Michael Baggish, MD

Also from PAGS 2016:

• Dr. Tommaso Falcone offers Top 3 things I learned at the PAGS 2016 symposium
• Visit PAGS

Also from PAGS 2016:

• Dr. Tommaso Falcone offers Top 3 things I learned at the PAGS 2016 symposium
• Visit PAGS

Also from PAGS 2016:

• Dr. Tommaso Falcone offers Top 3 things I learned at the PAGS 2016 symposium
• Visit PAGS

CASE: Adhesions complicate multiple surgeries

In early 2007, a 37-year-old woman with a history of hysterectomy, adhesiolysis, bilateral partial salpingectomy, and cholecystectomy underwent an attempted laparoscopic bilateral salpingo-oophorectomy (BSO) for pelvic pain. The operation was converted to laparotomy because of severe adhesions and required several hours to complete.

After the BSO, the patient developed hydronephrosis in her left kidney secondary to an inflammatory cyst. In March 2007, a urologist placed a ureteral stent to relieve the obstruction. One month later, the patient was referred to a gynecologic oncologist for chronic pelvic pain.

On October 29, 2007, the patient underwent operative laparoscopy for adhesiolysis and appendectomy. No retroperitoneal exploration was attempted at the time. According to the operative note, the 10-mm port incision was enlarged to 3 cm to enable the surgeon to inspect the descending colon. Postoperatively, the patient reported persistent abdominal pain and fever and was admitted to the hospital for observation. Although she had a documented temperature of 102°F on October 31, with tachypnea, tachycardia, and a white blood cell (WBC) count of 2.9 x 10³/μL, she was discharged home the same day.

The next morning, the patient returned to the hospital’s emergency room (ER) reporting worsening abdominal pain and shortness of breath. Her vital signs included a temperature of 95.8°F, heart rate of 135 bpm, respiration of 32 breaths/min, and blood pressure of 100/68 mm Hg. An examination revealed a tender, distended abdomen, and the patient exhibited guarding behavior upon palpation in all quadrants. Bowel sounds were hypoactive, and the WBC count was 4.2 x 10³/μL. No differential count was ordered. A computed tomography (CT) scan showed free air in the abdomen, pneumomediastinum, and subcutaneous emphysema of the abdominal wall and chest wall.

The next day, a differential WBC count revealed bands elevated at a 25% level. A cardiac consultant diagnosed heart failure and remarked that pneumomediastinum should not occur after abdominal surgery. In the evening, the gynecologic oncologist performed a laparotomy and observed enteric contents in the abdominal cavity, as well as a defect of approximately 2 mm in the lower portion of the rectosigmoid colon. According to the operative note, the gynecologic oncologist stapled off the area below the defect and performed a descending loop colostomy.

Postoperatively, the patient remained septic, and vegetable matter was recovered from one of the drains, so a surgical consultant was called. On November 9, a general surgeon performed an exploratory laparotomy and found necrosis, hemorrhage, acute inflammation of the colostomy, separation of the colostomy from its sutured position on the anterior abdominal wall, and mucosa at the end of the Hartman pouch, necessitating resection of this segment of the colon back to the rectum. Numerous intra-abdominal abscesses were also drained.

Two days later, the patient returned to the OR for further abscess drainage and creation of a left end colostomy. She was discharged 1 month later.

On January 4, 2008, she went to the ER for nausea and abdominal pain. Five days later, a plastic surgeon performed extensive skin grafting on the chronically open abdominal wound. On March 12, the patient returned to the ER because of abdominal pain and was admitted for nasogastric drainage and intravenous (IV) fluids. She returned to the ER again on April 26, reporting pain. A CT scan revealed a cystic mass in the pelvis, which was drained under CT guidance. In June and July, the patient was seen in the ER three times for pain, nausea, and vomiting.

In January 2009, she underwent another laparotomy for takedown of the colostomy, lysis of adhesions, and excision of a left 4-cm pelvic cyst (pathology later revealed the cyst to be ovarian tissue). She also underwent a left-sided myocutaneous flap reconstruction of an abdominal wall defect, and a right-sided myocutaneous flap with placement of a 16 x 20–cm sheet of AlloDerm Tissue Matrix (LifeCell). She continues to experience abdominal pain and visits the ER for that reason. In March 2009, she underwent repeat drainage of a pelvic collection via CT imaging. No further follow-up is available.

Could this catastrophic course have been avoided? What might have prevented it?

Adhesions are likely after any abdominal procedure

The biggest risk factor for laparoscopy-related intestinal injury is the presence of pelvic or abdominal adhesions.^1,2 Adhesions inevitably form after any intra-abdominal surgery, and new adhesions are likely with each successive intra-abdominal procedure. Even adhesiolysis leads to the formation of adhesions postoperatively.

Few reliable data suggest that adhesions cause pelvic pain, or that adhesiolysis relieves such pain.³ Furthermore, it may be impossible to predict with reasonable probability where adhesions may be located preoperatively or to know with certainty whether a portion of the intestine is adherent to the anterior abdominal wall directly below the usual subumbilical entry site. Because of the likelihood of adhesions in a patient who has undergone two or more laparotomies, it is risky to thrust a 10- to 12-mm trocar through the anterior abdominal wall below the navel.

A few variables influence the risk of injury

The trocar used in laparoscopic procedures plays a role in the risk of bowel injury. For example, relatively dull reusable devices may push nonfixed intestine away rather than penetrate the viscus. In contrast, razor-sharp disposable devices are more likely to cut into the underlying bowel.

Body habitus is also important. The obese woman is at greater risk for entry injuries, owing to physical aspects of the fatty anterior abdominal wall. When force is applied to the wall, it moves inward, toward the posterior wall, trapping intestine. In a thin woman, the abdominal wall is less elastic, so there is less excursion upon trocar entry.

Intestinal status is another variable to consider. A collapsed bowel is unlikely to be perforated by an entry trocar, whereas a thin, distended bowel is vulnerable to injury. Bowel status can be determined preoperatively using various modalities, including radiographic studies.

Careful surgical technique is imperative. Sharp dissection is always preferable to the blunt tearing of tissue, particularly in cases involving fibrous adhesions. Tearing a dense, unyielding adhesion is likely to remove a piece of intestinal wall because the tensile strength of the adhesion is typically greater than that of the viscus itself.

Thorough knowledge of pelvic anatomy is essential. It would be particularly egregious for a surgeon to mistake an adhesion for the normal peritoneal attachments of the left and sigmoid colon, or to resect the mesentery of the small bowel, believing it to be an adhesion.

Energy devices account for a significant number of intestinal injuries (FIGURE 1). Any surgeon who utilizes an energy device is obligated to protect the patient from a thermal injury—and the manufacturers of these instruments should provide reliable data on the safe use of the device, including information about the expected zone of conductive thermal spread based on power density and tissue type. As a general rule, avoid the use of monopolar electrosurgical devices for intra-abdominal dissection.

Adhesiolysis is a risky enterprise. Several studies have found a significant likelihood of bowel injury during lysis of adhesions.^4-6 In two studies by Baggish, 94% of adhesiolysis-related injuries involved moderate or severe adhesions.^5,6

FIGURE 1 Use of energy devices is risky near bowel
Energy devices account for a significant number of intestinal injuries. In this figure, the arrow indicates leakage of fecal matter from the bowel defect.

Is laparoscopy the wisest approach?

It is important to weigh the risks of laparoscopy against the potential benefits for the patient. Surgical experience and skill are perhaps the most important variables to consider when deciding on an operative approach. A high volume of laparoscopic operations—performed by a gynecologic surgeon—should translate into a lower risk of injury to intra-abdominal structures.⁷ That is, the greater the number of cases performed, the lower the risk of injury.

Garry and colleagues conducted two parallel randomized trials comparing 1) laparoscopic and abdominal hysterectomy and 2) laparoscopic and vaginal hysterectomy as part of the eVALuate study.⁸ Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy and took longer to perform. No major differences in the rate of complications were found between laparoscopic and vaginal hysterectomy.

