Laparoscopic Complications Case File
Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG
Case 8
A 35-year-old G2P2002 Hispanic woman presents to your office complaining of abdominal pain, nausea, and vomiting. Her abdominal pain has become progressively worse, and for the past 6 hours, she has had vomiting. She is postoperative day 3 from a right salpingo-oophorectomy for an 8-cm complex mass that was diagnosed as a mature teratoma on pathology. Some moderately dense adhesions of the omentum and small bowel were noted to be adherent to the mass and were dissected down. No complications were noted during the surgery, and the patient was discharged home the same day. Her past medical history is significant for pelvic inflammatory disease (PID) and two previous cesarean deliveries. Her vitals are temperature 101.4°F, pulse 110 beats/min, respiratory rate (RR) 22 breaths/min, and BP 120/70 mm Hg. On abdominal examination, the trocar sites are without erythema or induration and are well reapproximated. She has marked tenderness throughout the abdomen with rebound and guarding.
➤ What is the most likely diagnosis?
➤ What imaging modality is most helpful to confirm the diagnosis?
➤ What is the best treatment for this patient?
ANSWERS TO CASE 8:
Laparoscopic Complications
Summary: A 35-year-old G2P2002 Hispanic woman presents with fever and abdominal pain with rebound tenderness. She is postoperative day 3 from a right salpingo-oophorectomy for an 8-cm complex mass. Some moderately dense adhesions of the omentum and small bowel were noted adherent to the mass and were dissected down.
➤ Most likely diagnosis: Peritonitis from bowel injury.
➤ Most helpful imaging modality: Abdominal and pelvic computed tomography (CT) with water-soluble contrast.
➤ Best treatment for this patient: The patient should receive broad-spectrum antibiotics that cover anaerobic and aerobic organisms. She should then undergo a laparotomy. Meticulous inspection of the bowel should be carried out. Further treatment should take into consideration the location of the injury (small bowel or the large bowel), the cause of the injury (thermal, laceration, puncture), the size of the injury, and presence of fecal contamination. She may need a simple closure of the bowel wall defect or a colostomy.
ANALYSIS
Objectives
- List the different types of laparoscopic injuries.
- Know techniques to prevent laparoscopic injuries.
- Know the intra- and postoperative presentation of laparoscopic injuries.
- Know techniques for the management of various injuries.
Considerations
This is a patient who underwent a difficult laparoscopy. The patient had multiple risk factors for complications from surgery such as prior PID and prior cesareans. The surgical findings noted omentum and small bowel adherent to the ovarian mass. The patient’s surgery occurred 3 days previously, and now she presents with peritonitis. The most important goals in the approach to this patient are broad-spectrum antibiotics and expeditious exploratory laparotomy. Affected patients can become septic and hypotensive; intravenous fluid hydration and blood pressure support are important.
APPROACH TO
Laparoscopic Complications
DEFINITIONS
ENTEROTOMY: Full-thickness opening in the bowel wall where the lumen is entered.
URETEROURETEROSTOMY: Anastomosis of the two transected ends of the ureter.
URETERONEOCYSTOSTOMY WITH PSOAS HITCH: When the ureter is transected within 6 cm of the ureterovesical junction, this is the treatment of choice. The distal ureter segment is ligated. The bladder is mobilized and elongated toward the proximal injured ureter. The proximal ureter is anastomosed to the bladder. The bladder is attached to the psoas muscle to keep tension off the proximal ureter.
ILEAL INTERPOSITION: When a ureter injury takes place in the upper or middle third of the ureter and length for reanastomosis is lacking, the proximal ureter is anastomosed to a segment of ileum which in turn is anastomosed to the distal ureter.
URETEROILEONEOCYSTOSTOMY: When a ureter injury takes place in the upper or middle third of the ureter and the length for a tension-free reanastomosis is lacking, the proximal ureter is anastomosed to a segment of ileum which in turn is anastomosed to the bladder.
BOARI BLADDER FLAP: A flap of bladder wall shaped into a tube to replace a missing ureter segment.
