Injury-free vaginal surgery: Case-based protective tactics

Transvaginal repair

If the small bowel is cut during dissection, inspect the adjacent small bowel thoroughly to ascertain the extent of the injury. Transvaginal repair is recommended if the laceration and adjacent mesentery can be completely visualized and accessed through the vagina.

Small lacerations require a simple closure

If the laceration is small (1–2 cm) and does not involve the mesentery, irrigate it thoroughly and close it using a running imbricating 2-0 braided suture (eg, Vicryl or silk), with the suture line perpendicular to the long axis of the small bowel to decrease the risk of stricture. Inspect the suture line to ensure that it completely seals the laceration. Suture bites should incorporate the serosa and muscularis without transgressing the mucosa. Use a noncutting needle to place these sutures.

If the mesentery is involved in the laceration, make sure there are no bleeding vessels, and ligate any bleeding ones.

Large lacerations may necessitate abdominal surgery

An abdominal or laparoscopic procedure may be necessary to repair larger lacerations to the small bowel. If the surgeon is uncomfortable with bowel repair, it may be appropriate to obtain an intraoperative consult from a surgical service.

Postoperative monitoring

Watch for signs of ileus, which should be managed with bowel rest and nasogastric suction, as indicated.

CASE 2 OUTCOME

The small laceration was repaired with 2-0 Vicryl suture in the manner described above. The patient’s diet was advanced when bowel sounds returned. There were no further sequelae.

Generalists can manage most injuries

Incidental intraoperative injuries to the lower urinary and gastrointestinal tracts are relatively rare complications of vaginal surgery—but we must make every effort to anticipate, prevent, and promptly recognize such injuries.

If they do occur, pursue a course to thoroughly evaluate, repair, test, and provide appropriate followup for the patient. If promptly identified and addressed, these injuries can be made to resolve with minimal long-term sequelae. Appropriately timed intraoperative cystoscopy is a useful method for prompt intraoperative identification of bladder and ureteric injuries. Injuries identified intraoperatively can usually be repaired using simple techniques available to the general gynecologist.

The author reports no financial relationships relevant to this article