How to Avoid Intestinal and Urinary Tract Injuries During Gynecologic Laparoscopy

SurgicAl TecHniqueS lAST of 2 ArTicleS on lApAroScopic complicationS How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy By arming yourself with knowledge of the most common complications—and their causes—and employing well-chosen surgical strategies, you can lower the risk of laparoscopic-related morbidity and mortality michael Baggish, mD cASe Adhesions complicate multiple and appendectomy. No retroperitoneal explo- surgeries ration was attempted at the time. According In early 2007, a 37-year-old woman with a his- to the operative note, the 10-mm port incision tory of hysterectomy, adhesiolysis, bilateral was enlarged to 3 cm to enable the surgeon to partial salpingectomy, and cholecystectomy inspect the descending colon. Postoperatively, In thIs underwent an attempted laparoscopic bilateral Article the patient reported persistent abdominal pain salpingo-oophorectomy (BSO) for pelvic pain. and fever and was admitted to the hospital for Variables that The operation was converted to laparotomy observation. Although she had a documented influence the risk because of severe adhesions and required temperature of 102°F on October 31, with of bowel injury several hours to complete. tachypnea, tachycardia, and a white blood 3 page 36 After the BSO, the patient developed cell (WBC) count of 2.9 x 10 /µL, she was dis- hydronephrosis in her left kidney second- charged home the same day. ary to an inflammatory cyst. In March 2007, The next morning, the patient returned A review of a urologist placed a ureteral stent to relieve to the hospital’s emergency room (ER) report- the literature the obstruction. One month later, the patient ing worsening abdominal pain and shortness on intestinal was referred to a gynecologic oncologist for of breath. Her vital signs included a tempera- complications chronic pelvic pain. ture of 95.8°F, heart rate of 135 bpm, respira- page 38 On October 29, 2007, the patient under- tion of 32 breaths/min, and blood pressure went operative laparoscopy for adhesiolysis of 100/68 mm Hg. An examination revealed a How to protect the tender, distended abdomen, and the patient urinary tract Dr. Baggish practices Obstetrics exhibited guarding behavior upon palpation page 42 and Gynecology at The Women’s in all quadrants. Bowel sounds were hypoac- Center at Saint Helena Hospital in tive, and the WBC count was 4.2 x 103/µL. No Saint Helena, California. He also serves as Professor of Obstetrics differential count was ordered. A computed and Gynecology at the University tomography (CT) scan showed free air in the of California, San Francisco, and as Emeritus Chairman and Residency abdomen, pneumomediastinum, and subcuta- Director, Department of Obstetrics and Gynecology, neous emphysema of the abdominal wall and Good Samaritan Hospital, Cincinnati, Ohio. chest wall. Dr. Baggish reports no financial relationships The next day, a differential WBC count relevant to this article. revealed bands elevated at a 25% level. A car- diac consultant diagnosed heart failure and 34 OBG Management | October 2012 | Vol. 24 No. 10 obgmanagement.com SurgicAl TecHniqueS / gynecologic lApAroScopy remarked that pneumomediastinum should visits the ER for that reason. In March 2009, not occur after abdominal surgery. In the eve- she underwent repeat drainage of a pelvic col- ning, the gynecologic oncologist performed a lection via CT imaging. No further follow-up is laparotomy and observed enteric contents in available. the abdominal cavity, as well as a defect of could this catastrophic course have been approximately 2 mm in the lower portion of the avoided? What might have prevented it? rectosigmoid colon. According to the operative note, the gynecologic oncologist stapled off the area below the defect and performed a Adhesions are likely after any descending loop colostomy. abdominal procedure Postoperatively, the patient remained he biggest risk factor for laparoscopy- septic, and vegetable matter was recovered related intestinal injury is the presence from one of the drains, so a surgical consultant T of pelvic or abdominal adhesions.1,2 was called. On November 9, a general surgeon Adhesions inevitably form after any intra- performed an exploratory laparotomy and abdominal surgery, and new adhesions are found necrosis, hemorrhage, acute inflamma- likely with each successive intra-abdominal tion of the colostomy, separation of the colos- procedure. Even adhesiolysis leads to the tomy from its sutured position on the anterior formation of adhesions postoperatively. abdominal wall, and mucosa at the end of the Few reliable data suggest that adhe- Hartman pouch, necessitating resection of sions cause pelvic pain, or that adhesiolysis this segment of the colon back to the rectum. relieves such