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How to avoid injury to bowel during laparoscopy: be reluctant to perform laparoscopy in a patient known to have significant adhesions. Also, be aware of risk of injury at trocar entry and mindful of how you use energy devices.

[ILLUSTRATION OMITTED]

CASE

Postoperative abdominal pain. Is it gastroenteritis? R.B., 35 years old, undergoes laparoscopic adhesiolysis for abdominal pain. Previously, she underwent exploratory laparotomy for a ruptured tubal pregnancy and, in separate operations, right oophorectomy via laparotomy for a ruptured corpus luteum cyst and diagnostic laparoscopy.

During the current surgery, extensive adhesions are observed, including interloop intestinal adhesions. The adhesions are lysed using monopolar scissors and a needle electrode, and R.B. is discharged home the same day.

Later that day and the next day, R.B. complains of abdominal pain that does not respond to prescribed analgesics, as well as nausea and vomiting. A nurse practitioner takes her call and prescribes a stronger analgesic, an antiemetic, and an antibiotic.

The following day, the patient's husband telephones the treating gynecologist to report that his wife is still experiencing severe pain and nausea. He is told to bring her to the office, where she is described as having mild lower abdominal tenderness and mild rebound. An abdominal radiograph shows air-fluid levels and distended bowel. The gynecologist determines that the patient is experiencing gastroenteritis.

On postop day 3, R.B. continues to suffer from severe abdominal pain, nausea, and vomiting, and is unable to get out of bed. Her husband takes her to the emergency room at another hospital, where she is found to have diffuse peritonitis, absent bowel sounds, and:

* temperature, 101.8[degrees]F

* heart rate, 130/min

* respiratory rate, 24/min

* blood pressure, 90/60 mm Hg

* white blood cell (WBC) count, 21.5 x [10.sup.3]/[micro]L

* x-ray showing free air.

A general surgeon performs an exploratory laparotomy and finds foul-smelling abdominal fluid, 200 to 300 mL of pus, and a 1-cm perforation of the sigmoid colon. He performs sigmoid colon resection and a left-colon colostomy. A second laparotomy is necessary to drain a subphrenic abscess.

Four months later, the colostomy is taken down and bowel continuity is established.

Subsequently, the patient experiences episodes of gaseous and fecal incontinence, which are thought to be secondary to nerve damage. A ventral hernia is also diagnosed.

Could this outcome have been avoided?

No physician would wish a major complication of surgery upon any patient. Yet, sometimes, preventive efforts fall short of the goal or the physician is slow to suspect injury when the patient experiences postoperative abdominal pain and other symptoms. Intestinal injury may not be common during laparoscopy, but it is certainly not rare. And the longer diagnosis is delayed, the greater the risk of sepsis, even death.

Recognizing the limitations of laparoscopic surgery is a first step toward reducing the complication rate. (1,2) The ability to determine when laparotomy would better serve the patient's interests is also critical, and prompt diagnosis and repair of any complication that does occur will ensure and speed the patient's recovery.

The most serious complications associated with diagnostic and operative laparoscopy are major vessel and intestinal injuries. Both types of injury significantly raise the risk of mortality, which ranges from 2% to 23%. (3,4) The overall risk of injury to the gastrointestinal tract averages 1.6 to 2.0 for every 1,000 cases. The risk of major vessel injury averages 0.5 for every 1,000 cases. (5-9)

In an earlier article for OBG MANAGEMENT, I reviewed vascular injury during laparoscopy. (10) In Part 1 of this article, I focus on ways to avoid intestinal injury. In Part 2, which follows on page 55, I outline strategies to identify it in a timely manner when it does occur.

As laparoscopy evolves, the injury rate rises

Over the past 40 years, laparoscopy has evolved from an uncommonly utilized diagnostic tool to a minimally invasive alternative to laparotomy for even the most difficult and complex operations, reaching a high point with robotic laparoscopy. As this technology has developed, serious complications--to some degree, unique to laparoscopy--have increased. In the future, as less skilled surgeons perform a greater percentage of laparoscopic surgeries, a still greater number of complications will arise.