TAMPON TEST: Helps to differentiate between a ureteral and bladder fistula. The patient wears the largest size tampon that is comfortable. She then takes oral Phenazopyridine HCl (Pyridium) and liquids for 30 minutes. Orange-stained urine on the tampon indicates a ureteral or a cephalad bladder fistula. A fresh tampon is then placed in the vagina, and 300 cc of methylene blue–stained sterile water is placed into the bladder via transurethral catheter. If there is no blue stain on the tampon, the fistula is from the ureter. An exception is a very small vesicular fistula.
CLINICAL APPROACH
Complications of laparoscopic surgery include injury to the gastrointestinal tract, vessels, urinary tract; related to the pneumoperitoneum; and incisional hernia. It is essential to recognize the injuries intraoperatively. The injury can occur during insertion of Veress needle or trocars, or at the time of the operative laparoscopy.1 The management of the injury may include laparoscopic repair or laparotomy, depending on the level of surgeon comfort and expertise. Consultations with specialists in general surgery, urology, or vascular surgery may be invaluable.
Pneumoperitoneum
If the Veress needle fails to enter the peritoneal cavity and causes extraperitoneal insufflation, it may result in mediastinal emphysema and pneumothorax. If the gas from the extraperitoneal insufflation extends to the mediastinum, mediastinal emphysema will be seen. The anesthesiologist will have difficulty ventilating the patient. As much gas as possible should be released, and the patient should be carefully monitored. The patient may require assisted ventilation in severe cases. A pneumothorax can occur if the Veress needle is placed in the pleural cavity, and may be more likely if an upper abdomen site is chosen for insufflation. A penetrating injury into a blood vessel can cause a gas embolism. The anesthesiologist may note a “mill-wheel” murmur over the precordium. In this case, a central venous catheter can be placed in the right atrium or the superior vena cava and the CO2 gas can be aspirated.1
Vascular Injuries
The insertion of the Veress needle or the trocar can cause trauma to the omental or mesenteric blood vessels and major abdominal or pelvic vessels. Small vessels in the omentum can be coagulated. Injury to the mesenteric vessels may compromise blood supply to the bowel, which may lead to bowel resection. Large vessels require immediate laparotomy, blood transfusion, and vascular repair.
The most common complication of laparoscopic surgery is the injury of the superficial or inferior epigastric vessels.2 Laceration of these vessels is minimized by transillumination of the abdominal wall, directly visualizing the inferior epigastric vessels and inserting the trocar 6 to 7 cm lateral to the midline.1 However, transillumination identifies the superficial epigastric artery only 64% of the time, and it is less helpful in patients with dark skin and body mass index (exceeding 25 kg/m2).2 The inferior epigastric is seen 80% of the time with transillumination.4 Injury to these vessels can present with bleeding from the trocar site. Techniques that can help control the bleeding from these vessels include direct pressure, tamponade from the trocar, bipolar coagulation of the vessel, placing sutures cephalad and caudad to the sleeve, and compression with an inflated 12-Fr Foley catheter that is clamped to the skin.2 If a hematoma forms, it should be evacuated, the incision explored, and the bleeding vessel ligated.1
Dixon and Carrillo studied a small series of pelvic vessel injuries that occurred from Veress needle and trocar placement. They reported that rightsided iliac vessel injuries were more common, and the right iliac vein was the most common site of injury.5 This injury can be prevented by aiming the Veress needle and trocar toward the hollow of the sacrum with the patient’s bed in the horizontal position. Large vessel injury may present with rapid pooling of blood in the operative field, welling of blood from the Veress needle or trocar, or with a hemodynamically unstable patient. If large vessel injury is suspected, the needle or trocar should be kept in place to help identify the site of the injury and immediate laparotomy should be performed. The injured area should be identified and compressed. The repair is based on the location of the injured vessel, whether it is arterial or venous, and the degree of the hemorrhage.
