Bowel Injury

The other group of catastrophic injuries a urologic laparoscopist could encounter involves the bowel (76). These injuries represent the third most common cause of death from laparoscopic surgery following anesthesia complications and major vascular injury.

Unlike major vascular injury, many bowel injuries go unrecognized at the time of the laparoscopic procedure. This is because they have a tendency to be small and often out of the line of sight during the laparoscopic procedure. That is to say, they occur off camera and are thus easily overlooked.

Consequently, patients present in a delayed fashion often after being discharged from the hospital and return complaining of abdominal pain or frank peritonitis. This delay fosters fecal contamination and increases the potential morbidity and mortality of this complication. Bowel injuries usually are penetrating stab wounds secondary to pneumoperitoneum needle or trocar punctures. They can also occur secondary to lacerations of the mesentery and subsequent devascularization, lacerations from retraction, and thermal injuries from electrocautery. Predisposing conditions, such as previous surgery with adhesion formation have already been mentioned (77). Again, the gynecologic literature is the dominant source for large series (78). Estimates are that almost half (42.8%) of intestinal injuries are undetected at the time of laparoscopy. Obviously, these injuries are best dealt with at the time of occurrence. Pneumoperitoneum needle injury need not be sutured, unless a laceration is also present with fecal contamination. Miniperforations of the colon have been successfully followed with conservative measures, bowel rest, and intravenous antibiotics (79). Trocar injuries are usually much more extensive. Historically, acute large bowel perforations have been treated by prompt laparotomy, often with creation of a temporary stoma. The problem is fecal contamination from the unprepped colon (80). Increasing reports of traumatic series where closure and drainage are effective therapeutic modalities following copious irrigation. The increasing ability to be able to reconstruct visceral abdominal structures has yet to be demonstrated to produce adequate repairs.

Currently, a contaminating injury to the small or large bowel is best handled by open repair with or without proximal fecal diversion.

Delayed presentation of bowel injury represents the other major group of patients (50,51,76). This includes those patients who have a needle or trocar injury that are missed during the laparoscopy are usually present with peritonitis between 14 and 72 hours post procedure. Thermal injuries to the bowel are also capable of delayed perforations and peritonitis. These perforations can present from 7 to 12 days following the laparoscopic procedure. In one series, a total of 10 thermal bowel injuries were noted in 3600 laparoscopic sterilization procedures (0.3%), again half were unrecognized (35). Of those recognized, four out of five were superficial serosal burns <0.5 cm in diameter and were managed successfully by observation, bowel rest, and intravenous antibiotics.

Laparoscopic urologic surgery is not similar to gynecologic sterilization procedures or laparoscopic cholecystectomy (78). The exact risks inherent in these newer procedures are not yet known. Early reports from multi-institutional series of laparo-scopic pelvic lymph node dissection demonstrate a 15% complication rate (55 out of 372 cases). Of these complications, 7 out of 55 (12.7%) required immediate exploration, three vascular, and one bowel injury. An additional 6 out of 55 (10.9%) required delayed explorations, of which half involved bowel injuries (66).

Injuries to vascular structures and bowel are an ever-present possibility during laparoscopic surgery. They are best avoided by a thorough understanding of the equipment, meticulous attention to detail, and systematic inspection of the abdomen upon entrance and prior to exiting. Patient mortality is the major risk or missing an injury to either of these structures. Morbidity can be diminished by prompt identification of the injury and open exploration.

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