The frequency of intestinal perforation is not great relative to the total number of laparoscopic procedures performed. The TABLE (page 50) lists several series totaling more than 380,000 laparoscopic operations. The risk of reported bowel perforation ranged from 0.6 to 6 for every 1,000 procedures, with a mean risk of 2.4 for every 1,000. However, these data are inconclusive because the total number of laparoscopic operations performed in the United States is not accurately known. Nor is the precise number of complications associated with these procedures known--specifically, the number of intestinal perforations--as no law requires them to be reported.

Research surveys are unreliable in many cases. In addition, the relative expertise of the surgeon is impossible to quantify. For example, although a surgeon may have many years of operative experience, it is unclear whether this always translates into skill or comfort with laparoscopic procedures. And, when a resident scrubs in with a faculty surgeon, any data collected fail to reflect which part of the surgery was performed by the resident and which by the fully trained gynecologist.

These unknown variables are important in terms of risk, surgical complications, and outcomes. Surgical skill is the greatest un known factor in any outcome study of any surgical procedure.

Classifying intestinal injuries

As in the case of major vessel injury, intestinal injury sustained during laparoscopy can be classified as either:

* Injury secondary to the approach. This category refers to entry complications associated with creation of the pneumoperitoneum and insertion of primary and secondary trocars.

* Injury secondary to the procedure or operation. This type of injury occurs as a result of manipulation with various devices during laparoscopy. The devices may include probes, forceps, scissors, or energy devices such as laser, electrosurgical, and ultrasonic instruments.

How trocar injury happens

Several studies have demonstrated that abdominal adhesions place any patient into a high-risk category for trocar injury to the intestines. Patients who have undergone multiple laparotomies, like the patient in the case that opened this article, are more likely to have severe adhesions and fall into the highest risk category for bowel perforation. (11) It is impossible to predict with any degree of accuracy whether the intestine is adherent to the entry site.

Pneumoperitoneum can be protective

Creation of a pneumoperitoneum creates a cushion of gas between the intestines and the anterior abdominal wall (provided the intestines are not adherent to the abdominal wall). Manufacturers of disposable trocars with a retractable shield recommend creating an adequate pneumoperitoneum so that the "safety shield" deploys quickly and properly, unlike direct insertion, in which no gas is infused and space is insufficient for complete shield activation.

Open laparoscopy techniques, which allow the surgeon to enter the peritoneal cavity by direct vision without a sharp trocar, may diminish but not eliminate the risk of bowel injury.

What the data show

Of the 130 intestinal injuries recently reported by Baggish, 62 of 81 (77%) small bowel injuries were related to trocar insertion, as were 20 of 49 (41%) large intestinal injuries. (12) In other words, 82 of 130 intestinal injuries (63%) were the direct result of trocar entry.

Bhoyrul and associates reported 629 trocar injuries, of which 182 were visceral. (13) Of the 32 deaths, six were secondary to unrecognized bowel injury. Of 176 nonfatal visceral injuries, 128 (73%) involved the intestines, and 22 were unrecognized.

Optical-access and open laparoscopic systems were designed to prevent such injuries. Sharp and colleagues reported 24 intestinal injuries out of a total of 79 complications (30%) associated with optical-access trocars after reviewing data obtained from the Medical Device Reports (MDR) and Maude databases maintained by the Food and Drug Administration. (14) In the Baggish series, 4.6% of injuries were associated with open laparoscopy. (12)

Champault and colleagues reviewed complications in a survey of 103,852 operations. (15) Although they recommended use of open laparoscopy as opposed to blind insertion, they presented no data on the safety of open techniques.

How intraoperative injury happens

Operative injury of the large or small bowel often occurs during sharp or blunt dissection, performed during laparoscopy using accessory mechanical or energy devices. The latter type of device is utilized increasingly because laparoscopic knot tying and suturing are rather awkward and slow, and laparoscopic suturing to control bleeding is difficult. The size of the needle required for laparoscopic suture placement must be small enough to navigate a trocar sleeve.

Avoid blunt dissection when adhesions are present

The separation of dense adhesions between the intestines and neighboring bowel, other viscera, or abdominal wall is risky when blunt dissection is used. The tensile strength of the fibrotic connective tissue may well exceed that of the thin intestinal wall. Tearing the adhesion free may bring with it a portion of the bowel wall. Such injuries are frequently missed or described as serosal injuries and left unexplored and unrepaired.

