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 imperative. 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 Laparoscopic of bowel injury during lysis of adhesions.4–6 In hysterectomy was associated with a signifi- two studies by Baggish, 94% of adhesiolysis- cantly higher rate of major complications related injuries involved moderate or severe than abdominal hysterectomy and took adhesions.5,6 longer to perform. No major differences in management the rate of complications were found between obg laparoscopic and vaginal hysterectomy. for Is laparoscopy the wisest In a review of laparoscopy-related bowel k approach? injuries, Brosens and colleagues found signif- It is important to weigh the risks of lapa- icant variations in the complication rate, de- hartsoc roscopy against the potential benefits for pending on the experience of the surgeon—a

arcia the patient. Surgical experience and skill 0.2% rate of access injuries for surgeons

: M are perhaps the most important variables who had performed fewer than 100 proce- to consider when deciding on an operative dures versus 0.06% for those who had per- approach. A high volume of laparoscopic formed more than 100 cases, and a 0.3% rate ustration ll i operations—performed by a gynecologic of operative injuries for surgeons who had

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performed fewer than 100 procedures versus After any dissection involving the in- 0.04% for more experienced surgeons.7 testine, carefully inspect the bowel and describe that inspection in the operative re- A few precautions can improve the port (FIGURE 2). If injury is suspected, consult safety of laparoscopy a general surgeon and open the abdomen to If adhesions are known or suspected, pri- permit thorough inspection of the intestines. mary laparoscopic entry should be planned for a site other than the infra-umbilical area. Options include: What the literature reveals • entry via the left hypochondrium in the about intestinal injury midclavicular line Several published reports describe a large • an open procedure. number of laparoscopic cases and the major However, open laparoscopic entry does not attendant complications.12–16 A number of always avert intestinal injury.9–11 studies have focused on gastrointestinal (GI) If the anatomy is obscured once the ab- complications associated with laparoscopic domen has been entered safely, retroperito- procedures, providing site-specific data. neal dissection may be useful, particularly for exposure of the left colon. When it is un- Many injuries occur during entry clear whether a structure to be incised is a Vilos reported on 40 bowel injuries, of which loop of bowel or a distended, adherent ovi- 55% occurred during primary trocar entry duct, it is best to refrain from cutting it. (19 closed and three open entries).17 For adhesiolysis, traction and counter- In a report on 62 GI injuries in 56 pa- traction are the techniques of choice. Dis- tients, Chapron and colleagues found that section of intestine should always be parallel one-third occurred during the approach to the axis of the viscus. Remember, too, that phase of the laparoscopy; they advocated the blood supply enters via the mesenteric creation of a pneumoperitoneum rather Dissection of margin of the intestine. than direct trocar insertion.18 intestine should continued on page 41 always be parallel to FIGURE 2 Meticulous bowel inspection can identify perforation the axis of the viscus

Small Fibrin bowel deposits on wall peritoneum

Mesentery Puncture fat wound from trocar

Bile

It is vital to inspect the bowel after any dissection that involves the intestine, being especially alert for puncture wounds caused by a trocar and small tears associated with adhesiolysis. SOURCE: Baggish MS, Karram MM. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. Philadelphia: Elsevier; 2011:1142.

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In a report from the Netherlands, 24 of In the studies by Baggish, 82 of 130 (63%) 29 GI injuries occurred during the approach.2 intestinal injuries were diagnosed 48 hours In a review of 63 GI complications relat- or more after the operation.5,6 ed to diagnostic and operative laparoscopy, Baggish also made the following obser- 75% of injuries were associated with primary vations: trocar insertion.19 • The most common symptoms of in- Optical access trocars do not appear testinal injury were (in order of frequen- to be protective against bowel injury. One cy) abdominal pain, bloating, nausea and study of 79 complications associated with vomiting, and fever or chills (or both). these devices found 24 bowel injuries.20 The most common signs were abdominal In addition, in two reports detailing tenderness, abdominal distension, dimin- 130 cases of small- and large-bowel perfo- ished bowel sounds, and elevated or sub- rations associated with laparoscopic pro- normal temperature. cedures, Baggish found that 62 (77%) of • Sepsis was apparent (due to the onset small-bowel injuries and 20 (41%) of colonic of systemic inflammatory response syn- injuries were entry-related.5,6 drome) in the majority of small-bowel perforations and virtually all colonic Energy devices can be problematic perforations. Findings of tachycardia, In the study by Chapron and colleagues of tachypnea, elevated leukocyte count, and 62 GI injuries, six were secondary to the use bandemia suggested sepsis syndrome. of electrosurgical devices, four of them in- • Radiologically observed free air was volving monopolar instruments.18 often misinterpreted by the radiologist In a study from Scotland, 27 of 117 (23%) as being consistent with residual gas from of bowel injuries during laparoscopic proce- the initial laparoscopy. In reality, most— 21 dures were attributable to a thermal event. if not all—CO2 gas is absorbed within Baggish found that 43% of operative 24 hours, particularly in obese women. injuries among 130 intestinal perforations Early CT imaging with oral contrast leads Postoperative 5,6 were energy-related. to the most expeditious, correct diagnosis, findings of compared with flat and upright abdominal tachycardia, Intraoperative diagnosis is optimal radiographs. tachypnea, elevated Soderstrom reviewed 66 cases of laparoscopy- • Obese women did not exhibit rebound leukocyte count, and tenderness related bowel injuries and found three even though subsequent op- bandemia suggest deaths attributable to a delay in diagnosis erative findings revealed extensive and se- sepsis syndrome exceeding 72 hours.4 vere peritonitis. In a study by Vilos, the mean time for di- • When infection occurred, it usually agnosis of bowel injuries was 4 days (range, was polymicrobial in nature. The most 0–23 days), with intraoperative diagnosis in frequently cultured organisms include only 35.7% of cases.17 Escherichia coli, Enterococcus, alpha and In a Finnish nationwide analysis of lapa- beta Streptococcus, Staphylococcus, and roscopic complications, Harkki-Siren and Bacteroides. Kurki found that small-bowel injuries were Baggish concluded that earlier diagno- identified an average of 3.3 days after- oc sis could be achieved with careful inspection currence; when electrosurgery was involved of the intestine at the conclusion of each op- in the injury, the average time to diagnosis erative procedure (Figure 2, page 38). was 4.8 days.22 As for large-bowel injuries, Similarly, Chapron and colleagues 44% were identified intraoperatively. In the recommended meticulous inspection of remainder of cases, the average time from all areas where bowel lysis has been per- injury to diagnosis was 10.4 days for electro- formed. “When there is the slightest doubt, surgical injuries and 1.3 days for injuries re- carry out tests for leakage (transanal injec- lated to sharp dissection. tion of 200 mL methylene blue using a Foley

