For adhesiolysis, traction and counter-traction are the techniques of choice. Dissection of intestine should always be parallel to the axis of the viscus. Remember, too, that the blood supply enters via the mesenteric margin of the intestine.
After any dissection involving the intestine, carefully inspect the bowel and describe that inspection in the operative report (FIGURE 2). If injury is suspected, consult a general surgeon and open the abdomen to permit thorough inspection of the intestines.
What the literature reveals about intestinal injury
Several published reports describe a large number of laparoscopic cases and the major attendant complications.12-16 A number of studies have focused on gastrointestinal (GI) complications associated with laparoscopic procedures, providing site-specific data.
Many injuries occur during entry
Vilos reported on 40 bowel injuries, of which 55% occurred during primary trocar entry (19 closed and three open entries).17
In a report on 62 GI injuries in 56 patients, Chapron and colleagues found that one-third occurred during the approach phase of the laparoscopy; they advocated creation of a pneumoperitoneum rather than direct trocar insertion.18
In a report from the Netherlands, 24 of 29 GI injuries occurred during the approach.2
In a review of 63 GI complications related to diagnostic and operative laparoscopy, 75% of injuries were associated with primary trocar insertion.19
Optical access trocars do not appear to be protective against bowel injury. One study of 79 complications associated with these devices found 24 bowel injuries.20
In addition, in two reports detailing 130 cases of small- and large-bowel perforations associated with laparoscopic procedures, Baggish found that 62 (77%) of small-bowel injuries and 20 (41%) of colonic injuries were entry-related.5,6
Energy devices can be problematic
In the study by Chapron and colleagues of 62 GI injuries, six were secondary to the use of electrosurgical devices, four of them involving monopolar instruments.18
In a study from Scotland, 27 of 117 (23%) of bowel injuries during laparoscopic procedures were attributable to a thermal event.21
Baggish found that 43% of operative injuries among 130 intestinal perforations were energy-related.5,6
Intraoperative diagnosis is optimal
Soderstrom reviewed 66 cases of laparoscopy-related bowel injuries and found three deaths attributable to a delay in diagnosis exceeding 72 hours.4
In a study by Vilos, the mean time for diagnosis of bowel injuries was 4 days (range, 0–23 days), with intraoperative diagnosis in only 35.7% of cases.17
In a Finnish nationwide analysis of laparoscopic complications, Harkki-Siren and Kurki found that small-bowel injuries were identified an average of 3.3 days after occurrence; when electrosurgery was involved in the injury, the average time to diagnosis was 4.8 days.22 As for large-bowel injuries, 44% were identified intraoperatively. In the remainder of cases, the average time from injury to diagnosis was 10.4 days for electrosurgical injuries and 1.3 days for injuries related to sharp dissection.
In the studies by Baggish, 82 of 130 (63%) intestinal injuries were diagnosed 48 hours or more after the operation.5,6
Baggish also made the following observations:
- The most common symptoms of intestinal injury were (in order of frequency) abdominal pain, bloating, nausea and vomiting, and fever or chills (or both). The most common signs were abdominal tenderness, abdominal distension, diminished bowel sounds, and elevated or subnormal temperature.
- Sepsis was apparent (due to the onset of systemic inflammatory response syndrome) in the majority of small-bowel perforations and virtually all colonic perforations. Findings of tachycardia, tachypnea, elevated leukocyte count, and bandemia suggested sepsis syndrome.
- Radiologically observed free air was often misinterpreted by the radiologist as being consistent with residual gas from the initial laparoscopy. In reality, most—if not all—CO2 gas is absorbed within 24 hours, particularly in obese women. Early CT imaging with oral contrast leads to the most expeditious, correct diagnosis, compared with flat and upright abdominal radiographs.
- Obese women did not exhibit rebound tenderness even though subsequent operative findings revealed extensive and severe peritonitis.
- When infection occurred, it usually was polymicrobial in nature. The most frequently cultured organisms include Escherichia coli, Enterococcus, alpha and beta Streptococcus, Staphylococcus, and Bacteroides.
Baggish concluded that earlier diagnosis could be achieved with careful inspection of the intestine at the conclusion of each operative procedure (FIGURE 2).
Similarly, Chapron and colleagues recommended meticulous inspection of all areas where bowel lysis has been performed. “When there is the slightest doubt, carry out tests for leakage (transanal injection of 200 mL methylene blue using a Foley catheter) in order not to overlook a rectosigmoid injury which would become apparent secondarily in a context of peritonitis,” they wrote. They also suggested that the patient be educated about the signs and symptoms of intestinal injury.18