Hydrodissection is a safer alternative. It involves the infiltration of sterile water or saline under low pressure between the parietal peritoneum and underlying retroperitoneal structures, providing a safe and natural plane for dissection. In addition, when the C[O.sub.2] laser is used, the liquid acts as a heat sink to absorb any penetrating laser energy.

Energy devices create thermal effects

Energy devices used to cut tissue during operative laparoscopy coagulate blood vessels in a variety of ways, but the common pathway is thermal. Many hypotheses have evolved to explain how vessels are sealed, but none has demonstrated nonthermal activity except for cryocoagulation.

The devices most commonly used for cutting and hemostasis at laparoscopy are:

* electrosurgical (both monopolar and bipolar). Bipolar electrosurgical devices have advantages over monopolar devices when it comes to high-frequency leaks, direct coupling, and capacitive coupling.

* laser (C[O.sub.2], holmium:YAG, Nd:YAG, KTP-532, argon). As I mentioned, C[O.sub.2] laser devices are effectively backstopped by water, especially in strategic areas such as over and around intestines, major vessels, and the ureters.

* ultrasonic (Harmonic Scalpel, ultrasonic aspirator [CUSA]).

Laser and ultrasonic devices do not require a flow of electrons to create coagulation, but do produce heat that will spread peripherally by thermal conduction from the zone of impact (target).

The extent of energy-inflicted injury cannot be predicted

Inadvertent injury with energy devices can occur directly through contact with the bowel, indirectly by heat conduction through tissue, through capacitive coupling (monopolar electrical only), and by forward scatter (laser only).

Upon direct contact with the intestine, energy devices cut into the tissue in a manner similar to mechanical scissors or a knife but produce a larger wound. The reason? The transfer of heat to areas adjacent to the primary wound produces additional necrosis. Heat conduction, capacitive coupling, high-frequency leaks, and front scatter coagulate the intestinal wall with subsequent tissue devitalization and necrosis, the extent of which depends on the power density at contact and the duration of energy applied.

It is impossible to predict the depth or area of devitalization in energy-inflicted injury by visualization of the event.

In the Baggish review of 130 intestinal injuries, the number of injuries sustained during the operative procedure was 19 involving the small intestine and 29 involving the large bowel. (12) Of this subset, 44% (21 cases) were secondary to the use of energy devices, with monopolar electrosurgical instruments alone accounting for 9 (43%) of the injuries.

Even best-laid plans can go awry

Despite our best intentions and precautions, accidents do sometimes happen, and bowel injury is no exception. In Part 2 of this article, which follows on page 55, I detail steps you can take to detect injuries in as timely a manner as possible.

10 ways to lower the risk of intestinal injury

* Avoid laparoscopy when severe adhesions are anticipated--such as when the patient has a history of multiple laparotomies, or when significant adhesions have been documented.

* Be aware that laparoscopy carries additional risks beyond those of the primary surgical procedure, owing to factors peculiar to endoscopic technique and instrumentation.

* Consider open laparoscopy or insert the primary trocar at an alternative location, such as the left upper quadrant, when the patient has a history of laparotomy.

* Avoid blunt dissection for anything other than mild (filmy) adhesions. Sharp dissection associated with hydrodissection is the safest method of adhesiolysis. Clear visualization of the operative site is the sine qua non for precise dissection.

* Avoid monopolar electrosurgical devices for laparoscopic surgery whenever possible. Also remember that bipolar and ultrasonic devices can cause thermal injury by heat conduction as well as by direct application. Laser energy will continue beyond the target unless provision is made to absorb the residual energy.

* At the conclusion of any laparoscopic procedure, especially after adhesiolysis or bowel dissection, inspect the intestines and include the details in the operative report.

* After any laparoscopic procedure, if the patient does not improve steadily, the first presumptive diagnosis to be excluded is injury secondary to the procedure or technique.

* The major symptom of intestinal perforation is abdominal pain, which does not ease without increasing quantities of analgesics.

* Investigate any bowel injury thoroughly to determine viability at the site of injury. Whenever possible, repair all injuries intraoperatively.

* After intestinal perforation, the risk of sepsis is high. Look for early signs such as tachycardia, subnormal body temperature, depressed WBC count, and the appearance of immature white cell elements.