Bonjer and colleagues performed a retrospective comparison of open and closed laparoscopy. They reported rates of 0.075% of vascular injury with closed laparoscopy and 0% with open laparoscopy. Visceral injury rates were 0.083% and 0.048%, respectively.6 Although this study found statistical significance between open and closed laparoscopy for rates of vascular and bowel injuries, a meta-analysis found that open laparoscopy was not superior or inferior to any other entry technique.7
Gastric Injuries
Injury to the gastrointestinal tract can involve the stomach, small bowel, or large bowel. The injury can be sharp or thermal. A gastric injury may occur during gynecologic surgery from distention of the stomach during a difficult intubation. This can be minimized by gastric decompression prior to entry. If gastric juices are aspirated after the placement of the Veress needle or if a gastric injury is suspected, the Veress needle should be removed. The stomach should be decompressed with a nasogastric tube, and the Veress needle should be replaced. Gastric injuries may be recognized after the placement of the periumbilical trocar. The surgeon may visualize gastric contents or the rugal folds of the stomach.8 If the puncture is less than 5 mm in diameter and is hemostatic, the injury will usually resolve spontaneously. If the injury is larger, it may require a more extensive closure.1
Intestinal Injuries
A recent meta-analysis found that the incidence of bowel injuries to be 0.33%
with major operative laparoscopy.9 Women with previous abdominal surgeries
and pelvic adhesions are at greatest risk.
Bowel perforation with the Veress needle is often undiagnosed because the perforation seals off spontaneously. If perforation is suspected, the needle is removed and replaced at another site. Once the laparoscope is in place, the bowel should be inspected carefully. Most needle injuries to the small bowel do not require a laparotomy, but should be monitored closely. A hemostatic serosal injury does not need to be repaired.1
Trocar injuries are usually larger and require repair. A bowel injury is suspected if the trocar obturator has fecal matter upon removal from the sleeve or if the bowel lumen is visualized via the laparoscope. If the trocar or the laparoscope creates an enterotomy, it should be left in place to decrease contamination and for identification of the injured site; a laparotomy should then be performed. A small enterotomy that occurs during the surgical procedure can be repaired laparoscopically. Colon injuries can be repaired laparoscopically if the patient has undergone a bowel preparation or if fecal spill is minimal. Copious irrigation and broad-spectrum antibiotics are essential in prevention of peritonitis. Depending on the site and nature of the injury, a colostomy may be necessary.1
A thermal bowel injury can result from direct contact of electrical, thermal, or laser energy. The area of tissue destruction is larger than the initial area of contact due to thermal spread. Unrecognized thermal injury can result in tissue necrosis and subsequent perforation up to 72 to 96 hours after the surgery. One should suspect thermal bowel injury in a patient who presents several days after operative laparoscopic surgery with fever and abdominal pain. Significant thermal bowel injury should be treated with wide resection and reanastomosis.1
Approximately 15% of bowel injuries are not recognized at the time of laparoscopy. Brosens and associates reported that one in five cases of delayed diagnosis of bowel injury resulted in death.9
Bladder Injuries
Bladder injury can take place with trocar insertion. Women with previous pelvic surgery are at highest risk. To avoid this complication, the bladder should be drained prior to initiating the surgical procedure. If the surgery is anticipated to take longer than 30 minutes, a catheter should be placed for continuous drainage. The size of the injury will determine the treatment. A Veress needle puncture can be managed expectantly. Lacerations less than 5 mm will resolve spontaneously with continuous bladder drainage for 4 to 5 days postoperatively. Larger injuries should be closed in two layers. The mucosa should be reapproximated with 2-0 chromic suture, and the detrusor muscle should be reapproximated with 2-0 polyglycolic acid suture. Care should be taken to avoid involvement of the ureteral orifices in the repair. The repair should be tension free with a good seal. A catheter should be placed in the bladder for continuous drainage for 5 to 7 days.1
Ureteral Injuries
Ureteral injuries occur less frequently than those involving the bladder. The best way to prevent ureteral injury is to identify the course of the ureter prior to clamping the pedicle.
Leonard and associates performed a review of ureteral injuries during total laparoscopic hysterectomies and found an incidence of 0.3% with all injuries occurring at the level of the uterine artery and the uterosacral ligament.10 Laparoscopic ureteral injuries are more likely to result from thermal injuries. Furthermore, these injuries have a significant delay of diagnosis.1 If patients present with flank pain, fever, retroperitoneal fluid collection, or ileus in the postoperative period, an injury to the ureter should be suspected. A creatinine elevation of 0.8 mg/dL may be related to a unilateral ureteral ligation. A CT scan will be most helpful at this time. It will provide information about the integrity and function of the renal collecting system while identifying urinomas and surrounding postoperative anatomy. If intrinsic renal damage is present and there is concern for the use of contrast medium, a renal and proximal ureter ultrasound can be performed. However, it has a 25% false-negative rate.1 A retrograde stent, anterograde stent, or a percutaneous nephrostomy tube should be performed if an obstruction is noted and cannot be immediately relieved. If the obstruction is not relieved, permanent renal damage may result. If there is no ureteral obstruction but leakage of urine is noted, a ureteral stent should be placed. The best chance of healing after repair is when reoperation occurs within the first 48 hours. With increasing delay, more edema, necrosis, and tissue damage decrease the likelihood of a successful primary repair.
