Date Published: December , 2017
Publisher: Makerere Medical School
Author(s): Hassan M Elbiss, Fikri M Abu-Zidan.
Bowel injury remains a serious complication of gynecological laparoscopic surgery. We aimed to review the literature on this topic, combined with personal experiences, so as to give recommendations on how to avoid and manage this complication.
We performed a narrative review on bowel injury following gynecological laparoscopic surgery using PubMed covering prevention, diagnosis, and management. Search terms used were laparoscopy, gynaecology, injury, bowel, prevention, treatment.
Important principles of prevention include proper pre-operative evaluation and increased laparoscopic surgical skills and knowledge. High clinical suspicion is crucial for early diagnosis. Diagnostic workup of suspected cases includes serial abdominal examination, measuring inflammatory markers, and performing imaging studies including abdominal ultrasound and CT scan. When bowel injury is recognized during the first laparoscopic procedure then laparoscopic primary suturing could be tried although laparotomy may be needed. When diagnosis is delayed, then laparotomy is the treatment of choice. The role of robotic surgery and three-dimensional laparoscopic gynecological surgery on bowel injury needs to be further assessed.
Early recognition of bowel injury is crucial for a favorable clinical outcome. A combined collaboration between gynecologists and general surgeons is important for timely and proper decisions to be made.
Laparoscopy has many advantages over open surgery including less post-operative pain, earlier return of normal bowel function, shorter hospital stay, and earlier recovery.1 Despite advanced technology and improved surgical skills and knowledge, complication rates, including preventable injuries, are increasing. It is difficult to determine the exact incidence of complications. Definitions of complications vary and they are usually under-reported. The reported overall complication rates range from 0.2% to 10.3%. Major laparoscopic procedures are associated with a higher rate of complications.
In the last thirty years, several entry approaches, new instruments, and new techniques have been introduced to minimize laparoscopic complications. Electrosurgery during laparoscopy can be used for coagulation, dissection, cutting, and ablation. Electrosurgery-induced injury can be either direct mechanical or indirect electrothermal injury. The use of ultrasonic energy through a harmonic scalpel might reduce the risk of collateral damage. The development of microprocessor-controlled generators with feedback from the electrode-tissue interface to determine the power output with autostop facility has made bipolar energy even safer. However, experience with this technology is still primitive. Therefore, understanding the principles of electrosurgery and practicing it in simulation is important before using it in laparoscopic surgery. Newer hemostatic technologies such as Ultrasonic Technology which does not have electrosurgical current generated can be used to decrease the incidence of complications.
Closure of a port of 10 mm or more has been recommended to avoid herniation of the small bowel17 (Figure 2). However, other factors including elderly patients, high body mass index, pre-existing hernia, the port size, trocar design, and increased time of surgery should be considered. 18
Early recognition of bowel injury and early intervention is crucial to reduce its morbidity and mortality.19 Despite care to identify bowel injury during surgery, only less than half of these injuries are diagnosed during laparoscopy. 5 When bowel injuries are not diagnosed during surgery, and dealt with at the same time, it may become a life-threatening condition. That is why it is the most common cause of laparoscopy-related death.20 A review of 66 cases showed that the mortality rate significantly increased if the diagnosis was delayed more than three days.21 The average time between surgery and diagnosis of small bowel injury was 3.3 days. However it was longer with an average of 4.8 days when injuries resulted from electrosurgery.22 The average time to diagnose large bowel injury was 1.3 days when sharp dissection was used and 10.4 days when electrosurgery was used. In a more recent study, 63% of missed bowel injuries were diagnosed two days or more after surgery.23
Difficulty or repeat trials in creating adequate pneumoperitoneum should alert the surgeon to the possibility of bowel injury (Figure 3). This indicates careful inspection of the bowel surface to diagnose any bowel injury. If the bowel is entered by the Veress needle or trocar, then bowel contents or gas passage might be observed. Aspiration of bowel’s content during Palmer saline test is highly suggestive of large bowel injury. Fecal odor might be noted if the large bowel was injured. Present of air bubbles when irrigating suspected injured bowel might be suggestive of bowel injury.24 The bowel should be always inspected following sharp or blunt dissection that in particular caused bleeding or hematoma so as to exclude bowel injury.
A patient who does not improve after laparoscopy should be suspected to have unrecognized bowel injury. Delay in diagnosing a bowel perforation can lead to acute peritonitis and even death. If bowel injury is suspected, a general surgeon should be involved early in the management of these patients. The patient should be strictly observed and worked up to confirm or exclude the diagnosis. Work-up of these patients include serial abdominal examination and repeated laboratory and imaging studies as needed.
If recognized early and on table by an experienced laparoscopic surgeon, majority of bowel injuries can be repaired by laparoscopy or by mini-laparotomy.19,24 Nevertheless, early involvement of an experienced general surgeon is recommended whenever an intestinal injury is suspected during or following laparoscopic gynecological surgery. Laparoscopic repair of injury depends on its size and nature, and on the surgeon’s experience.33
Ideally, the best and cheapest solution for bowel injury is prevention. Bowel adhesion is a potential risk factor for bowel injury. Different anti-adhesive agents have been developed and tested to reduce adhesion formation. Nevertheless, strong evidence to support their general use is still lacking.38