Familiarity with intestinal and pelvic anatomy can prevent surgical injury

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A thorough familiarity with pelvic anatomy is important to avoid injury at trocar entry, but it is even more critical in regard to operative injury. The small intestine spreads diffusely throughout the abdomen beneath the anterior abdominal wall. It lies beneath the umbilicus and anterior midline, whereas the large bowel is located at the periphery. The sigmoid colon swings left to right before joining the rectum anterior to the presacral space. The sigmoid junction with the descending colon lies well to the left of the midline, and the cecum lies at the pelvic brim to the right of midline.

Depending on the degree of redundancy of the mesentery of the cecum or sigmoid colon, these structures may droop into the pelvis and cover the adnexa Therefore, adhesions are likely to develop between the large or small intestine, or both, and the adnexa following dissection in the vicinity of or immediately over the tubes and ovaries. Knowing the normal anatomic relationships is vital for restorative surgery.

When severe adhesions involve the large intestine, it is critical to know the anatomy of the retroperitoneum and be skilled enough to gain safe entry and to dissect that space to safely separate the adnexa when they are densely adhered to the pelvic sidewall in the area of the obturator fossa.

FAST TRACK

Surgical skill is the greatest unknown variable in any outcome study of any surgical procedure

FAST TRACK

Upon direct contact with the intestine, energy devices produce a larger wound than mechanical scissors or a knife, owing to heat transfer

FAST TRACK

It is impossible to predict the depth of devitalization in energy-inflicted injury by visualization of the event

References

(1.) Makinen J, Johansson J, Tomas C, et al. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod. 2001;16:1473-1478.

(2.) Fuller J, Ashar BS, Corrado-Carey J. Trocar-associated injuries and fatalities: an analysis of 1399 reports to the FDA. J Minim Invasive Gynecol. 2005;12:302-307.

(3.) Chapron CM, Pierre F, Lacroix S, Querleu O, Lansac J, Dubuisson JB. Major vascular injuries during gynecologic laparoscopy. J Am Coll Surg. 1997;185:461-465.

(4.) Baggish MS. Analysis of 31 cases of major-vessel injury associated with gynecologic laparoscopy operations. J Gynecol Surg. 2003;19:63-73.

(5.) Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy: a prospective multicenter observational study. Br J Obstet Gynaecol. 1997;104:595-600.

(6.) Chapron C, Querleu D, Bruhat MA, et al. Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 29,966 cases. Hum Reprod. 1998; 13:867-872.

(7.) Harkki-Siren P, Sjoberg J, Makinen J, et al. Finnish National Register of Laparoscopic Hysterectomies: a review and complications of 1165 operations. Am J Obstet Gynecol. 1997;176(1 Pt. 1):110-122.

(8.) Harkki-Siren P, Kurki T. A nationwide analysis of laparoscopic complications. Obstet Gynecol. 1997;69:108-112.

(9.) Chapron C, Pierre F, Harchaoui Y, et al. Gastrointestinal injuries during gynaecological laparoscopy. Hum Reprod. 1999;14:333-337.

(10.) Baggish MS. Avoiding vascular injury at laparoscopy. OBG Management. 2004;16(10):70-87.

(11.) Smith ARB. Postoperative complications following minimal access surgery. Balllieres Clin Obstet Gynecol. 2000;14:123.

(12.) Baggish MS. One hundred and thirty small and large bowel injuries associated with gynecologic laparoscopic operations. J Gynecol Surg. 2007;23:83-95.

(13.) Bhoyrul S, Vierra MA, Nezhat CR, Krummel TM, Way LW. Trocar injuries in laparoscopic surgery. J Am Coll Surg. 2001;192:677-603.

(14.) Sharp HT, Dodson MK, Draper ML, Watts DA, Doucette RC, Hurd WW. Complications associated with optical-access laparoscopic trocars. Obstet Gynecol. 2002;99:553-555.

(15.) Champault G, Cazacu F, Taffinder N. Serious trocar accidents in laparoscopic surgery: a French survey of 103,852 operations. Surg Laparosc Endosc. 1996;6:367-370.

(16.) Brown JA, Chamberlain GVP, Jordan JA, et al. Gynaecological laparoscopy. The Report of the Working Party of the Confidential Enquiry into Gynaecological Laparoscopy. Br J Obstet Gynaecol. 1978;85:401-403.

(17.) Soderstrom RM. Bowel injury ligation after laparoscopy. J Am Assoc Gynecol Laparosc. 1993;1:74-77.

