The author reports no financial relationships relevant to this article.
In Part 1 of this article, I outlined circumstances in which abdominal adhesions should be anticipated and described strategies to prevent intestinal injury during operative procedures. Here, I describe ways to identify intestinal injury as soon as possible after it occurs, which is vital to prevent serious sequelae such as sepsis and even death.
During operative laparoscopy, a quick search for injury through the laparoscope cannot assure any surgeon that the intestinal wall has not been seriously denuded. A damaged muscularis—even if it is not recognized as transmural injury—may subsequently rupture if it is not appropriately repaired intraoperatively.
Following dissection of adhesions, irrigate the neighboring intestine with sterile saline, and perform a detailed inspection of the intestine to ascertain integrity of the bowel wall. The color of the intestine is important, as it can indicate whether the abundant vascular supply has been compromised. Include a detailed description of the intestines in the operative note.
Avoid stapling or vascular clips when repairing any wound; careful suturing is preferred.
Why early diagnosis is critical
The most favorable time to diagnose an iatrogenic intestinal perforation is within the intraoperative period. Prompt recognition and repair of bowel perforation offers several advantages:
- A second or third operation is less likely (
- The risk of abdominal sepsis is decreased.
- The volume of peripheral injury to the intestine is reduced.
- The patient can be followed for subsequent complications more precisely, permitting earlier diagnosis, more timely and effective treatment, and lower morbidity.
The 130 intestinal injuries reported by Baggish reflect the clinical significance of timely diagnosis.1 Seventy percent of small bowel and 51% of large bowel perforations were correctly diagnosed more than 48 hours postoperatively. Sepsis was present in a majority of these cases at the time of diagnosis.
Infection, fluid-electrolyte imbalance, sepsis syndrome
The principal derangements that arise as a result of bowel perforation are infection and fluid-electrolyte imbalance and their sequelae. Intestinal fluid and feces contain a variety of bacteria, such as Escherichia coli, Enterococcus, Klebsiella, Proteus, Pseudomonas, and Clostridium, to name a few. These bacteria produce toxins that facilitate entry of bacteria into the circulation and contribute to a downward spiral of events, referred to as sepsis syndrome, as well as intra-abdominal abscess:
- Contamination of the abdominal cavity leads to inflammation of the peritoneum
- In turn, subperitoneal blood vessels become porous, causing interstitial fluid to leak into the third space
- Paralytic ileus and an accumulation of intra-abdominal fluid push the diaphragm upward, lowering the capacity for lung expansion within the thorax and contributing to partial lung collapse
- Fluid of inflammatory origin may accumulate in the chest as pleural cavity effusion.
A number of progressive complications are predictable, but may occur at variable intervals after the initial perforation. The most frequent complications associated with colonic injuries are:
- peritonitis (98% of cases)
- ileus (92%)
- pleural effusion (84%)
- colostomy (80%)
- intra-abdominal abscess (78%).
The most common sequelae after small-bowel perforation are:
- peritonitis (100% of cases)
- ileus (89%)
- intra-abdominal abscess (63%)
- pleural effusion (59%).1
Reasons for diagnostic delay
- The gynecologic surgeon fails to place intestinal injury at the top of the differential diagnosis.
- A surgical consultant is delayed in making a correct diagnosis. Surgeons have less experience with perforation than do gynecologists, and invariably consider the postoperative abdominal problem to be ileus or intestinal obstruction. The presence of postoperative pneumoperitoneum is incorrectly thought to be lingering CO2 gas from the initial laparoscopy rather than air from a perforated viscus.
- Ancillary diagnosis confuses the primary physician. Pleural effusion, chest pain, and tachypnea are usually thought to indicate pulmonary embolism; as a result, the gynecologist and consulting pulmonologist focus on pulmonary embolus and deep-vein thrombosis. Only a spiral computed tomography (CT) scan, a ventilation perfusion (VQ) scan, or arteriogram quickly rules pulmonary embolus in or out. Peritonitis associated with ileus or third-space fluid leakage resulting in diaphragmatic elevation also creates pleural effusion, tachypnea, and dyspnea.
Presumptive diagnosis is critical
Definitive diagnosis of intestinal perforation happens at the operating table under direct vision and is corroborated by the pathology laboratory if bowel resection is performed. However, presumptive diagnosis helps overcome inertia and gets the patient to the operating room sooner.