pain.3 Furthermore, it may be Numerous intra-abdominal abscesses were impossible to predict with reasonable prob- also drained. ability where adhesions may be located pre- Two days later, the patient returned to the operatively or to know with certainty whether OR for further abscess drainage and creation a portion of the intestine is adherent to the of a left end colostomy. She was discharged anterior abdominal wall directly below the We lack definitive 1 month later. usual subumbilical entry site. Because of the evidence that On January 4, 2008, she went to the ER likelihood of adhesions in a patient who has adhesions cause for nausea and abdominal pain. Five days undergone two or more laparotomies, it is pelvic pain, or that later, a plastic surgeon performed extensive risky to thrust a 10- to 12-mm trocar through adhesiolysis relieves skin grafting on the chronically open abdomi- the anterior abdominal wall below the navel. such pain nal wound. On March 12, the patient returned to the ER because of abdominal pain and was admitted for nasogastric drainage and A few variables influence the intravenous (IV) fluids. She returned to the ER risk of injury again on April 26, reporting pain. A CT scan The trocar used in laparoscopic procedures revealed a cystic mass in the pelvis, which was plays a role in the risk of bowel injury. For ex- drained under CT guidance. In June and July, ample, relatively dull reusable devices may the patient was seen in the ER three times for push nonfixed intestine away rather than Read Dr. Baggish’s pain, nausea, and vomiting. penetrate the viscus. In contrast, razor-sharp first article on In January 2009, she underwent another disposable devices are more likely to cut into laparoscopic laparotomy for takedown of the colostomy, the underlying bowel. complications lysis of adhesions, and excision of a left 4-cm Body habitus is also important. The pelvic cyst (pathology later revealed the cyst to obese woman is at greater risk for entry in- ›› How to avoid major vessel injury be ovarian tissue). She also underwent a left- juries, owing to physical aspects of the fatty during gynecologic sided myocutaneous flap reconstruction of an anterior abdominal wall. When force is ap- laparoscopy abdominal wall defect, and a right-sided myo- plied to the wall, it moves inward, toward the Michael Baggish, MD cutaneous flap with placement of a 16 x 20–cm posterior wall, trapping intestine. In a thin (Surgical Techniques, August 2012) sheet of AlloDerm Tissue Matrix (LifeCell). She woman, the abdominal wall is less elastic, so continues to experience abdominal pain and there is less excursion upon trocar entry. 36 OBG Management | October 2012 | Vol. 24 No. 10 obgmanagement.com intestinal status is another variable to FIGURE 1 use of energy devices is risky consider. A collapsed bowel is unlikely to be near bowel perforated by an entry trocar, whereas a thin, distended bowel is vulnerable to injury. Bow- el status can be determined preoperatively using various modalities, including radio- graphic studies. Careful surgical technique is impera- tive. Sharp dissection is always preferable to the blunt tearing of tissue, particularly in cases involving fibrous adhesions. Tear- ing a dense, unyielding adhesion is likely to remove a piece of intestinal wall because the tensile strength of the adhesion is typically greater than that of the viscus itself. Thorough knowledge of pelvic anatomy is essential. It would be particularly egregious for a surgeon to mistake an adhesion for the normal peritoneal attachments of the left and sigmoid colon, or to resect the mesentery of the small bowel, believing it to be an adhesion. energy devices account for a significant number of intestinal injuries (FIGURE 1). Energy devices account for a significant number of intestinal injuries. In this Any surgeon who utilizes an energy device is figure, the arrow indicates leakage of fecal matter from the bowel defect. obligated to protect the patient from a thermal injury—and the manufacturers of these instruments should provide reliable data on surgeon—should translate into a lower risk of the safe use of the device, including informa- injury to intra-abdominal structures.7 That is, tion about the expected zone of conductive the greater the number of cases performed, thermal spread based on power density and the lower the risk of injury. tissue type. As a general rule, avoid the use of Garry and colleagues conducted two monopolar electrosurgical devices for intra- parallel randomized trials comparing 1) lap- abdominal dissection. aroscopic and abdominal hysterectomy and Adhesiolysis is a risky enterprise. Sever- 2) laparoscopic and vaginal hysterectomy as al studies have found a significant likelihood part of the eVALuate study.8

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