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Avoiding and repairing bowel injury in gynecologic surgery

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Tips for avoiding the pitfalls in at-risk patients and injury-prone procedures, plus techniques for adhesiolysis, repair of serosal and small bowel injuries, and inspection of the bowel to rule out perforations.


 

References

KEY POINTS
  • Although the optimal method is a matter of choice, preoperative bowel preparation is recommended to reduce bacteria, stool bulk, and infectious complications.
  • When entering the peritoneal cavity in patients with prior surgery, watch for adhesions between a loop of bowel and the abdominal wall.
  • In high-risk patients, enter the peritoneal cavity by extending the previous abdominal scar superiorly and inferiorly to minimize risk of injury.
  • Close small perforations in 2 layers, with the suture line always perpendicular to the long axis of the bowel.
  • For more extensive injury or compromised blood supply to the bowel wall, resection and anastomosis may be necessary. Obtain intraoperative general surgical consultation if not trained to perform this kind of repair.

This dreaded complication requires vigilance and skill to avoid, and adequate training and experience to manage and repair. In a perfect world, every gynecologist would be trained in techniques to prevent and repair inadvertent bowel injuries. Unfortunately, residency programs often do not provide such training.

Gynecologists routinely operate on patients with risk factors for bowel injury—obesity, endometriosis, multiple abdominal procedures, pelvic inflammatory disease, history of malignancy, and advanced age. A general surgeon is often called, however, for bowel repairs that can be performed by a gynecologist with sufficient training and experience. (There are instances, however, in which a general surgical consultation may not be readily available—another reason to master repair of bowel injuries encountered during gynecologic surgery.)

This article describes techniques to avert and manage intestinal injury. Topics include adhesiolysis, repair of bowel perforations, segmental bowel resection, and pre- and postoperative management. Vascular anatomy of the bowel is illustrated.

We emphasize the need for direct supervision by an experienced surgeon while mastering these techniques.

Bowel preparation: A useful tool to reduce infection, leakage

Isolated reports have questioned the need for mechanical bowel preparation,1,2 and some experts point to the recent success of primary repairs of gunshot and stab wounds to the colon as evidence that bowel preparation and preoperative oral antibiotics are unnecessary.

Other studies indicate potential benefits, namely reducing infectious complications and anastomotic leakage following repair of inadvertent enterotomy. Indeed, the vast majority of North American surgeons continue to use some form of bowel preparation,3,4 and it is the standard of care for elective intestinal surgery. For these reasons, bowel preparation is strongly encouraged for the gynecologic surgeon operating on a pelvic mass, endometriosis, or malignancy, or when difficult dissection is anticipated with the potential for inadvertent enterotomy and spillage of intestinal contents.

Bowel preparation consists of 2 phases: mechanical cleansing and antibiotic administration (TABLE). The postoperative infection rate can be reduced to well below 10% when these are properly performed.

Mechanical cleansing reduces the bulk of stool content within the lumen of the bowel, which also decreases the absolute amount of bacteria.5 Anaerobes are the predominant flora in the colon, with an estimated density of 1010 organisms per gram of stool. Perforation and spillage of colon contents contaminates the peritoneal cavity with more than 400 species of bacteria.

Perforation and spillage of colon contents contaminates the peritoneal cavity with more than 400 species of bacteria.

In the past, stool bulk was reduced via a low-residue or liquid diet combined with cathartics, enemas, or other agents given over 2 to 3 days. This regimen was time-consuming, patient compliance was poor, and nutritional intake was severely restricted prior to major surgery.

Today, polyethylene glycol and sodium phosphate are the 2 most popular methods of bowel preparation.

  • Polyethylene glycol (Golytely, Braintree Labs, Braintree, Mass) is a balanced electrolyte solution dispensed in a 4-L quantity that must be taken over 4 hours. Some patients find this volume difficult to consume; one option is administering the solution via a small nasogastric tube. Complications may include nausea/vomiting, abdominal cramping, and, rarely, fluid overload and electrolyte disturbances.
  • Sodium phosphate (Fleet Phosphosoda, C.B. Fleet Co, Lynchburg, Va) is administered in two 45-mL increments several hours apart. There is no consensus on which bowel-prep method is superior3,4; most surgeons prefer one or the other. Due to potential electrolyte abnormalities with the use of sodium phosphate, polyethylene glycol is favored for patients with significant renal, cardiac, or hepatic disease.
  • We recommend minimally absorbed oral antibiotics (1 g each of neomycin and erythromycin, given at 1 PM, 2 PM, and 11 PM the day before surgery) in combination with an intravenous second-generation cephalosporin (1 g if using cefotetan, 2 g if using cefoxitin; given immediately before surgery and continued postoperatively for 3 doses).
  • Timing of antibiotic administration is important, since postoperative antibiotics alone do not appear to be effective. If significant spillage occurs intraoperatively, parenteral antibiotics should be continued for 5 days.

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