In a review of laparoscopy-related bowel injuries, Brosens and colleagues found significant variations in the complication rate, depending on the experience of the surgeon—a 0.2% rate of access injuries for surgeons who had performed fewer than 100 procedures versus 0.06% for those who had performed more than 100 cases, and a 0.3% rate of operative injuries for surgeons who had performed fewer than 100 procedures versus 0.04% for more experienced surgeons.⁷

A few precautions can improve the safety of laparoscopy

If adhesions are known or suspected, primary laparoscopic entry should be planned for a site other than the infra-umbilical area. Options include:

• entry via the left hypochondrium in the midclavicular line
• an open procedure.

However, open laparoscopic entry does not always avert intestinal injury.^9-11

If the anatomy is obscured once the abdomen has been entered safely, retroperitoneal dissection may be useful, particularly for exposure of the left colon. When it is unclear whether a structure to be incised is a loop of bowel or a distended, adherent oviduct, it is best to refrain from cutting it.

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

Whenever a bowel injury is visualized intraoperatively, assume that it is transmural until it is proved otherwise.

FIGURE 2 Meticulous bowel inspection can identify perforation
It is vital to inspect the bowel after any dissection that involves the intestine, being especially alert for puncture wounds caused by a trocar and small tears associated with adhesiolysis.

SOURCE: Baggish MS, Karram MM. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. Philadelphia: Elsevier; 2011:1142.

How to avoid urinary tract injuries

Along with major vessel injury and intestinal perforation, bladder and ureteral injuries are the most common complications of laparoscopic surgery. Although urinary tract injuries are rarely fatal, they can cause a range of sequelae, including urinoma, vesicovaginal and ureterovaginal fistulas, hydroureter, hydronephrosis, renal damage, and kidney atrophy.

The incidence of ureteral injury during laparoscopy ranges from less than 0.1% to 1.0%, and the incidence of bladder injury ranges from less than 0.8% to 2.0%.^23-26 Investigators in Singapore described eight urologic injuries among 485 laparoscopic hysterectomies and identified several risk factors:

• previous cesarean delivery
• multiple fibroids
• severe endometriosis.²⁷

Another set of investigators found a history of laparotomy to be a risk factor for bladder injury during laparoscopic hysterectomy.²⁸

Rooney and colleagues studied the effect of previous cesarean delivery on the risk of injury during hysterectomy.²⁹ Among 5,092 hysterectomies—including 433 laparoscopic-assisted vaginal hysterectomies, 3,140 abdominal procedures, and 1,539 vaginal operations—the rate of bladder injury varied by approach. Cystotomy was observed in 0.76% of abdominal hysterectomies (33% had a previous cesarean delivery), 1.3% of vaginal procedures (21% had a previous cesarean), and 1.8% of laparoscopic operations (62.5% had a previous cesarean). The odds ratio for cystotomy during hysterectomy among women with a previous cesarean delivery was 1.26 for the abdominal approach, 3.00 for the vaginal route, and 7.50 for laparoscopic-assisted vaginal hysterectomy.²⁹

Two studies highlight common aspects of injury

In a recent report of 75 urinary tract injuries associated with laparoscopic surgery, Baggish identified a total of 33 injuries involving the bladder and 42 of ureteral origin. Twelve of the bladder injuries were associated with the approach, and 21 were related to the surgery. In contrast, only one of the 42 ureteral injuries was related to the approach.³⁰

Baggish also found that just under 50% of urinary tract injuries were related to the use of thermal energy, including all three vesicovaginal fistulas. Fourteen bladder lacerations occurred during separation of the bladder from the uterus during laparoscopic hysterectomy.³⁰

Common sites of injury were at the infundibulopelvic ligament, between the infundibulopelvic ligament and the uterine vessels, and at or below the uterine vessels.³⁰

None of the 42 ureteral injuries were diagnosed intraoperatively. In fact, 37 of these injuries were not correctly diagnosed until more than 48 hours after surgery. Two uterovaginal fistulas were also diagnosed in the late postoperative period.³⁰

Bladder injuries were identified via cystoscopy or cystometrogram or by the instillation of methylene blue into the bladder, with observation from above for leakage. Ureteral injuries were identified by IV pyelogram, retrograde pyelogram, or attempted passage of a stent. Every ureteral injury showed up as hydroureter and hydronephrosis via pyelography.³⁰

Grainger and colleagues reported five ureteral injuries associated with laparoscopic procedures.³¹ The principal symptoms were low back pain, abdominal pain, leukocytosis, and peritonitis. All five injuries were associated with endometriosis surgery, most commonly near the uterosacral ligaments.

Grainger and colleagues cited eight additional cases of injury. Three patients among the 13 total cases lost renal function, and two eventually required nephrectomy.³¹

How to prevent, identify, and manage urinary tract injuries

Thorough knowledge of anatomy and meticulous technique are imperative to prevent urinary tract injuries. Strategies include:

• Use sharp rather than blunt dissection.
• Know the risk factors for urinary tract injury, which include previous cesarean delivery or intra-abdominal surgery, presence of adhesions, and deep endometriosis.
• Be aware of the dangers posed by energy devices when they are used near the bladder and ureter. Even bipolar devices can cause thermal injury.
• Employ hydrodissection when there are bladder adhesions, and work nearer the uterus or vagina than the bladder, leaving a margin of tissue.
• When the ureter’s location is unclear relative to the operative site, do not hesitate to open the retroperitoneal space to observe the ureter. If necessary, dissect the ureter distally.
• Perform cystoscopy with IV indigo carmine injection at the conclusion of surgery to ensure that the ureter is not occluded.
• Be aware that peristalsis is not an indication of ureteral integrity. In fact, an obstructed ureter will pulsate more vigorously than a normal one.
• Consider preoperative ureteral catheterization, which may avert injury without increasing operative time, blood loss, and hospital stay,³² although the data are not definitive.³³
• Be vigilant. Early identification of injuries reduces morbidity. In the case of ureteral obstruction, immediate stenting will usually obviate the need for ureteral implantation and nephrostomy if the obstruction is not complete.
• Intervene early to cut an obstructing suture or relieve ureteral bowing. Doing so may eliminate the obstruction altogether in many cases.
• If a laceration is found in the bladder trigone or its vicinity, always perform ureteral catheterization to help prevent the inadvertent suturing of the intravesical ureter into the repair.
• After repair of a bladder laceration, perform cystoscopy with IV injection of indigo carmine to ensure ureteral integrity.
• Use only absorbable suture in bladder repairs. I recommend 2-0 chromic catgut for the first layer, which should encompass muscularis and mucosa. Place a second layer of sutures using 3-0 polyglactin 910 (Vicryl), imbricating the first layer.
• After completion of a bladder repair, instill a solution of diluted methylene blue (1 part methylene blue to 100 parts sterile water or saline) to distend the bladder, and carefully inspect the closure to ensure that it is watertight. Then place a Foley catheter for a minimum of 2 weeks. Four to 6 weeks after repair, perform a cystogram to ensure that healing is complete, with no leakage.
• Call a urologist if you are not well-versed in bladder repair, or if the ureter is injured (or injury is suspected).
• Watch for fistula formation, an inevitable outcome of untreated bladder and ureteral injury, which may occur early or late in the postoperative course.

Choose an approach wisely

Laparoscopy is a learned skill. Supervised practice generally leads to greater levels of proficiency, and repetition of the same operations improves dexterity and execution. However, laparoscopy is also an art—some people have the touch and some do not.

Although laparoscopic techniques offer many advantages, they also have shortcomings. The complications described here, and the strategies I have offered for preventing and managing them, should help gynecologic surgeons determine whether laparoscopy is the optimal route of operation, based on surgical experience, characteristics of the individual patient, and other variables.

