly and properly, unlike direct insertion, in which no gas is infused and space is insufficient for complete shield activation.
Open laparoscopy techniques, which allow the surgeon to enter the peritoneal cavity by direct vision without a sharp trocar, may diminish but not eliminate the risk of bowel injury.
What the data show
Of the 130 intestinal injuries recently reported by Baggish, 62 of 81 (77%) small bowel injuries were related to trocar insertion, as were 20 of 49 (41%) large intestinal injuries. 12 In other words, 82 of 130 intestinal injuries (63%) were the direct result of trocar entry.