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catheter) in order not to overlook a rectosig- hysterectomy among women with a previ- moid injury which would become apparent ous cesarean delivery was 1.26 for the ab- secondarily in a context of peritonitis,” they dominal approach, 3.00 for the vaginal route, wrote. They also suggested that the patient and 7.50 for laparoscopic-assisted vaginal be educated about the signs and symptoms hysterectomy.29 of intestinal injury.18 Whenever a bowel injury is visualized Two studies highlight common intraoperatively, assume that it is transmural aspects of injury until it is proved otherwise. In a recent report of 75 urinary tract injuries associated with laparoscopic surgery, Bag- gish identified a total of 33 injuries involving How to avoid urinary tract the bladder and 42 of ureteral origin. Twelve injuries of the bladder injuries were associated with Along with major vessel injury and intestinal the approach, and 21 were related to the sur- perforation, bladder and ureteral injuries are gery. In contrast, only one of the 42 ureteral the most common complications of laparo- injuries was related to the approach.30 scopic surgery. Although urinary tract inju- Baggish also found that just under 50% ries are rarely fatal, they can cause a range of urinary tract injuries were related to the of sequelae, including urinoma, vesicovagi- use of thermal energy, including all three nal and ureterovaginal fistulas, hydroureter, vesicovaginal fistulas. Fourteen bladder lac- hydronephrosis, renal damage, and kidney erations occurred during separation of the atrophy. bladder from the uterus during laparoscopic The incidence of ureteral injury- dur hysterectomy.30 ing laparoscopy ranges from less than Common sites of injury were at the in- 0.1% to 1.0%, and the incidence of bladder fundibulopelvic ligament, between the in- injury ranges from less than 0.8% to 2.0%.23–26 fundibulopelvic ligament and the uterine Risk factors for Investigators in Singapore described eight vessels, and at or below the uterine vessels.30 urinary tract injury urologic injuries among 485 laparoscopic None of the 42 ureteral injuries were di- include previous hysterectomies and identified several risk agnosed intraoperatively. In fact, 37 of these cesarean delivery, factors: injuries were not correctly diagnosed until multiple fibroids, • previous cesarean delivery more than 48 hours after surgery. Two utero- and severe • multiple fibroids vaginal fistulas were also diagnosed in the • severe endometriosis.27 late postoperative period.30 endometriosis Another set of investigators found a history Bladder injuries were identified via cys- of laparotomy to be a risk factor for bladder toscopy or cystometrogram or by the instilla- injury during laparoscopic hysterectomy.28 tion of methylene blue into the bladder, with Rooney and colleagues studied the observation from above for leakage. Ureteral effect of previous cesarean delivery on injuries were identified by IV pyelogram, the risk of injury during hysterectomy.29 retrograde pyelogram, or attempted pas- Among 5,092 hysterectomies—including sage of a stent. Every ureteral injury showed 433 laparoscopic-assisted vaginal hysterec- up as hydroureter and hydronephrosis via tomies, 3,140 abdominal procedures, and pyelography.30 1,539 vaginal operations—the rate of blad- Grainger and colleagues reported five der injury varied by approach. Cystotomy ureteral injuries associated with laparoscop- was observed in 0.76% of abdominal hyster- ic procedures.31 The principal symptoms ectomies (33% had a previous cesarean de- were low back pain, abdominal pain, leuko- livery), 1.3% of vaginal procedures (21% had cytosis, and peritonitis. All five injuries were a previous cesarean), and 1.8% of laparo- associated with endometriosis surgery, most scopic operations (62.5% had a previous ce- commonly near the uterosacral ligaments. sarean). The odds ratio for cystotomy during Grainger and colleagues cited eight