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CASE: Adhesions complicate multiple surgeries

In early 2007, a 37-year-old woman with a history of hysterectomy, adhesiolysis, bilateral partial salpingectomy, and cholecystectomy underwent an attempted laparoscopic bilateral salpingo-oophorectomy (BSO) for pelvic pain. The operation was converted to laparotomy because of severe adhesions and required several hours to complete.

After the BSO, the patient developed hydronephrosis in her left kidney secondary to an inflammatory cyst. In March 2007, a urologist placed a ureteral stent to relieve the obstruction. One month later, the patient was referred to a gynecologic oncologist for chronic pelvic pain.

On October 29, 2007, the patient underwent operative laparoscopy for adhesiolysis and appendectomy. No retroperitoneal exploration was attempted at the time. According to the operative note, the 10-mm port incision was enlarged to 3 cm to enable the surgeon to inspect the descending colon. Postoperatively, the patient reported persistent abdominal pain and fever and was admitted to the hospital for observation. Although she had a documented temperature of 102°F on October 31, with tachypnea, tachycardia, and a white blood cell (WBC) count of 2.9 x 10³/μL, she was discharged home the same day.

The next morning, the patient returned to the hospital’s emergency room (ER) reporting worsening abdominal pain and shortness of breath. Her vital signs included a temperature of 95.8°F, heart rate of 135 bpm, respiration of 32 breaths/min, and blood pressure of 100/68 mm Hg. An examination revealed a tender, distended abdomen, and the patient exhibited guarding behavior upon palpation in all quadrants. Bowel sounds were hypoactive, and the WBC count was 4.2 x 10³/μL. No differential count was ordered. A computed tomography (CT) scan showed free air in the abdomen, pneumomediastinum, and subcutaneous emphysema of the abdominal wall and chest wall.

The next day, a differential WBC count revealed bands elevated at a 25% level. A cardiac consultant diagnosed heart failure and remarked that pneumomediastinum should not occur after abdominal surgery. In the evening, the gynecologic oncologist performed a laparotomy and observed enteric contents in the abdominal cavity, as well as a defect of approximately 2 mm in the lower portion of the rectosigmoid colon. According to the operative note, the gynecologic oncologist stapled off the area below the defect and performed a descending loop colostomy.

Postoperatively, the patient remained septic, and vegetable matter was recovered from one of the drains, so a surgical consultant was called. On November 9, a general surgeon performed an exploratory laparotomy and found necrosis, hemorrhage, acute inflammation of the colostomy, separation of the colostomy from its sutured position on the anterior abdominal wall, and mucosa at the end of the Hartman pouch, necessitating resection of this segment of the colon back to the rectum. Numerous intra-abdominal abscesses were also drained.

Two days later, the patient returned to the OR for further abscess drainage and creation of a left end colostomy. She was discharged 1 month later.

On January 4, 2008, she went to the ER for nausea and abdominal pain. Five days later, a plastic surgeon performed extensive skin grafting on the chronically open abdominal wound. On March 12, the patient returned to the ER because of abdominal pain and was admitted for nasogastric drainage and intravenous (IV) fluids. She returned to the ER again on April 26, reporting pain. A CT scan revealed a cystic mass in the pelvis, which was drained under CT guidance. In June and July, the patient was seen in the ER three times for pain, nausea, and vomiting.

In January 2009, she underwent another laparotomy for takedown of the colostomy, lysis of adhesions, and excision of a left 4-cm pelvic cyst (pathology later revealed the cyst to be ovarian tissue). She also underwent a left-sided myocutaneous flap reconstruction of an abdominal wall defect, and a right-sided myocutaneous flap with placement of a 16 x 20–cm sheet of AlloDerm Tissue Matrix (LifeCell). She continues to experience abdominal pain and visits the ER for that reason. In March 2009, she underwent repeat drainage of a pelvic collection via CT imaging. No further follow-up is available.

Could this catastrophic course have been avoided? What might have prevented it?

Adhesions are likely after any abdominal procedure

The biggest risk factor for laparoscopy-related intestinal injury is the presence of pelvic or abdominal adhesions.^1,2 Adhesions inevitably form after any intra-abdominal surgery, and new adhesions are likely with each successive intra-abdominal procedure. Even adhesiolysis leads to the formation of adhesions postoperatively.

Few reliable data suggest that adhesions cause pelvic pain, or that adhesiolysis relieves such pain.³ Furthermore, it may be impossible to predict with reasonable probability where adhesions may be located preoperatively or to know with certainty whether a portion of the intestine is adherent to the anterior abdominal wall directly below the usual subumbilical entry site. Because of the likelihood of adhesions in a patient who has undergone two or more laparotomies, it is risky to thrust a 10- to 12-mm trocar through the anterior abdominal wall below the navel.

A few variables influence the risk of injury

The trocar used in laparoscopic procedures plays a role in the risk of bowel injury. For example, relatively dull reusable devices may push nonfixed intestine away rather than penetrate the viscus. In contrast, razor-sharp disposable devices are more likely to cut into the underlying bowel.

Body habitus is also important. The obese woman is at greater risk for entry injuries, owing to physical aspects of the fatty anterior abdominal wall. When force is applied to the wall, it moves inward, toward the posterior wall, trapping intestine. In a thin woman, the abdominal wall is less elastic, so there is less excursion upon trocar entry.

Intestinal status is another variable to consider. A collapsed bowel is unlikely to be perforated by an entry trocar, whereas a thin, distended bowel is vulnerable to injury. Bowel status can be determined preoperatively using various modalities, including radiographic studies.

Careful surgical technique is imperative. Sharp dissection is always preferable to the blunt tearing of tissue, particularly in cases involving fibrous adhesions. Tearing a dense, unyielding adhesion is likely to remove a piece of intestinal wall because the tensile strength of the adhesion is typically greater than that of the viscus itself.

Thorough knowledge of pelvic anatomy is essential. It would be particularly egregious for a surgeon to mistake an adhesion for the normal peritoneal attachments of the left and sigmoid colon, or to resect the mesentery of the small bowel, believing it to be an adhesion.

Energy devices account for a significant number of intestinal injuries (FIGURE 1). Any surgeon who utilizes an energy device is obligated to protect the patient from a thermal injury—and the manufacturers of these instruments should provide reliable data on the safe use of the device, including information about the expected zone of conductive thermal spread based on power density and tissue type. As a general rule, avoid the use of monopolar electrosurgical devices for intra-abdominal dissection.

Adhesiolysis is a risky enterprise. Several studies have found a significant likelihood of bowel injury during lysis of adhesions.^4-6 In two studies by Baggish, 94% of adhesiolysis-related injuries involved moderate or severe adhesions.^5,6

FIGURE 1 Use of energy devices is risky near bowel
Energy devices account for a significant number of intestinal injuries. In this figure, the arrow indicates leakage of fecal matter from the bowel defect.

Is laparoscopy the wisest approach?

It is important to weigh the risks of laparoscopy against the potential benefits for the patient. Surgical experience and skill are perhaps the most important variables to consider when deciding on an operative approach. A high volume of laparoscopic operations—performed by a gynecologic surgeon—should translate into a lower risk of injury to intra-abdominal structures.⁷ That is, the greater the number of cases performed, the lower the risk of injury.

Garry and colleagues conducted two parallel randomized trials comparing 1) laparoscopic and abdominal hysterectomy and 2) laparoscopic and vaginal hysterectomy as part of the eVALuate study.⁸ Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy and took longer to perform. No major differences in the rate of complications were found between laparoscopic and vaginal hysterectomy.

In a review of laparoscopy-related bowel injuries, Brosens and colleagues found significant variations in the complication rate, depending on the experience of the surgeon—a 0.2% rate of access injuries for surgeons who had performed fewer than 100 procedures versus 0.06% for those who had performed more than 100 cases, and a 0.3% rate of operative injuries for surgeons who had performed fewer than 100 procedures versus 0.04% for more experienced surgeons.⁷

A few precautions can improve the safety of laparoscopy

If adhesions are known or suspected, primary laparoscopic entry should be planned for a site other than the infra-umbilical area. Options include:

• entry via the left hypochondrium in the midclavicular line
• an open procedure.

