The author reports no financial relationships relevant to this article.
CASE Postoperative abdominal pain. Is it gastroenteritis?
R.B., 35 years old, undergoes laparoscopic adhesiolysis for abdominal pain. Previously, she underwent exploratory laparotomy for a ruptured tubal pregnancy and, in separate operations, right oophorectomy via laparotomy for a ruptured corpus luteum cyst and diagnostic laparoscopy.
During the current surgery, extensive adhesions are observed, including interloop intestinal adhesions. The adhesions are lysed using monopolar scissors and a needle electrode, and R.B. is discharged home the same day.
Later that day and the next day, R.B. complains of abdominal pain that does not respond to prescribed analgesics, as well as nausea and vomiting. A nurse practitioner takes her call and prescribes a stronger analgesic, an antiemetic, and an antibiotic.
The following day, the patient’s husband telephones the treating gynecologist to report that his wife is still experiencing severe pain and nausea. He is told to bring her to the office, where she is described as having mild lower abdominal tenderness and mild rebound. An abdominal radiograph shows air-fluid levels and distended bowel. The gynecologist determines that the patient is experiencing gastroenteritis.
On postop day 3, R.B. continues to suffer from severe abdominal pain, nausea, and vomiting, and is unable to get out of bed. Her husband takes her to the emergency room at another hospital, where she is found to have diffuse peritonitis, absent bowel sounds, and:
- temperature, 101.8°F
- heart rate, 130/min
- respiratory rate, 24/min
- blood pressure, 90/60 mm Hg
- white blood cell (WBC) count, 21.5 × 103/μL
- x-ray showing free air.
A general surgeon performs an exploratory laparotomy and finds foul-smelling abdominal fluid, 200 to 300 mL of pus, and a 1-cm perforation of the sigmoid colon. He performs sigmoid colon resection and a left-colon colostomy. A second laparotomy is necessary to drain a subphrenic abscess.
Four months later, the colostomy is taken down and bowel continuity is established.
Subsequently, the patient experiences episodes of gaseous and fecal incontinence, which are thought to be secondary to nerve damage. A ventral hernia is also diagnosed.
Could this outcome have been avoided?
No physician would wish a major complication of surgery upon any patient. Yet, sometimes, preventive efforts fall short of the goal or the physician is slow to suspect injury when the patient experiences postoperative abdominal pain and other symptoms. Intestinal injury may not be common during laparoscopy, but it is certainly not rare. And the longer diagnosis is delayed, the greater the risk of sepsis, even death.
Recognizing the limitations of laparoscopic surgery is a first step toward reducing the complication rate.1,2 The ability to determine when laparotomy would better serve the patient’s interests is also critical, and prompt diagnosis and repair of any complication that does occur will ensure and speed the patient’s recovery.
The most serious complications associated with diagnostic and operative laparoscopy are major vessel and intestinal injuries. Both types of injury significantly raise the risk of mortality, which ranges from 2% to 23%.3,4 The overall risk of injury to the gastrointestinal tract averages 1.6 to 2.0 for every 1,000 cases. The risk of major vessel injury averages 0.5 for every 1,000 cases.5-9
In an earlier article for OBG Management, I reviewed vascular injury during laparoscopy.10 In Part 1 of this article, I focus on ways to avoid intestinal injury.In Part 2 , I outline strategies to identify it in a timely manner when it does occur.
- Avoid laparoscopy when severe adhesions are anticipated—such as when the patient has a history of multiple laparotomies, or when significant adhesions have been documented.
- Be aware that laparoscopy carries additional risks beyond those of the primary surgical procedure, owing to factors peculiar to endoscopic technique and instrumentation.
- Consider open laparoscopy or insert the primary trocar at an alternative location, such as the left upper quadrant, when the patient has a history of laparotomy.
- Avoid blunt dissection for anything other than mild (filmy) adhesions. Sharp dissection associated with hydrodissection is the safest method of adhesiolysis. Clear visualization of the operative site is the sine qua non for precise dissection.
- Avoid monopolar electrosurgical devices for laparoscopic surgery whenever possible. Also remember that bipolar and ultrasonic devices can cause thermal injury by heat conduction as well as by direct application. Laser energy will continue beyond the target unless provision is made to absorb the residual energy.
- At the conclusion of any laparoscopic procedure, especially after adhesiolysis or bowel dissection, inspect the intestines and include the details in the operative report.
- After any laparoscopic procedure, if the patient does not improve steadily, the first presumptive diagnosis to be excluded is injury secondary to the procedure or technique.
- The major symptom of intestinal perforation is abdominal pain, which does not ease without increasing quantities of analgesics.
- Investigate any bowel injury thoroughly to determine viability at the site of injury. Whenever possible, repair all injuries intraoperatively.
- After intestinal perforation, the risk of sepsis is high. Look for early signs such as tachycardia, subnormal body temperature, depressed WBC count, and the appearance of immature white cell elements.