(18.) Bateman BG, Kolp LA, Hoeger K. Complications of laparoscopy--operative and diagnostic. Fertil Steril. 1996;66:30-35.

(19.) Saidi MH, Vancaillie TG, White J, Sadler RK, Akright BD, Farhart SA. Complications of major operative laparoscopy. A review of 452 cases. J Reprod Med. 1996;41:471-476.

(20.) Gordts S, Watrelot A, Camp R, Brosens I. Risk and outcome of bowel injury during transvaginal pelvic endoscopy. Fertil Steril. 2001;76:1238-1241.

(21.) Wang PH, Lee WL, Yuan CC, et al. Major complications of operative and diagnostic laparoscopy for gynecologic disease. J Am Assoc Gynecol Laparosc. 2001;8:68-73.

(22.) Brosens I, Gordon A, Campo R, Gordts S. Bowel injury in gynecologic laparoscopy. J Am Assoc Gynecol Laparosc. 2003;10:9-13.

Michael S. Baggish, MD

Dr. Baggish is Chairman of the Department of Obstetrics and Gynecology at Good Samaritan Hospital and Director of Obstetrics and Gynecology Residency Training for TriHealth Hospitals in Cincinnati. He is also Professor of Obstetrics and Gynecology at the University of Cincinnati College of Medicine and a Course Director of the 2008 Pelvic Anatomy and Gynecologic Symposium (PAGS), to be held December 11-13 at the Wynn Las Vegas. For more information go to: www.PAGS-cme.org

The author reports no financial relationships relevant to this article.
TABLE Studies of complications reveal: Gastrointestinal injury is
no rare event during laparoscopic surgery

Study (year; country)                    Cases     Complications

Brown et al (1978; UK) (16)               50,247        345
Soderstrom (1993; US) (17)               No data      No data
Bateman et al (1996; US) (18)             1,162       No data
Champault et al (1996; France) (15)      103,852        337
Saidi et al (1996; US) (19)                452           47
Jansen et al (1997; Netherlands) (5)      25,764        145
Harkki-Siren et al (1997; Finland) (8)    70,607         96
Harkki-Siren et al (1997; Finland) (7)     1,165        119
Chapron et al (1998; France) (6)          29,996         96
Chapron et al (1999; France) (9)         No data       No data
Gordts et al (2001; France) (20)          3,667        No data
Bhoyrul et al (2001; US) (13)            No data         629
Wang et al (2001; Taiwan) (21)            6,451           42
Sharp et al (2002; US) (14)                185            84
Brosens et al (2003; Belgium) (22)       85,727        No data

Study (year; country)                    Deaths       GI injury

Brown et al (1978; UK) (16)                4       117 (2.3/1,000)
Soderstrom (1993; US) (17)                 3             66
Bateman et al (1996; US) (18)            No data    3 (2.6/1,000) *
Champault et al (1996; France) (15)        6        63 (0.6/1,000)
                                                      ([dagger])
Saidi et al (1996; US) (19)                0              0
Jansen et al (1997; Netherlands) (5)       2        29 (1.31/1,000)
Harkki-Siren et al (1997; Finland) (8)     0        44 (0.6/1,000)
Harkki-Siren et al (1997; Finland) (7)     0         5 (4/1,000)
                                                   ([double dagger])
Chapron et al (1998; France) (6)           1        48 (1.6/1,000)
Chapron et al (1999; France) (9)         No data    62 (0.6-1.6/1,000)
Gordts et al (2001; France) (20)         No data       24 (6/1,000)
Bhoyrul et al (2001; US) (13)              32        128 ([section])
Wang et al (2001; Taiwan) (21)              0        10 (1.6/1,000)
Sharp et al (2002; US) (14)                 2              24 **
Brosens et al (2003; Belgium) (22)       No data    195 (2.3/1,000)

* 80 open laparoscopy procedures; 30 closed laparoscopy procedures

([dagger]) Limited to trocar injuries

([double dagger]) Laparoscopic hysterectomy

([section]) All trocar injuries obtained through Food and Drug
Administration reports

** Limited to optical access trocars
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Title Annotation:SURGICAL TECHNIQUES
Author:Baggish, Michael S.
Publication:OBG Management
Article Type:Case study
Geographic Code:1USA
Date:Jul 1, 2008
Words:3467
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