However, open laparoscopic entry does not always avert intestinal injury.^9-11

If the anatomy is obscured once the abdomen has been entered safely, retroperitoneal dissection may be useful, particularly for exposure of the left colon. When it is unclear whether a structure to be incised is a loop of bowel or a distended, adherent oviduct, it is best to refrain from cutting it.

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

Whenever a bowel injury is visualized intraoperatively, assume that it is transmural until it is proved otherwise.

FIGURE 2 Meticulous bowel inspection can identify perforation
It is vital to inspect the bowel after any dissection that involves the intestine, being especially alert for puncture wounds caused by a trocar and small tears associated with adhesiolysis.

SOURCE: Baggish MS, Karram MM. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. Philadelphia: Elsevier; 2011:1142.

How to avoid urinary tract injuries

Along with major vessel injury and intestinal perforation, bladder and ureteral injuries are the most common complications of laparoscopic surgery. Although urinary tract injuries are rarely fatal, they can cause a range of sequelae, including urinoma, vesicovaginal and ureterovaginal fistulas, hydroureter, hydronephrosis, renal damage, and kidney atrophy.

The incidence of ureteral injury during laparoscopy ranges from less than 0.1% to 1.0%, and the incidence of bladder injury ranges from less than 0.8% to 2.0%.^23-26 Investigators in Singapore described eight urologic injuries among 485 laparoscopic hysterectomies and identified several risk factors:

• previous cesarean delivery
• multiple fibroids
• severe endometriosis.²⁷

Another set of investigators found a history of laparotomy to be a risk factor for bladder injury during laparoscopic hysterectomy.²⁸

Rooney and colleagues studied the effect of previous cesarean delivery on the risk of injury during hysterectomy.²⁹ Among 5,092 hysterectomies—including 433 laparoscopic-assisted vaginal hysterectomies, 3,140 abdominal procedures, and 1,539 vaginal operations—the rate of bladder injury varied by approach. Cystotomy was observed in 0.76% of abdominal hysterectomies (33% had a previous cesarean delivery), 1.3% of vaginal procedures (21% had a previous cesarean), and 1.8% of laparoscopic operations (62.5% had a previous cesarean). The odds ratio for cystotomy during hysterectomy among women with a previous cesarean delivery was 1.26 for the abdominal approach, 3.00 for the vaginal route, and 7.50 for laparoscopic-assisted vaginal hysterectomy.²⁹

Two studies highlight common aspects of injury

In a recent report of 75 urinary tract injuries associated with laparoscopic surgery, Baggish identified a total of 33 injuries involving the bladder and 42 of ureteral origin. Twelve of the bladder injuries were associated with the approach, and 21 were related to the surgery. In contrast, only one of the 42 ureteral injuries was related to the approach.³⁰

Baggish also found that just under 50% of urinary tract injuries were related to the use of thermal energy, including all three vesicovaginal fistulas. Fourteen bladder lacerations occurred during separation of the bladder from the uterus during laparoscopic hysterectomy.³⁰

Common sites of injury were at the infundibulopelvic ligament, between the infundibulopelvic ligament and the uterine vessels, and at or below the uterine vessels.³⁰

None of the 42 ureteral injuries were diagnosed intraoperatively. In fact, 37 of these injuries were not correctly diagnosed until more than 48 hours after surgery. Two uterovaginal fistulas were also diagnosed in the late postoperative period.³⁰

Bladder injuries were identified via cystoscopy or cystometrogram or by the instillation of methylene blue into the bladder, with observation from above for leakage. Ureteral injuries were identified by IV pyelogram, retrograde pyelogram, or attempted passage of a stent. Every ureteral injury showed up as hydroureter and hydronephrosis via pyelography.³⁰

Grainger and colleagues reported five ureteral injuries associated with laparoscopic procedures.³¹ The principal symptoms were low back pain, abdominal pain, leukocytosis, and peritonitis. All five injuries were associated with endometriosis surgery, most commonly near the uterosacral ligaments.

Grainger and colleagues cited eight additional cases of injury. Three patients among the 13 total cases lost renal function, and two eventually required nephrectomy.³¹

How to prevent, identify, and manage urinary tract injuries

Thorough knowledge of anatomy and meticulous technique are imperative to prevent urinary tract injuries. Strategies include:

• Use sharp rather than blunt dissection.
• Know the risk factors for urinary tract injury, which include previous cesarean delivery or intra-abdominal surgery, presence of adhesions, and deep endometriosis.
• Be aware of the dangers posed by energy devices when they are used near the bladder and ureter. Even bipolar devices can cause thermal injury.
• Employ hydrodissection when there are bladder adhesions, and work nearer the uterus or vagina than the bladder, leaving a margin of tissue.
• When the ureter’s location is unclear relative to the operative site, do not hesitate to open the retroperitoneal space to observe the ureter. If necessary, dissect the ureter distally.
• Perform cystoscopy with IV indigo carmine injection at the conclusion of surgery to ensure that the ureter is not occluded.
• Be aware that peristalsis is not an indication of ureteral integrity. In fact, an obstructed ureter will pulsate more vigorously than a normal one.
• Consider preoperative ureteral catheterization, which may avert injury without increasing operative time, blood loss, and hospital stay,³² although the data are not definitive.³³
• Be vigilant. Early identification of injuries reduces morbidity. In the case of ureteral obstruction, immediate stenting will usually obviate the need for ureteral implantation and nephrostomy if the obstruction is not complete.
• Intervene early to cut an obstructing suture or relieve ureteral bowing. Doing so may eliminate the obstruction altogether in many cases.
• If a laceration is found in the bladder trigone or its vicinity, always perform ureteral catheterization to help prevent the inadvertent suturing of the intravesical ureter into the repair.
• After repair of a bladder laceration, perform cystoscopy with IV injection of indigo carmine to ensure ureteral integrity.
• Use only absorbable suture in bladder repairs. I recommend 2-0 chromic catgut for the first layer, which should encompass muscularis and mucosa. Place a second layer of sutures using 3-0 polyglactin 910 (Vicryl), imbricating the first layer.
• After completion of a bladder repair, instill a solution of diluted methylene blue (1 part methylene blue to 100 parts sterile water or saline) to distend the bladder, and carefully inspect the closure to ensure that it is watertight. Then place a Foley catheter for a minimum of 2 weeks. Four to 6 weeks after repair, perform a cystogram to ensure that healing is complete, with no leakage.
• Call a urologist if you are not well-versed in bladder repair, or if the ureter is injured (or injury is suspected).
• Watch for fistula formation, an inevitable outcome of untreated bladder and ureteral injury, which may occur early or late in the postoperative course.

Choose an approach wisely

Laparoscopy is a learned skill. Supervised practice generally leads to greater levels of proficiency, and repetition of the same operations improves dexterity and execution. However, laparoscopy is also an art—some people have the touch and some do not.

Although laparoscopic techniques offer many advantages, they also have shortcomings. The complications described here, and the strategies I have offered for preventing and managing them, should help gynecologic surgeons determine whether laparoscopy is the optimal route of operation, based on surgical experience, characteristics of the individual patient, and other variables.

We want to hear from you! Tell us what you think.

CASE: Adhesions complicate multiple surgeries

In early 2007, a 37-year-old woman with a history of hysterectomy, adhesiolysis, bilateral partial salpingectomy, and cholecystectomy underwent an attempted laparoscopic bilateral salpingo-oophorectomy (BSO) for pelvic pain. The operation was converted to laparotomy because of severe adhesions and required several hours to complete.

After the BSO, the patient developed hydronephrosis in her left kidney secondary to an inflammatory cyst. In March 2007, a urologist placed a ureteral stent to relieve the obstruction. One month later, the patient was referred to a gynecologic oncologist for chronic pelvic pain.

