Bowel Complications in Laparoscopic Gynecologic Surgery

Video Description

Bowel injuries complicate 0.13% of laparoscopic gynecologic surgeries. Intraoperative diagnosis is critical to preventing mortality.

A high index of suspicion should be maintained when patients present postoperatively with signs and symptoms suggesting bowel injury, and these patients should be promptly evaluated with imaging.

The general approach to bowel injury includes involving consultants early if needed, intraoperative antibiotics if appropriate, thorough evaluation of the injury, surgical repair, and monitoring for possible postoperative complications. The specific approach to repair depends on the type of bowel injury. Veress needle injuries can be managed expectantly. Superficial, small thermal and partial thickness injuries can be oversewn or repaired with a one layer closure.

Full thickness injuries should be closed in one or two layers. Large or infected injuries often require bowel resection with re-anastomosis and a possible diverting stoma. Considerations for postoperative care are also reviewed.

Presented By

Affiliations

University of Toronto, Queen’s University, University of Ottawa

See Also

• All our gynecology education videos and articles.
• Laparoscopy videos

Video Transcript: Bowel Complications in Laparoscopic Gynecologic Surgery

In this video, we will review an approach to bowel complications in laparoscopic gynecologic surgery. We will review the epidemiology of bowel injury, diagnostic techniques and principles of surgical repair. What percent of gynecologic surgeries are complicated by bowel injury? According to a recent systematic review, about one in 770, or 0.13%. 

Factors that may predispose the patient to bowel injury include adhesions from previous surgeries, particularly midline laparotomies, endometriosis, history of intraabdominal infection such as a ruptured appendix or necrotic uterus and previous radiation therapy to the pelvis or abdomen. Just over half of injuries occur during abdominal entry with Veress or trocar. Injuries may occur throughout the gastrointestinal tract. The most commonly injured organ is the small bowel, accounting for 47% of cases, followed by the colon in 30% of cases, the rectum in 18% of cases and the stomach in 6% of cases. 

What percent of bowel injuries are diagnosed later than 24 hours postoperatively? 41%. And out of these, 3.2% died as a result, compared to no deaths in patients with bowel injuries recognized intraoperatively. Intraoperative diagnosis is, therefore, critical when possible. 

It is important to maintain a high index of suspicion when patients present postoperatively with symptoms including pain, nausea or vomiting, no flatus, signs of sepsis or electrolyte abnormalities. These patients usually present in the first two to four days postoperatively. Fistulisation may take longer to present. However, almost all bowel injuries will declare themselves within 14 days. 

Patients presenting with these signs and symptoms should be promptly evaluated with imaging. On X-ray, free air may be noted, as demonstrated here. The percentage of patients with free air noted on X-ray postoperatively is 20% on day three and 4% on day seven. Imaging should include a CT scan with water-soluble oral and IV contrast. In this CT scan, contrast can be seen spilling into the abdominal cavity at the site of a bowel anastomosis leak. The most common findings associated with bowel injury on CT are spillage of contrast into the abdominal cavity, free air, bowel wall thickening and abscess. 

The specific approach to a bowel injury repair depends on the type of injury, which can be divided into four categories, Veress needle, superficial, small thermal or partial thickness, full thickness and large or complex injuries. The common approach to bowel injury involves the following components, involve consultants early if needed, interoperative antibiotics with coverage for enteric flora and anaerobes are typically sufficient, for example, Cefazolin two grams IV if not already given and Metronidazole 500 milligrams IV. 

The injury should be evaluated and surgically repaired. A laparotomy may be considered. If suspicion is high for bowel injury, a mini-laparotomy and a wound retractor may be needed to adequately run the bowel and ensure there are no occult injuries, especially when the injuries are unwitnessed such as during entry. The patient should then be observed at least overnight for complications depending on patient and surgical factors. 

Various needle injuries can typically be managed conservatively with observation. It is important to not waggle the needle side to side on intraabdominal entry as this practice can enlarge the size of an injury from 1.6 millimetres to up to one centimetre, as demonstrated. Superficial sharp injuries can be oversewn in an interrupted fashion, with a 3-0 delayed absorbable suture such as Polyglactin 910 or Vicryl in a cross-sectional plane. Small thermal injuries may appear as subtle blanched spots on the serosa, and their appearance may change over time. These can be oversewn in a similar fashion.  

Partial thickness seromuscular defects that are not penetrating the mucosa can also be repaired using a 2-0 or a 3-0 delayed absorbable suture in a single layer. Suturing should start at one apex and progress to the midline. It is important not to decrease the diameter of the bowel, particularly in the small bowel. To achieve this, the injury can be reorientated and then closed perpendicular to the line of the bowel. 

In penetrating injuries, the instrument can be left in the bowel until you’re ready for repair, and then the bowel can be mobilized. It can be easy to lose the spot of injury in the small bowel. The area can be tagged using an Endo loop, as seen here, or a stitch in the mesentery until you’re ready for repair. In rectosigmoid full-thickness injuries, a bowel probe can help delineate anatomy as well as the extent of the defect. 

A full-thickness injury can be repaired in one or two layers. If the vagina has been entered or a hysterectomy has been done, one may consider an omental patch interposed between the repaired bowel and the vagina in order to prevent a fistula. If the full-thickness injury is larger than one centimetre, a bowel resection with possible anastomosis may be required. Re-section may also be required in cases of thermal injuries without discrete margins, signs of infection, necrosis or non-viable segments. 

If there is a high risk of anastomotic breakdown, for example, an extensive infection, the patient may need a permanent stoma. The temporary stoma may be required to de-function the bowel anastomosis while it heals if the risk of breakdown is high. Examples include a highly infected bowel or a low rectal injury if there is inadequate rectal tissue. A stoma may also be required if there is a significant rectovaginal fistula. 

After repairing the large bowel, copious irrigation is needed. Their repair can be assessed with the flat tire test or proctoscopy. A closed suction pelvic drain may be considered to monitor for signs of repair breakdown. Postoperatively complications such as bowel injury should be communicated to the patient. Diet can be as tolerated unless there is a large defect or resection is required. Patients should then be monitored for complications. An anastomotic leak can occur in up to 19% of patients. 

To summarise, we discussed the epidemiology and diagnosis of bowel injuries as well as general approaches to repair. Various injuries can be managed expectantly. Superficial small thermal and partial thickness injuries can be oversewn or repaired with a one-layer closure. Full-thickness injuries should be repaired in one or two layers, with some injuries requiring resection and re-anastomosis.