Nonaccessrelated Bowel Injuries

Bishoff et al. performed a retrospective review of bowel injuries during urologic laparoscopy in 915 cases at two institutions and reported an overall incidence of 0.8% non-access-related bowel injuries (6). The authors reported bowel perforation in two patients (0.2%) and serosal injury of the intestine or stomach in six patients (0.6%). Intraoperatively recognized bowel injuries occurred in six patients: three during staging pelvic lymph node dissection, two during pyeloplasty, and one during nephrectomy. Unrecognized bowel perforation during surgery occurred in two patients. Additionally, there were two patients referred from outside institutions who had unrecognized bowel perforation. In this series, three of the four patients with unrecognized bowel injuries had rapid progression to sepsis, and two subsequently died.

The authors observed that the postoperative signs and symptoms of laparoscopic bowel perforation were different from the classic postoperative symptoms of bowel perforation that occur with open surgery.

In the above series, all five patients with unrecognized bowel injuries presented in a characteristic manner that did not include traditional peritoneal signs. The initial presentation in each of these cases included persistent and relatively increased pain at a single trocar site without significant erythema or discharge. Each patient had leukopenia, and only one patient had fever greater than 38°C. Upon exploration, the painful trocar site was closest to the injured bowel segment. Abdominal distension and diarrhea were also noted. Two patients with colonic injuries after pelvic lymph node dissection had rapid onset of sepsis, without typical peritoneal signs, and died within four days.

TABLE2 ■ Location of Bowel Injury, Treatment, and Outcome

Bowel

Small

Treatment

Reference

Specialty

No. of pts

injury

intestine

Colon

Stomach

Recognized Unrecognized

(No. pts/total)

No. of deaths

Harkki Siren and

Gynecology

7O,GO7

44

2G

1G

2

8

3G

All laparotomy

Kurki (20)

Bateman et al. (21)

Gynecology

2,324

G

3

2

1

Wolfe et al. (22)

General surgery

381

2

1

1

O

O

2

2

Deziel et al. (23)

General surgery

77,GO4

1O9

G9

35

5

Laparotomy (85/109)

5

Philllips et al. (24)

General surgery

51

O

Schrenk et al. (25)

Gynecology; general surgery

4,G72

1O

G

4

O

G

4

Laparotomy (9/10)

1

Penfield (17)

Gynecology

1O,84O

G

4

2

All laparotomy

Loffer and Pent (26)

Gynecology

32,719

G4

44

11

9

Laparotomy (47/64)

Kaali and Barad (27)

Gynecology

4,532

4

All laparotomy

Casey et al. (28)

Gynecology

93

4

2

1

1

O

4

All laparotomy

Davis et al. (29)

Gynecology

4O

1

O

1

All laparotomy

Chapron et al. (30)

Gynecology

1,191

8

1

7

Bishoff et al. (6)

Urology

915

8

1

7

G

4

Total

2O5,9G9

2GG

153

84

18

24

53

8

Source: From Ref. 6.

The authors also performed a Medline search on laparoscopic bowel injuries reported in the surgical and gynecological literature and discovered a total of 12 series with an overall incidence of 0.13% (266/205,969 cases) bowel injuries (both access and non-access-related), the majority (69%) of which were not recognized at surgery (Table 2) (6,17,20-30). Of the 266 patients with bowel injuries, eight patients died as a direct result of unrecognized intraoperative bowel injury. Small bowel injuries accounted for 58%, and colon and stomach injuries comprised 32% and 7%, respectively. Fifty percent of injuries resulted from application of electrocautery, and 32% of injuries were access related from Veress needles or trocars. Eighty percent of bowel injuries were managed by laparotomy and open repair.

The etiology of the unusual presentation of laparoscopic bowel injury compared to the open surgery is uncertain. It has been speculated that the possible lower immune and metabolic stimulus caused by laparoscopic surgery may allow more rapid progression toward sepsis before natural homeostatic responses occur (31-34). The absence of a large skin incision, which may be the site of maximum trauma, may result in less stimulation of acute phase reactants and reduced postoperative metabolic and cytokine response.

When bowel injury is recognized intraoperatively, immediate repair is indicated.

Several reports have demonstrated the safety of laparoscopic repair and avoidance of diverting colostomy. Colonic injuries in unprepared patients that require bowel resection should be considered for a diverting colostomy.

Almost all unrecognized injuries that present in the postoperative period will require open laparotomy.

On rare occasions, patients have been managed by total parenteral nutrition and percutaneous drainage or expectantly for sepsis and cardiovascular collapse. However, this is not considered a standard management strategy and should be reserved for highly selected cases.

In the postoperative period, if there is any concern for possible unrecognized bowel injury, a computed tomography scan of the abdomen with oral contrast should be performed expeditiously.

Computed tomography scan can identify bowel perforation, postoperative bleeding, urinoma, and urinary obstruction. Contrast in the peritoneal cavity and a local thickening of the bowel wall may be noted on computed tomography, and this finding should prompt immediate exploration (Fig. 1). At times, computed tomography scan with contrast may have to be done two or three times over a one- to two-week period before the diagnosis is made. A plain abdominal film may reveal an ileus. The finding

When bowel injury is recognized intraoperatively, immediate repair is indicated.

Almost all unrecognized injuries that present in the postoperative period will require open laparotomy.

In the postoperative period, if there is any concern for possible unrecognized bowel injury, a computed tomography scan of the abdomen with oral contrast should be performed expeditiously.

FIGURE 1 ■ Postoperative computed tomography scan of the abdomen in a patient four days after laparoscopic radical nephrec-tomy. Scan performed after administering oral contrast shows contrast outside the bowel lumen (A), suggestive of bowel perforation.

FIGURE 1 ■ Postoperative computed tomography scan of the abdomen in a patient four days after laparoscopic radical nephrec-tomy. Scan performed after administering oral contrast shows contrast outside the bowel lumen (A), suggestive of bowel perforation.

If the patient does not respond quickly to antibiotics and signs of peritonitis develop, laparotomy is mandated.

of free air is often seen up to two weeks after laparoscopy and is not absolutely indicative of bowel perforation.

If the patient does not respond quickly to antibiotics, and signs of peritonitis develop, laparotomy is mandated.

On exploration if there is suspected thermal bowel injury, the area of damage is usually more extensive than what is visually appreciated; hence, a wide excision should be performed to ensure removal of all potentially compromised tissue. The wound should be adequately drained, and the patient should have antibiotic coverage. Aggressive clinical and radiological monitoring will allow early recognition of bowel injury and will expedite early surgical exploration when warranted. A high level of suspicion and rapid clinical response are crucial in avoiding a disaster.

Thermal or energy-based bowel injuries represent some of the most serious complications of laparoscopic surgery. Monopolar electrosurgical current is attributed with the greatest number of instrument-related mishaps.

Unfortunately energy-based bowel injuries are frequently not recognized during surgery, and manifest only in the postoperative period. The majority of patients present three to seven days postoperatively with abdominal pain, nausea, low-grade fever, and a moderate leukocytosis/leukopenia.

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