On October 29, 2007, the patient underwent operative laparoscopy for adhesiolysis and appendectomy. No retroperitoneal exploration was attempted at the time. According to the operative note, the 10-mm port incision was enlarged to 3 cm to enable the surgeon to inspect the descending colon. Postoperatively, the patient reported persistent abdominal pain and fever and was admitted to the hospital for observation. Although she had a documented temperature of 102°F on October 31, with tachypnea, tachycardia, and a white blood cell (WBC) count of 2.9 x 10³/μL, she was discharged home the same day.

The next morning, the patient returned to the hospital’s emergency room (ER) reporting worsening abdominal pain and shortness of breath. Her vital signs included a temperature of 95.8°F, heart rate of 135 bpm, respiration of 32 breaths/min, and blood pressure of 100/68 mm Hg. An examination revealed a tender, distended abdomen, and the patient exhibited guarding behavior upon palpation in all quadrants. Bowel sounds were hypoactive, and the WBC count was 4.2 x 10³/μL. No differential count was ordered. A computed tomography (CT) scan showed free air in the abdomen, pneumomediastinum, and subcutaneous emphysema of the abdominal wall and chest wall.

The next day, a differential WBC count revealed bands elevated at a 25% level. A cardiac consultant diagnosed heart failure and remarked that pneumomediastinum should not occur after abdominal surgery. In the evening, the gynecologic oncologist performed a laparotomy and observed enteric contents in the abdominal cavity, as well as a defect of approximately 2 mm in the lower portion of the rectosigmoid colon. According to the operative note, the gynecologic oncologist stapled off the area below the defect and performed a descending loop colostomy.

Postoperatively, the patient remained septic, and vegetable matter was recovered from one of the drains, so a surgical consultant was called. On November 9, a general surgeon performed an exploratory laparotomy and found necrosis, hemorrhage, acute inflammation of the colostomy, separation of the colostomy from its sutured position on the anterior abdominal wall, and mucosa at the end of the Hartman pouch, necessitating resection of this segment of the colon back to the rectum. Numerous intra-abdominal abscesses were also drained.

Two days later, the patient returned to the OR for further abscess drainage and creation of a left end colostomy. She was discharged 1 month later.

On January 4, 2008, she went to the ER for nausea and abdominal pain. Five days later, a plastic surgeon performed extensive skin grafting on the chronically open abdominal wound. On March 12, the patient returned to the ER because of abdominal pain and was admitted for nasogastric drainage and intravenous (IV) fluids. She returned to the ER again on April 26, reporting pain. A CT scan revealed a cystic mass in the pelvis, which was drained under CT guidance. In June and July, the patient was seen in the ER three times for pain, nausea, and vomiting.

In January 2009, she underwent another laparotomy for takedown of the colostomy, lysis of adhesions, and excision of a left 4-cm pelvic cyst (pathology later revealed the cyst to be ovarian tissue). She also underwent a left-sided myocutaneous flap reconstruction of an abdominal wall defect, and a right-sided myocutaneous flap with placement of a 16 x 20–cm sheet of AlloDerm Tissue Matrix (LifeCell). She continues to experience abdominal pain and visits the ER for that reason. In March 2009, she underwent repeat drainage of a pelvic collection via CT imaging. No further follow-up is available.

Could this catastrophic course have been avoided? What might have prevented it?

Adhesions are likely after any abdominal procedure

The biggest risk factor for laparoscopy-related intestinal injury is the presence of pelvic or abdominal adhesions.^1,2 Adhesions inevitably form after any intra-abdominal surgery, and new adhesions are likely with each successive intra-abdominal procedure. Even adhesiolysis leads to the formation of adhesions postoperatively.

Few reliable data suggest that adhesions cause pelvic pain, or that adhesiolysis relieves such pain.³ Furthermore, it may be impossible to predict with reasonable probability where adhesions may be located preoperatively or to know with certainty whether a portion of the intestine is adherent to the anterior abdominal wall directly below the usual subumbilical entry site. Because of the likelihood of adhesions in a patient who has undergone two or more laparotomies, it is risky to thrust a 10- to 12-mm trocar through the anterior abdominal wall below the navel.

A few variables influence the risk of injury

The trocar used in laparoscopic procedures plays a role in the risk of bowel injury. For example, relatively dull reusable devices may push nonfixed intestine away rather than penetrate the viscus. In contrast, razor-sharp disposable devices are more likely to cut into the underlying bowel.

Body habitus is also important. The obese woman is at greater risk for entry injuries, owing to physical aspects of the fatty anterior abdominal wall. When force is applied to the wall, it moves inward, toward the posterior wall, trapping intestine. In a thin woman, the abdominal wall is less elastic, so there is less excursion upon trocar entry.

Intestinal status is another variable to consider. A collapsed bowel is unlikely to be perforated by an entry trocar, whereas a thin, distended bowel is vulnerable to injury. Bowel status can be determined preoperatively using various modalities, including radiographic studies.

Careful surgical technique is imperative. Sharp dissection is always preferable to the blunt tearing of tissue, particularly in cases involving fibrous adhesions. Tearing a dense, unyielding adhesion is likely to remove a piece of intestinal wall because the tensile strength of the adhesion is typically greater than that of the viscus itself.

Thorough knowledge of pelvic anatomy is essential. It would be particularly egregious for a surgeon to mistake an adhesion for the normal peritoneal attachments of the left and sigmoid colon, or to resect the mesentery of the small bowel, believing it to be an adhesion.

Energy devices account for a significant number of intestinal injuries (FIGURE 1). Any surgeon who utilizes an energy device is obligated to protect the patient from a thermal injury—and the manufacturers of these instruments should provide reliable data on the safe use of the device, including information about the expected zone of conductive thermal spread based on power density and tissue type. As a general rule, avoid the use of monopolar electrosurgical devices for intra-abdominal dissection.

Adhesiolysis is a risky enterprise. Several studies have found a significant likelihood of bowel injury during lysis of adhesions.^4-6 In two studies by Baggish, 94% of adhesiolysis-related injuries involved moderate or severe adhesions.^5,6

FIGURE 1 Use of energy devices is risky near bowel
Energy devices account for a significant number of intestinal injuries. In this figure, the arrow indicates leakage of fecal matter from the bowel defect.

Is laparoscopy the wisest approach?

It is important to weigh the risks of laparoscopy against the potential benefits for the patient. Surgical experience and skill are perhaps the most important variables to consider when deciding on an operative approach. A high volume of laparoscopic operations—performed by a gynecologic surgeon—should translate into a lower risk of injury to intra-abdominal structures.⁷ That is, the greater the number of cases performed, the lower the risk of injury.

Garry and colleagues conducted two parallel randomized trials comparing 1) laparoscopic and abdominal hysterectomy and 2) laparoscopic and vaginal hysterectomy as part of the eVALuate study.⁸ Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy and took longer to perform. No major differences in the rate of complications were found between laparoscopic and vaginal hysterectomy.

In a review of laparoscopy-related bowel injuries, Brosens and colleagues found significant variations in the complication rate, depending on the experience of the surgeon—a 0.2% rate of access injuries for surgeons who had performed fewer than 100 procedures versus 0.06% for those who had performed more than 100 cases, and a 0.3% rate of operative injuries for surgeons who had performed fewer than 100 procedures versus 0.04% for more experienced surgeons.⁷

A few precautions can improve the safety of laparoscopy

If adhesions are known or suspected, primary laparoscopic entry should be planned for a site other than the infra-umbilical area. Options include:

• entry via the left hypochondrium in the midclavicular line
• an open procedure.

However, open laparoscopic entry does not always avert intestinal injury.^9-11

If the anatomy is obscured once the abdomen has been entered safely, retroperitoneal dissection may be useful, particularly for exposure of the left colon. When it is unclear whether a structure to be incised is a loop of bowel or a distended, adherent oviduct, it is best to refrain from cutting it.

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

Whenever a bowel injury is visualized intraoperatively, assume that it is transmural until it is proved otherwise.

