How to avoid injury to bowel during laparoscopy
Be reluctant to perform laparoscopy in a patient known to have significant adhesions. Also, be aware of risk of injury at trocar entry and mindful of how you use energy devices.
IN THIS ARTICLE
A thorough familiarity with pelvic anatomy is important to avoid injury at trocar entry, but it is even more critical in regard to operative injury. The small intestine spreads diffusely throughout the abdomen beneath the anterior abdominal wall. It lies beneath the umbilicus and anterior midline, whereas the large bowel is located at the periphery. The sigmoid colon swings left to right before joining the rectum anterior to the presacral space. The sigmoid junction with the descending colon lies well to the left of the midline, and the cecum lies at the pelvic brim to the right of midline.
In some women, the intestines droop into the pelvis and cover the adnexa, making adhesions between these structures highly likely following dissection in the vicinity of the tubes and ovaries.
Depending on the degree of redundancy of the mesentery of the cecum or sigmoid colon, these structures may droop into the pelvis and cover the adnexa. Therefore, adhesions are likely to develop between the large or small intestine, or both, and the adnexa following dissection in the vicinity of or immediately over the tubes and ovaries. Knowing the normal anatomic relationships is vital for restorative surgery.
When severe adhesions involve the large intestine, it is critical to know the anatomy of the retroperitoneum and be skilled enough to gain safe entry and to dissect that space to safely separate the adnexa when they are densely adhered to the pelvic sidewall in the area of the obturator fossa.
As laparoscopy evolves, the injury rate rises
Over the past 40 years, laparoscopy has evolved from an uncommonly utilized diagnostic tool to a minimally invasive alternative to laparotomy for even the most difficult and complex operations, reaching a high point with robotic laparoscopy. As this technology has developed, serious complications—to some degree, unique to laparoscopy—have increased. In the future, as less skilled surgeons perform a greater percentage of laparoscopic surgeries, a still greater number of complications will arise.
The frequency of intestinal perforation is not great relative to the total number of laparoscopic procedures performed. The TABLE lists several series totaling more than 380,000 laparoscopic operations. The risk of reported bowel perforation ranged from 0.6 to 6 for every 1,000 procedures, with a mean risk of 2.4 for every 1,000. However, these data are inconclusive because the total number of laparoscopic operations performed in the United States is not accurately known. Nor is the precise number of complications associated with these procedures known—specifically, the number of intestinal perforations—as no law requires them to be reported.
Research surveys are unreliable in many cases. In addition, the relative expertise of the surgeon is impossible to quantify. For example, although a surgeon may have many years of operative experience, it is unclear whether this always translates into skill or comfort with laparoscopic procedures. And, when a resident scrubs in with a faculty surgeon, any data collected fail to reflect which part of the surgery was performed by the resident and which by the fully trained gynecologist.
These unknown variables are important in terms of risk, surgical complications, and outcomes. Surgical skill is the greatest unknown factor in any outcome study of any surgical procedure.
TABLE
Studies of complications reveal: Gastrointestinal injury is no rare event during laparoscopic surgery
| Study (year; country) | Cases | Complications | Deaths | GI injury |
|---|---|---|---|---|
| Brown et al (1978; UK)16 | 50,247 | 345 | 4 | 117 (2.3/1,000) |
| Soderstrom (1993; US)17 | No data | No data | 3 | 66 |
| Bateman et al (1996; US)18 | 1,162 | No data | No data | 3 (2.6/1,000)* |
| Champault et al (1996; France)15 | 103,852 | 337 | 6 | 63 (0.6/1,000)† |
| Saidi et al (1996; US)19 | 452 | 47 | 0 | 0 |
| Jansen et al (1997; Netherlands)5 | 25,764 | 145 | 2 | 29 (1.13/1,000) |
| Harkki-Siren et al (1997; Finland)8 | 70,607 | 96 | 0 | 44 (0.6/1,000) |
| Harkki-Siren et al (1997; Finland)7 | 1,165 | 119 | 0 | 5 (4/1,000)‡ |
| Chapron et al (1998; France)6 | 29,996 | 96 | 1 | 48 (1.6/1,000) |
| Chapron et al (1999; France)9 | No data | No data | No data | 62 (0.6–1.6/1,000) |
| Gordts et al (2001; France)20 | 3,667 | No data | No data | 24 (6/1,000) |
| Bhoyrul et al (2001; US)13 | No data | 629 | 32 | 128§ |
| Wang et al (2001; Taiwan)21 | 6,451 | 42 | 0 | 10 (1.6/1,000) |
| Sharp et al (2002; US)14 | 185 | 84 | 2 | 24** |
| Brosens et al (2003; Belgium)22 | 85,727 | No data | No data | 195 (2.3/1,000) |
| * 80 open laparoscopy procedures; 30 closed laparoscopy procedures | ||||
| † Limited to trocar injuries | ||||
| ‡ Laparoscopic hysterectomy | ||||
| § All trocar injuries obtained through Food and Drug Administration reports | ||||
| ** Limited to optical access trocars | ||||
Classifying intestinal injuries
As in the case of major vessel injury, intestinal injury sustained during laparoscopy can be classified as either:
- Injury secondary to the approach. This category refers to entry complications associated with creation of the pneumoperitoneum and insertion of primary and secondary trocars.
- Injury secondary to the procedure or operation. This type of injury occurs as a result of manipulation with various devices during laparoscopy. The devices may include probes, forceps, scissors, or energy devices such as laser, electrosurgical, and ultrasonic instruments.