An intraoperative ureteral transection or ligation injury may be suspected if the ureter seems to enter a clamped or cut pedicle, a tubular structure is noted in a cut pedicle, there is lack of peristalsis from the ureter, and no urine output if both ureters are transected. If a ureteral injury is suspected intraoperatively, indigo carmine can be injected intravenously. A cystoscopy will show dye from the ureteral orifices after 5 minutes. If the ureteral injury is suspected immediately postoperatively, an intravenous pyelogram should be obtained. Up to 50% of cases of unilateral ureteral injury are asymptomatic postoperatively.11 Patients may also present with urine leakage from the vagina, indicating that an undetected ureteral or bladder injury has caused a fistula. A fistula can be diagnosed with a tampon test.
If a ureteral injury does occur, the management is based on the location, mechanism of the injury,4 and time of diagnosis. Repair of ureters is most often done via laparotomy. If the ureter is kinked by a ligature, simple dissection of the ureter away from the ligature is needed. In cases where the ureter is partially or completely ligated, the suture is removed and a stent is placed. If there is a question of ureteral viability, especially in cases of devascularization or thermal injury, the portion of concern must be resected. If a partial ureteral transection has taken place, a stent is introduced via the ureterotomy and the ureter is reapproximated over the stent with 5-0 polyglycolic acid suture. A closed suction drain should be placed at the base of the repair. If a complete transection has occurred in the upper or middle third of the ureter, a ureteroureterostomy over a stent is recommended. Care must be taken to ensure the repair is tension free and the ends are spatulated to increase the lumen size. If a transection of the ureter has occurred in the upper or middle third and the repair cannot be performed in a tension-free manner, a ureteroileal interposition or a ureteroileoneocystostomy is carried out. If a ureteral injury takes place within 6 cm of the ureterovesical junction, there is concern for vascular compromise of the distal portion of the ureter. The repair of choice in this situation is a ureteroneocystostomy with psoas hitch over a stent.
Trocar Hernia
Incisional hernia after laparoscopy is rare. With the use of bladed trocars, the incidence of hernia was found to be 0.23% at the 10-mm site and 3.1% at the 12-mm site.12 The recommendation is to close the fascia at trocar sites 10 mm or larger. With the use of bladeless trocars, the incidence of hernia is 0% to 0.2% at the 10- and 12-mm sites, respectively. The lower rate of hernia is thought to result from a smaller residual defect after the bladeless trocars are removed.13
Comprehension Questions
8.1 A 34-year-old woman is undergoing a tubal sterilization procedure. Bipolar cautery is planned to be used to cauterize the isthmic portion of the tubes. Which of the following statements regarding this patient is most accurate?
A. In general unipolar cautery is safer than bipolar cautery in avoiding thermal injury.
B. A thermal injury to the bowel is usually not apparent immediately and takes several days to a week to manifest.
C. The most likely cause of death to this patient related to the surgery is hemorrhage.
D. The ampulla of the tube is a more appropriate location rather than the isthmic portion.
8.2 A 29-year-old woman has chronic pelvic pain that has been worsening over the past 6 months despite medical therapy. The patient has had a thorough work-up, and is being scheduled for a diagnostic laparoscopy. In consenting the patient for complications, the gynecologist explains that vascular injury can occur. Which of the following is the most common vessel to be injured in this procedure?
A. Deep (inferior) epigastric artery
B. Aorta
C. Vena cava
D. Common iliac artery
E. Internal iliac artery
8.3 A 29-year-old woman undergoes extensive lysis of adhesions and ablation of endometriosis via laparoscopy. Postoperatively, she has abdominal distention and some leakage of yellowish fluid from her incision site. The fluid is sent for analysis. Which of the following statements is most accurate regarding this patient’s condition?