FIGURE 2 Meticulous bowel inspection can identify perforation
It is vital to inspect the bowel after any dissection that involves the intestine, being especially alert for puncture wounds caused by a trocar and small tears associated with adhesiolysis.

SOURCE: Baggish MS, Karram MM. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. Philadelphia: Elsevier; 2011:1142.

How to avoid urinary tract injuries

Along with major vessel injury and intestinal perforation, bladder and ureteral injuries are the most common complications of laparoscopic surgery. Although urinary tract injuries are rarely fatal, they can cause a range of sequelae, including urinoma, vesicovaginal and ureterovaginal fistulas, hydroureter, hydronephrosis, renal damage, and kidney atrophy.

The incidence of ureteral injury during laparoscopy ranges from less than 0.1% to 1.0%, and the incidence of bladder injury ranges from less than 0.8% to 2.0%.^23-26 Investigators in Singapore described eight urologic injuries among 485 laparoscopic hysterectomies and identified several risk factors:

• previous cesarean delivery
• multiple fibroids
• severe endometriosis.²⁷

Another set of investigators found a history of laparotomy to be a risk factor for bladder injury during laparoscopic hysterectomy.²⁸

Rooney and colleagues studied the effect of previous cesarean delivery on the risk of injury during hysterectomy.²⁹ Among 5,092 hysterectomies—including 433 laparoscopic-assisted vaginal hysterectomies, 3,140 abdominal procedures, and 1,539 vaginal operations—the rate of bladder injury varied by approach. Cystotomy was observed in 0.76% of abdominal hysterectomies (33% had a previous cesarean delivery), 1.3% of vaginal procedures (21% had a previous cesarean), and 1.8% of laparoscopic operations (62.5% had a previous cesarean). The odds ratio for cystotomy during hysterectomy among women with a previous cesarean delivery was 1.26 for the abdominal approach, 3.00 for the vaginal route, and 7.50 for laparoscopic-assisted vaginal hysterectomy.²⁹

Two studies highlight common aspects of injury

In a recent report of 75 urinary tract injuries associated with laparoscopic surgery, Baggish identified a total of 33 injuries involving the bladder and 42 of ureteral origin. Twelve of the bladder injuries were associated with the approach, and 21 were related to the surgery. In contrast, only one of the 42 ureteral injuries was related to the approach.³⁰

Baggish also found that just under 50% of urinary tract injuries were related to the use of thermal energy, including all three vesicovaginal fistulas. Fourteen bladder lacerations occurred during separation of the bladder from the uterus during laparoscopic hysterectomy.³⁰

Common sites of injury were at the infundibulopelvic ligament, between the infundibulopelvic ligament and the uterine vessels, and at or below the uterine vessels.³⁰

None of the 42 ureteral injuries were diagnosed intraoperatively. In fact, 37 of these injuries were not correctly diagnosed until more than 48 hours after surgery. Two uterovaginal fistulas were also diagnosed in the late postoperative period.³⁰

Bladder injuries were identified via cystoscopy or cystometrogram or by the instillation of methylene blue into the bladder, with observation from above for leakage. Ureteral injuries were identified by IV pyelogram, retrograde pyelogram, or attempted passage of a stent. Every ureteral injury showed up as hydroureter and hydronephrosis via pyelography.³⁰

Grainger and colleagues reported five ureteral injuries associated with laparoscopic procedures.³¹ The principal symptoms were low back pain, abdominal pain, leukocytosis, and peritonitis. All five injuries were associated with endometriosis surgery, most commonly near the uterosacral ligaments.

Grainger and colleagues cited eight additional cases of injury. Three patients among the 13 total cases lost renal function, and two eventually required nephrectomy.³¹

How to prevent, identify, and manage urinary tract injuries

Thorough knowledge of anatomy and meticulous technique are imperative to prevent urinary tract injuries. Strategies include:

• Use sharp rather than blunt dissection.
• Know the risk factors for urinary tract injury, which include previous cesarean delivery or intra-abdominal surgery, presence of adhesions, and deep endometriosis.
• Be aware of the dangers posed by energy devices when they are used near the bladder and ureter. Even bipolar devices can cause thermal injury.
• Employ hydrodissection when there are bladder adhesions, and work nearer the uterus or vagina than the bladder, leaving a margin of tissue.
• When the ureter’s location is unclear relative to the operative site, do not hesitate to open the retroperitoneal space to observe the ureter. If necessary, dissect the ureter distally.
• Perform cystoscopy with IV indigo carmine injection at the conclusion of surgery to ensure that the ureter is not occluded.
• Be aware that peristalsis is not an indication of ureteral integrity. In fact, an obstructed ureter will pulsate more vigorously than a normal one.
• Consider preoperative ureteral catheterization, which may avert injury without increasing operative time, blood loss, and hospital stay,³² although the data are not definitive.³³
• Be vigilant. Early identification of injuries reduces morbidity. In the case of ureteral obstruction, immediate stenting will usually obviate the need for ureteral implantation and nephrostomy if the obstruction is not complete.
• Intervene early to cut an obstructing suture or relieve ureteral bowing. Doing so may eliminate the obstruction altogether in many cases.
• If a laceration is found in the bladder trigone or its vicinity, always perform ureteral catheterization to help prevent the inadvertent suturing of the intravesical ureter into the repair.
• After repair of a bladder laceration, perform cystoscopy with IV injection of indigo carmine to ensure ureteral integrity.
• Use only absorbable suture in bladder repairs. I recommend 2-0 chromic catgut for the first layer, which should encompass muscularis and mucosa. Place a second layer of sutures using 3-0 polyglactin 910 (Vicryl), imbricating the first layer.
• After completion of a bladder repair, instill a solution of diluted methylene blue (1 part methylene blue to 100 parts sterile water or saline) to distend the bladder, and carefully inspect the closure to ensure that it is watertight. Then place a Foley catheter for a minimum of 2 weeks. Four to 6 weeks after repair, perform a cystogram to ensure that healing is complete, with no leakage.
• Call a urologist if you are not well-versed in bladder repair, or if the ureter is injured (or injury is suspected).
• Watch for fistula formation, an inevitable outcome of untreated bladder and ureteral injury, which may occur early or late in the postoperative course.

Choose an approach wisely

Laparoscopy is a learned skill. Supervised practice generally leads to greater levels of proficiency, and repetition of the same operations improves dexterity and execution. However, laparoscopy is also an art—some people have the touch and some do not.

Although laparoscopic techniques offer many advantages, they also have shortcomings. The complications described here, and the strategies I have offered for preventing and managing them, should help gynecologic surgeons determine whether laparoscopy is the optimal route of operation, based on surgical experience, characteristics of the individual patient, and other variables.

We want to hear from you! Tell us what you think.

CASE: Abdominal entry leads to life-threatening injury

A 50-year-old woman with a BMI of 25 kg/m², a strong family history of breast and ovarian cancer, and a confirmed BRCA mutation was scheduled for prophylactic bilateral salpingo-oophorectomy via robotic laparoscopy on November 26, 2009. At the time of the procedure, the gynecologic surgeon selected a site for the camera trocar that was several centimeters above the umbilicus. After making a transverse incision, he inserted a Veress needle and insufflated the abdomen with CO₂ gas until intra-abdominal pressure reached 17 mm Hg. He then thrust an 11-inch disposable trocar through the anterior abdominal wall, attached the camera to the laparoscope, confirmed proper intraperitoneal placement, and inserted two additional trocars under direct vision.

Shortly after these actions, the anesthesiologist reported that the patient’s blood pressure had dropped precipitously, along with end tidal CO₂. The surgeon examined the peritoneal cavity and discovered blood in the right paracolic gutter. The anesthesiologist advised the surgeon that he could no longer detect the patient’s blood pressure; electrocardiography revealed pulseless electrical activity.

The surgical team began chest compressions, evacuated the pneumoperitoneum, and removed all trocars. Blood was noted on the camera trocar, and the device was secured by the OR staff. The surgeon performed an emergent laparotomy, making the incision within 4 minutes of the beginning of CPR. Exploration revealed a large retroperitoneal hematoma above the area of the aortic bifurcation and inferior vena cava.

