Abdominal Accessrelated Bowel Injuries

The reported incidence of bowel injuries due to Veress needle and trocar insertion is 0.03% to 0.3% (7-10). Veress needle injuries are more common than trocar injuries.

Correct Veress needle placement should be confirmed before proceeding with insufflation of the abdomen (Table 1). Bowel insufflation through a Veress needle may produce asymmetrical abdominal distension, insufflation of only a small amount of CO2 (less than 2 L) before high intra-abdominal pressures are reached, and passage of flatus during insufflation. If these signs are identified, insufflation should be immediately terminated. A pneumoperitoneum may then be established using a second Veress needle or an open Hasson technique at a different site.

During Veress needle or trocar insertion, the stomach or bowel may be entered. Typically, transgression into a hollow viscus is immediately apparent because of aspiration of gastrointestinal contents.

Rarely, patients with urachal abnormalities, i.e., cysts or sinuses, may be encountered with a history of umbilical discharge, which should alert the surgeon to this possibility and high risk for viscus perforation. Once identified, the Veress needle bowel injury is managed based on the level of severity. If the Veress needle perforates any intra-abdominal hollow viscus and no leakage of enteric content is noted, conservative management can be undertaken. If the bowel defect appears to be a small puncture, a simple suture may be placed to close the needle hole. However, larger defects that may result from the Veress needle or from a trocar require formal repair. Formal repair of

Intestinal injury is a rare but potentially fatal complication of abdominal laparoscopy.

The reported incidence of bowel injuries due to Veress needle and trocar insertion is 0.03% to 0.3%. Veress needle injuries are more common than trocar injuries.

During Veress needle or trocar insertion, the stomach or bowel may be entered. Typically, transgression into a hollow viscus is immediately apparent because of aspiration of gastrointestinal contents.

TABLE 1 ■ Safe Veress Needle and Trocar Insertion

Place patient in Trendelenburg position, make a 12 mm incision at the site of desired needle entry, spread the underlying fat with a Kelly clamp, and grasp the underlying fascia with two Allis clamps Pass Veress needle (midline two "pops") into the peritoneal cavity Aspirate Veress needle for blood/bowel content Irrigate needle with 5 cc of saline: fluid should inject without any force Aspirate: there should be no return

Inject another 2-3 cc of saline (to push any aspirated fat, omentum, etc. away from the needle) Drop test: fluid in the hub of the needle should flow into the peritoneal cavity Advancement test: needle should be able to be advanced 1-2 cm without encountering any resistance (i.e., indicator in the hub of the needle should not move)

Ensure intra-abdominal pressure is low (<10 mmHg) when connected to the insufflator Place first trocar after the intra-abdomenal pressure reaches 15-25 mmHg Use visual dilating obturator trocar for primary trocar insertion Always insert secondary trocars under vision

Visually inspect each site of trocar entry (including that of the primary trocar) for bleeding or visceral injury

Source: From Ref. 11.

When a trocar-induced bowel injury is suspected, the surgeon should resist the temptation to remove the trocar, because the offending trocar can be used to identify the site of bowel injury expeditiously and minimize the leakage of bowel contents into the peritoneal cavity.

significant bowel injuries may be performed via open or laparoscopic technique based on the level of experience of the operating surgeon. A general surgeon should be consulted to help determine the level of injury and to help establish an intraoperative management strategy. Trocar-induced bowel injuries should typically occur only during insertion of the primary trocar; the primary trocar is the only access that is generally not placed under direct vision.

When a trocar-induced bowel injury is suspected, the surgeon should resist the temptation to remove the trocar, because the offending trocar can be used to identify the site of bowel injury expeditiously and minimize the leakage of bowel contents into the peritoneal cavity.

The site of primary trocar passage should always be considered as a suspect for injury, and after additional access is gained, the primary access site should be inspected to rule out a bowel injury. During upper abdominal trocar deployment, gastric perforation may occur as a result of trocar insertion into a distended stomach. Keeping patients without oral intake eight hours prior to surgery, and the insertion of an orogastric or a nasogastric tube are helpful in minimizing the risk of gastric injury.

If a trocar-based bowel injury is appreciated, the site of perforation should be carefully evaluated. The evaluation should include consideration of a possible through-and-through bowel injury.

■ Penetrating bowel injuries should be managed like any other penetrating injury within the abdomen.

■ Open conversion and traditional management are most typically performed.

■ Small perforations or lacerations can be repaired primarily.

■ Extensive bowel injuries require resection.

■ If the patient has undergone bowel preparation and the surgeon is comfortable with laparoscopic reconstruction, repair of an injured hollow viscus can be carried out by laparoscopic intracorporeal suturing or stapling techniques.

■ Consultation with a general surgeon is strongly recommended.

Despite consensus to the contrary, analysis of three prospective, randomized studies to date shows that that a Veress needle access technique for trocar insertion is no more hazardous than a direct vision trocar insertion (Hasson technique) (10,12,13). As with any technique, the skill and experience of the surgeon is the key. For Veress needle insertion, adherence to the proper Veress needle insufflation protocol is essential. Specifically, the needle should irrigate easily, aspiration should not yield blood or fecal matter, the surgeon should observe a positive drop test (fluid passes through needle into the peritoneal cavity), there should be unrestricted advancement of the needle by 1 to 2 cm after entry, and the initial insufflation pressures should be low (Table 1). If these signs are not all present, the needle should be withdrawn and passed again via the same site or a different site to minimize the potential for access-based injury.

Before exiting the abdomen, careful and meticulous inspection of the bowel and trocar sites should be performed to identify any unrecognized bowel injury.

The open or Hasson technique is a safe method of access, and is recommended in patients with previous abdominal surgery, if there is difficulty in the establishment of pneumoperitoneum with Veress needle, or for children and very thin patients.

Halevy et al., in a series comparing open and laparoscopic cholecystectomy, have demonstrated that laparoscopic surgery results in significantly less disruption of normal gastrointestinal motility when compared to open surgery.

Certain patients deserve special consideration as they represent an increased risk for access. Patients with very high or low body mass index can be a challenge. Similarly, patients with prior abdominal surgery should be approached with great caution. In the authors' experience, and documented in the literature, application of nonbladed (dilating) trocars minimize the risk of bowel and vascular injury (14,15).

Trocar access via any technique is generally safe. However, meticulous technique should always be applied to minimize the potential for injury. An open laparotomy set should be immediately available in the operating room during laparoscopic procedures for expeditious emergent conversion.

Before exiting the abdomen, careful and meticulous inspection of the bowel and trocar sites should be performed to identify any unrecognized bowel injury.

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