A. If the fluid has a sodium level of 140 mEq/L, it is likely to be urine.
B. If the fluid has a creatinine level of 0.8 mg/L, it is unlikely to be urinary in origin.
C. If the fluid has a pH of 7.40, it is likely to be urine.
D. If the fluid has a cloudy appearance, it is likely to be peritoneal fluid (ascites).
ANSWERS
8.1 B. Thermal injury often does not manifest itself until several days to a week after the initial surgery, due to the ischemia and necrosis that takes place. Bipolar is in general safer since the current passes from one paddle to another, whereas unipolar current can arc from the device to adjacent tissue. The most common cause of death due to female sterilization is anesthetic in nature. The isthmus of the tube is the most appropriate location for tubal ligation/occlusion.
8.2 A. In general, the deep epigastric artery is the most commonly injured vessel in laparoscopy that is associated with significant hemorrhage. This vessel is located between the rectus muscle and the parietal peritoneum of the anterior abdominal wall.
8.3 B. If the creatinine level is 0.8 mg/dL, it is unlikely to be urinary in origin, since the creatinine concentration is typically in the range of 40 to 50 mg/dL in the ureteral/bladder due to the concentrating ability of the kidneys. The sodium concentration is usually between 20 to 50 mEq/L. The pH varies and is not a good differentiating criterion.
Clinical Pearls
See Table 1-2 for definition of level of evidence and strength of recommendation
➤ Early detection of laparoscopic complication is the key to preventing patient morbidity and mortality (Level A).
➤ Fascia should be closed at trocar sites 5 mm or larger to prevent hernias (Level B).
➤ Repair of the ureter or bladder must be tension free for optimal healing (Level B).
➤ Thermal injuries may not be noted intraoperatively. Urinary and gastrointestinal tract injuries can present days later. An unrecognized bowel injury can present 72 to 96 hours from surgery (Level A).
➤ Although not consistent, some studies have noted decreased visceral and vascular complications with open laparoscopy compared to closed laparoscopy (Level B).
REFERENCES
1. Namnoum AB, Murphy AA. Diagnostic and Operative Laparoscopy in TeLinde’s Operative Gynecology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.
2. Donnez J, Nisolle M. An Atlas of Operative Laparoscopy and Hysteroscopy. 2nd ed. New York, NY: The Parthenon Publishing Group Inc.; 2001.
3. Hurd WW, Amesse LS, Gruber JS, et al. Visualization of the epigastric vessels and bladder before laparoscopic trocar placement. Fertil Steril. 2003;80:209-212.
4. Stany MP, Farley JH. Complications of gynecologic surgery. Surg Clin North Am. 2008;88:343-359.
5. Dixon M, Carrillo EH. Iliac vascular injuries during elective laparoscopic surgery. Surg Endosc. 1999;13:1230-1233.
6. Bonjer HJ, Hazebroek, EJ, Kazemier G, et al. Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg. 1997;84:599-602.
7. Vilos Ga, Ternamian A, Dempster J, et al. Laparoscopic entry: a review of techniques, technologies, and complications. J Obstet Gynaecol Can. 2007;29:434-465.
8. Mateus J, Pezzi C, Somkuti SG. Recognition and prevention of gastric injury during gynecologic laparoscopy. Obstet Gyencol. 2006;108:804-806.
9. Brosens I, Gordon A, Campo R, et al. Bowel injury in gynecologic laparoscopy. J Am Assoc Gyencol Laparosc. 2003;10:9-13.
10. Leonard F, Fotso A, Borghese B, et al. Ureteral complications from laparoscopic hysterectomy indicated for benign uterine pathologies: a 13-year experience in a continuous series of 1300 patients. Hum Reprod. 2007;22:2006-2011.
11. Nezhat FNC, Nezhat CR. Averting complications of laparoscopy: pearls from 5 patients. OBG Management. 2007;19:69.
12. Kadar N, Reich H, Liu CY, et al. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol. 1993;168:1493-1495.
13. Liu CD, McFadden DW. Laparoscopic port sites do not require fascial closure when nonbladed trocars are used. Am Surg. 2000;66:853-854.
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