General and vascular surgeons were called. The general surgeon opened the retroperitoneum and found an extreme amount of clotted and unclotted blood. The vascular surgeon described the initial injury as a 1.5-cm laceration of the distal aorta, just above the bifurcation. A cell saver was requested and recorded blood loss of 12,000 mL.

The vascular surgeon clamped the aorta proximally; he also clamped both common iliac arteries. He then repaired the lacerations on the aorta using 5-0 Prolene suture (Ethicon). The aorta was significantly narrowed, however, so the surgeon decided to replace the distal aorta, which he then resected and repaired using a 14-mm Dacron graft (DuPont).

Further inspection revealed continuing retroperitoneal bleeding. The vascular surgeon found and repaired a laceration of the inferior mesenteric vein. He also clipped multiple small veins to stop bleeding.

When a hole in the transverse colon was identified, the general surgeon—who had left the operating table—rescrubbed to repair it. He also discovered an injury to the mesentery of the transverse colon and repaired both wounds, resecting the perforated segment. The divided, stapled colon was dropped back into the abdomen because the bowel was dusky. Despite an epinephrine drip, the patient was hypotensive and coagulopathic. The abdomen was packed and covered with sterile cassette film, with towels covering the open wound.

The patient was taken to the postanesthesia care unit in guarded condition and was subsequently transferred to the ICU, where her blood pressure dropped again. She was returned to the OR, where the packs were removed and a bleeding right common iliac artery was repaired using 5-0 Prolene suture. The next day, she underwent bilateral salpingo-oophorectomy with a transverse colon colostomy.

Because of the colon injury, the vascular surgeon believed that the Dacron graft had been contaminated. On December 1, the graft was taken down, a left femoral-vein autograft was harvested, and a reconstructive conduit was created for the terminal aorta. The patient underwent three additional procedures to place mesh into the abdominal wall. When the mesh became infected, it was removed.

The patient remained in the hospital for 1 month, after which she was transferred to a long-term care facility. She suffered permanent neurologic injuries because of prolonged hypoxia and continues to require supportive care.

How could this catastrophe have been avoided?

Traumatic injury to the great retroperitoneal vessels is an emergent and life-threatening event. During gynecologic laparoscopy, it is most likely to occur during entry into the anterior abdominal wall.

Most laparoscopic procedures require entry into the anterior abdominal wall for placement of a trocar and a sleeve that serves as a portal for insertion of the endoscope. Secondary ports provide entry points for manipulative and operative tools.

The most critical entry point is primary placement of the viewing device. Secondary trocars are always inserted under direct visualization; therefore, they carry a lower risk of inflicting injury to underlying viscera and vessels.

Practice safe entry

In the early days of laparoscopy, only one method of entry existed. Over time, however, several other techniques have been devised.

The initial method—still widely utilized—is known as the closed or blind technique. The surgeon creates a pneumoperitoneum with the use of a needle that is 18 gauge to 2.5 mm in diameter; the needle is placed through a subumbilical incision. Once intraperitoneal placement is confirmed, CO₂ gas is infused into the peritoneal cavity until the abdomen is tympanic to percussion (usually at pressures of 14 to 18 mm Hg).

Next, the surgeon aims the trocar toward the uterus at a 45° angle, maintaining the device in the midline. Entry is confirmed by opening the trocar’s trap-door valve and witnessing a rush of CO₂ gas.

Another entry technique—the open technique—is used almost universally by general surgeons. The procedure is a type of microlaparotomy. After making the subumbilical incision, the fascia of the abdominal wall is pierced and the peritoneum is grasped and opened bluntly or sharply. Once the edges of the peritoneum are secured, a blunt trocar (Hasson trocar) is inserted. Then the trocar is removed, leaving the sleeve in place to accept the laparoscope.

Another entry variation, called direct entry, employs no pneumoperitoneum. In this approach, the surgeon grabs the anterior abdominal wall, sharply elevating it, and directly thrusts the reusable or disposable trocar into the abdominal cavity.

An extensive review of entry techniques has been published elsewhere.¹

Many complications arise from entry techniques and devices

A survey of Australian gynecologists about entry techniques found that 73% of respondents used a Veress needle and pneumoperitoneum for entry and that 83% used a location other than the infraumbilical site when periumbilical adhesions were suspected. Twenty-one percent had experienced a major retroperitoneal vascular injury, but 33% lacked a plan to manage such injuries.²

In their review of entry techniques, Vilos and colleagues asserted that Veress-needle insertion should be accompanied by pneumoperitoneal pressures of 20 to 30 mm Hg rather than a predetermined volume of CO₂ gas.¹ They also recommended insertion in the left upper quadrant when periumbilical adhesions are suspected or when insufflation at the umbilicus fails three times.

Newer entry devices include the optical-view trocar and the radially expanding trocar. The first consists of a plastic, conically tipped instrument that is optically clear. At least hypothetically, this device permits the surgeon to view each layer of the abdominal wall as he or she thrusts the device under “direct vision” into the abdominal cavity.

The radially expanding trocar is inserted over a Veress needle into the abdominal cavity. Its initial diameter is only 3 mm; once the instrument is in place, however, a blunt plastic trocar and sleeve are pushed into the mesh-like, radially expanding tube until it reaches 11 to 12 mm in diameter. The blunt trocar is then removed, leaving the plastic sheath and mesh material in place to accept the laparoscope. One key advantage of this device is the mesh component, which resists slippage or movement as the laparoscope is moved in and out of the sheath.

Vilos and colleagues concluded that open entry was neither superior nor inferior to other entry techniques and that direct entry without pneumoperitoneum may be as safe as Veress-needle techniques and associated with a lower risk of gas embolism. They also reported that shielded trocars are not associated with fewer visceral or vascular injuries and that visual-entry trocars lack superiority, compared with other devices, for the prevention of visceral or vascular injuries.¹

Other review articles about entry techniques similarly found no objective evidence that any single technique is superior.³ However, data are conflicting on the safety of the optical trocar, compared with other trocars, with some data showing marginal advantages and others demonstrating no difference.^4-6

Follow a few key entry guidelines

In 1990, Yuzpe reported a mail-in survey of 800 practicing ObGyns in Canada on the topic of pneumoperitoneum and trocar injuries.⁷ Of the 407 physicians who responded, 16.7% reported that the pneumoperitoneum needle caused a visceral or major vessel injury, and 16.5% attributed the injury to the primary trocar. Among 109 vessel injuries, 31 were caused by the pneumoperitoneum needle, and 28 of 104 injuries were caused by the primary trocar.

To be safe, Veress needle and primary trocar entry require critical attention to the angle and direction of the thrust relative to the abdominal cavity (FIGURE, page 24). For example, if the Veress needle or the sharp tip of the trocar deviate to the right or left of the midline during entry into the abdomen, injury to the iliac vessels is a clear risk.

Most laparoscopic surgeons stand on the left-hand side of the patient and face her feet. Trocar deviation for a right-handed person tends to vector to the right, especially when a twisting motion is utilized. Correct alignment of the primary trocar is straight down the middle of the lower abdomen on a virtual or real line drawn from the center of the navel to the center of the symphysis.

An entry angle of 45° to 60° will carry the needle or trocar toward the bladder or uterus and away from the aorta and left common iliac vein. In contrast, a 90° thrust will aim the device dangerously toward the great vessels. A slightly upward and right-sided deviation from the subumbilical entry will place the needle and trocar in the direction of the inferior vena cava and right common iliac vessels. A 90° entry with deviation to the left will position the entry device at the inferior mesenteric vessels and the left common iliac vessels.

