Averting complications of laparoscopy: Pearls from 5 patients
Ureter, bladder, small bowel, colon, vascular system—all are at risk of damage during operative laparoscopy
IN THIS ARTICLE
Delay in detection can have serious ramifications
When a large-bowel injury goes undetected at the time of operation, the patient generally presents on the third or fourth postoperative day with mild fever, occasionally sudden sharp epigastric pain, lower abdominal pain, slight nausea, and anorexia. By the fifth or sixth day, these symptoms have become more severe and are accompanied by peritonitis and an elevated WBC count.
Whenever a patient complains of abdominal pain and a deteriorating condition, assume that bowel injury is the cause until it is proved otherwise.
Intraoperative management
Repair small trocar wounds using primary suture closure. Copious lavage of the peritoneal cavity, drainage, and a broad-spectrum antibiotic minimize the risk of infection. Manage deep electrical injury to the right colon by resecting the injured segment and performing primary anastomosis. Primary closure or resection and reanastomosis may not be adequate when the vascular supply of the descending colon or rectum is compromised. In that case, perform a diverting colostomy or ileostomy, which can be reversed 6 to 12 weeks later.25,26
CASE 5: Vascular injury
A tall, thin, athletic 19-year-old undergoes diagnostic laparoscopy to rule out pelvic pathology after she complains of severe, monthly abdominal pain. Upon insertion of the laparoscope, the surgeon observes a large hematoma forming at the right pelvic sidewall. At the same time, the anesthesiologist reports a significant drop in blood pressure, and vascular injury is diagnosed. The surgeon attempts to control the bleeding using bipolar coagulation, but the problem only becomes worse. He decides to switch to laparotomy.
A vascular surgeon is called in, and injury to the right common iliac artery and vein—apparently caused during insertion of the primary umbilical trocar—is repaired. The patient is given 5 U of red blood cells. She goes home 10 days later, but returns with thrombophlebitis and rejection of the graft. After several surgeries, she finally recovers, with some sequelae, such as unilateral leg edema.
Management of vascular injury depends on the source and type of injury. On major vessels, electrocoagulation is contraindicated. After immediate atraumatic compression with tamponade to control bleeding, vascular repair, in consultation with a vascular surgeon, is indicated. At times, a vascular graft may be required.
Smaller vessels, such as the infundibulopelvic ligament or uterine vessels, can be managed by clips, suture, or loop ligatures. If thermal energy is used in the repair, be careful to avoid injury to surrounding structures.
Most emergency laparotomies are performed for uncontrolled bleeding.30,31 Lack of control or a wrong angle at insertion of the Veress needle and trocars is a major cause of large-vessel injury. Sharp dissection of adhesions, uterosacral ablation, transection of vascular pedicles without adequate dessication, and rough handling of tissues can all cause bleeding. Distorted anatomy is a main cause of vascular injury and can compound injury in areas more prone to bleeding, such as the oviduct, infundibulopelvic ligament, mesosalpinx, and pelvic sidewall vessels.
The return of pressure gradients to normal levels at the end of a procedure can be accompanied by bleeding into the retroperitoneal space, so evaluate the patient in a supine position after intra-abdominal pressure is reduced.
A vascular surgeon may be required
Depending on the type of vessel, size and location of the injury, and degree of bleeding, you may use unipolar or bipolar electrocoagulation, suture, clips, vasopressin, or loop ligatures to control bleeding. Although diluted vasopressin (10 U in 60 mL of lactated Ringer’s saline) can decrease oozing from raw peritoneal areas, injury to a major vessel, such as the iliac vessels, vena cava, or aorta, needs immediate control and proper repair. The decision to perform laparoscopy or laparotomy depends on your preference and experience. In any case, a vascular surgeon may be consulted for major vascular injuries.32
If a major vessel is injured, do not crush-clamp it. If possible (and if your laparoscopic skills are advanced), insert a sponge via a 10-mm trocar and apply pressure to the vessel to minimize bleeding and enhance visualization. The decision to repair the injury laparoscopically or by laparotomy should be made judiciously and promptly. n
The authors acknowledge the editorial contributions of Kristina Petrasek and Barbara Page, of the University of California, Berkeley, to the manuscript of this article.