42 OBG Management | October 2012 | Vol. 24 No. 10 obgmanagement.com additional cases of injury. Three patients trigone or its vicinity, always perform ure- among the 13 total cases lost renal function, teral catheterization to help prevent the and two eventually required nephrectomy.31 inadvertent suturing of the intravesical ureter into the repair. How to prevent, identify, and manage • After repair of a bladder laceration, per- urinary tract injuries form cystoscopy with IV injection of in- Thorough knowledge of anatomy and me- digo carmine to ensure ureteral integrity. ticulous technique are imperative to prevent • Use only absorbable suture in bladder re- urinary tract injuries. Strategies include: pairs. I recommend 2-0 chromic catgut for • Use sharp rather than blunt dissection. the first layer, which should encompass • Know the risk factors for urinary tract inju- muscularis and mucosa. Place a second ry, which include previous cesarean deliv- layer of sutures using 3-0 polyglactin 910 ery or intra-abdominal surgery, presence (Vicryl), imbricating the first layer. of adhesions, and deep endometriosis. • After completion of a bladder repair, in- • Be aware of the dangers posed by energy still a solution of diluted methylene blue devices when they are used near the blad- (1 part methylene blue to 100 parts sterile der and ureter. Even bipolar devices can water or saline) to distend the bladder, and cause thermal injury. carefully inspect the closure to ensure that • Employ hydrodissection when there are it is watertight. Then place a Foley catheter bladder adhesions, and work nearer the for a minimum of 2 weeks. Four to 6 weeks uterus or vagina than the bladder, leaving after repair, perform a cystogram to ensure a margin of tissue. that healing is complete, with no leakage. • When the ureter’s location is unclear rela- • Call a urologist if you are not well-versed in tive to the operative site, do not hesitate to bladder repair, or if the ureter is injured (or open the retroperitoneal space to observe injury is suspected). the ureter. If necessary, dissect the ureter • Watch for fistula formation, an inevitable distally. outcome of untreated bladder and ureteral Peristalsis is not an • Perform cystoscopy with IV indigo car- injury, which may occur early or late in the indication of ureteral mine injection at the conclusion of surgery postoperative course. integrity. In fact, an to ensure that the ureter is not occluded. obstructed ureter • Be aware that peristalsis is not an indi- will pulsate more cation of ureteral integrity. In fact, an Choose an approach wisely vigorously than a obstructed ureter will pulsate more vigor- Laparoscopy is a learned skill. Supervised normal one. ously than a normal one. practice generally leads to greater levels • Consider preoperative ureteral catheter- of proficiency, and repetition of the same ization, which may avert injury without operations improves dexterity and execution. increasing operative time, blood loss, and However, laparoscopy is also an art—some hospital stay,32 although the data are not people have the touch and some do not. definitive.33 Although laparoscopic techniques offer • Be vigilant. Early identification of inju- many advantages, they also have shortcom- ries reduces morbidity. In the case of ings. The complications described here, and ureteral obstruction, immediate stenting the strategies I have offered for preventing will usually obviate the need for ureteral and managing them, should help gyneco- implantation and nephrostomy if the ob- logic surgeons determine whether laparos- struction is not complete. copy is the optimal route of operation, based • Intervene early to cut an obstructing su- on surgical experience, characteristics of the ture or relieve ureteral bowing. Doing so individual patient, and other variables. may eliminate the obstruction altogether in many cases. References 1. Brill AW, Nezhat F, Nezhat CH, et al. The incidence of • If a laceration is found in the bladder adhesions after prior laparotomy: a laparoscopic appraisal. continued on page 44

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Am J Obstet Gynecol. 2004;190(3):634–638. women’s and children’s hospital, Singapore. Singapore Med 11. Shirk GJ, Johns A, Redwine DB. Complications of J. 2007;48(3):217–221. laparoscopic surgery: how to avoid them and how to repair 28. Lafay PMC, Leonard F, Chopin N, et al. Incidence and risk them. J Minim Invasive Surg. 2006;13(4):352–359. factors of bladder injuries during laparoscopic hysterectomy 12. Fuller J, Binita AS, Carey-Corrado J. Trocar-associated indicated for benign pathologies: a 14.5 years experience injuries and fatalities: an analysis of 1399 reports to the FDA. in a continuous series of 1501 procedures. Hum Reprod. J Min Invasive Gynecol. 2005;12(4):302–307. 2009;24(4):842–849. 13. Saidi MH, Vancaille TG, White J, et al. Complications 29. Rooney CM, Crawford AT, Vassallo BJ, et al. Is previous of major operative laparoscopy. Obstet Gynecol Surv. cesarean section a risk for incidental cystotomy at the time of 1996;51(11):661–662. hysterectomy? 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