Primary abdominal entry
An entry angle of 45° to 60°, regardless of whether a needle or trocar is used, will carry the device toward the bladder or uterus and away from the aorta and left common iliac vein.In a review of access complications associated with laparoscopy, including major vascular injuries, Philips and Amaral listed variables responsible for large-vessel injury; they also documented the incidence of such injuries associated with laparoscopic cholecystectomy.⁸ They recommended that the patient be placed in the Trendelenburg position and that the needle or trocar be inserted at a 45° angle that stays within the midline; they also concluded that the trocar should be placed when pneumoperitoneal pressures exceed 20 mm Hg. They advised against direct insertion in patients with a history of pelvic surgery as well as in thin patients.

Place secondary trocars under direct visualization

Secondary trocars should always be placed under direct, visually controlled entry and, at least hypothetically, should never injure any great vessel. Nevertheless, secondary trocars do sometimes cause injury, most often as a result of extreme lateral entry near the inguinal ligament. The vessels at risk are the external iliac artery and vein.

Injuries are also invariably associated with adhesiolysis and anatomic problems. Precise knowledge of pelvic anatomy is not only a requisite for pelvic surgery in general but also for laparoscopic surgery, in which the operative view is less clear than it is in open procedures.

Know the risks associated with operative tools

Suturing and knot tying are not easy maneuvers during laparoscopic procedures and add significant operative time. Although they are performed more easily when robotics is utilized, few gynecologists are skilled practitioners. As a result, accessory instruments have been developed to prevent and control bleeding during laparoscopic operations. These devices include monopolar and bipolar instruments, lasers, ultrasonic tools, and stapling devices.

Avoid monopolar electrosurgery

This modality should be avoided whenever possible because the risk of injury is significantly higher than with bipolar electrosurgery. The key disadvantages of monopolar energy are high-frequency leaks; low-frequency currents; direct, indirect, and capacitative coupling; and return-electrode failures. None of these problems are common with bipolar techniques.

However, all electrosurgical devices carry a risk of thermal injury through direct tissue contact and conduction of heat to neighboring tissues and structures.

A full discussion of the physics and tissue actions of electrosurgical devices may be found elsewhere.⁹

CO₂ is the safest laser

A variety of lasers have been used in laparoscopic surgery. The neodymium–YAG, KTP-532, and CO₂ lasers have been used most frequently for gynecologic operations.

Because of its wavelength, the CO₂ laser is the safest device for intra-abdominal use. Advantages include precision and control. In addition, the CO₂ laser is absorbed by water very effectively. As a result, hydrodissection techniques can facilitate effective backstopping of the laser beam in strategic locations, thereby preventing injury to surrounding structures.

Laser energy is not conducted through tissue in the same way that electrosurgical energy is conducted. Therefore, the laser is ideal for vaporizing endometrial implants and cutting adhesions.

Beware of heat generated by the ultrasonic shears

This device, known more commonly as the Harmonic Scalpel (Ethicon), employs high-frequency sound waves to shear and coagulate tissue and prevent bleeding. It does not require conduction through tissues but does require contact with tissues. Because friction produces heat, these devices can become hot enough to inflict unintended burns on tissues that are inadvertently touched by the hot tip or by heat transmitted from the operative site by thermal conduction.

Stapler may inadvertently involve adjacent structures

This laparoscopic device has the advantage of not requiring or emitting energy other than the mechanical force of the operator’s hand. Disadvantages associated with the stapler center on the inadvertent inclusion of other structures within the jaws of the instrument. In addition, the staplers themselves tend to be large and somewhat unwieldy in close quarters, adding to the risk of stapling nearby viscera.

Further information on the physics and actions of lasers, ultrasonic shears, and staplers is available.^10,11

Obesity may increase the risk of major vessel injury

A recent study by Baggish found obesity to be a high-risk circumstance for major vessel injury.¹² In the study, 22 of 31 women who sustained injury were overweight or obese, with a BMI ranging from 26 to 30 kg/m².

Obesity increases the risk of major vessel injury because of the greater elasticity of the anterior abdominal wall. As force secondary to the downward thrust of the trocar is placed on the abdominal wall, it is pushed inward in the direction of the posterior wall. In contrast, thin women have rigid abdominal walls with minimal elasticity, so the force of the trocar thrust does not create significant displacement.

Baggish also found that disposable trocars accounted for 90% of major vascular injuries and that use of long trocars accounted for 43% of deaths.¹²

Injury and death are rare but real risks

In a multicenter study in France over 9 years, investigators reviewed 29,966 diagnostic and operative laparoscopic procedures and found a mortality rate of 3.33 deaths for every 100,000 laparoscopies and an overall complication rate of 4.64 complications for every 1,000 procedures.¹³ They found the complication rate to be significantly correlated with the complexity of the procedure (P = .0001). One in three complications (34.1%; n = 43) occurred during set-up, and one in four (28.6%) were not identified intraoperatively.¹³

The risk of great vessel injury associated with laparoscopy most frequently quoted is 0.5 injury for every 1,000 procedures.¹⁴ A multicenter study reported the prevalence of this complication to be 1.05 injuries per 1,000 procedures.¹⁵

The mortality rate associated with major vessel injury has been reported in several studies to range from 8% to 17%.^14-17

Two articles measured the distance from various points on the anterior abdominal wall to the great retroperitoneal vessels during laparoscopic operations; they also measured the force required for the trocar to penetrate the abdominal wall.^18,19 They found significant differences in the distance from the site of primary trocar insertion to the aorta and iliac vessels, depending on the BMI of the patient. In women with a BMI below 25 kg/m², the mean distance to the aorta was 11.21 cm. In women with a BMI of 25 to 30, it was 14.14 cm, and in women with a BMI over 30, it was 15.14 cm. They also found variations in the mean thickness of the abdominal wall, which was 3.48 cm, 3.85 cm, and 5.05 cm in women with a BMI of less than 25, 25–30, and more than 30, respectively.

As for the force required for entry, investigators found that disposable cutting trocars can traverse the anterior abdominal wall with less force and less time, compared with reusable trocars and optical viewing devices.^18,19

Another study measured the thickness of the abdominal wall and the distance to the great vessels by magnetic resonance imaging or computed tomography.²⁰ However, this study was not performed during laparoscopy with pneumoperitoneum in place.

As previously mentioned, Baggish reported on 31 cases of major-vessel injury associated with laparoscopic operations involving 49 major-vessel injuries. Twenty-eight injuries occurred as a result of entry techniques: 26 occurred during primary trocar insertion, and two were related to secondary trocar thrusts.¹² Four injuries and three deaths were associated with use of an 11-inch disposable trocar.

Of the injuries associated with primary trocar insertion, 10 occurred during direct insertion and 26 after creation of pneumoperitoneum. Open laparoscopy was performed in two cases.¹² The TABLE details the number of vessels injured and the sites of injury in this study.

Seven women (23%) died as a direct result of venous injury. Collateral injury to other structures was observed in 16 cases. Blood loss ranged from 1,000 mL to 7,000 mL.¹²

Sites of major vessel injury in one study of gynecologic laparoscopy

Avoid these common errors

The most common errors in gynecologic laparoscopy include:

• delayed diagnosis
• failure to act on a visible retroperitoneal hematoma
• failure to cross-match adequate supplies of blood and blood products
• failure to adequately transfuse blood and blood products
• clamping the large damaged vessel
• opening the abdomen via Pfannenstiel incision
• failure to call for a vascular surgeon in a timely manner.

Recommended interventions

When a major vascular injury occurs, a well-informed surgeon will take the following measures:

• call for a vascular surgeon immediately. (Baggish found that there was a substantial delay in getting a vascular surgeon to the operating table in four of 31 cases.¹²)
• open the abdomen via a midline incision
• use a sponge stick to apply direct pressure to the bleeding vessel
• obtain an emergency type and cross-match and order a minimum of 6 U of blood plus fresh frozen plasma
• obtain a baseline complete blood count, platelet count, fibrinogen level, and test for fibrin-split products
• advise the anesthesiologist to seek additional help
• call for additional OR nursing personnel
• assign one circulator to run stats and record critical data.^21-33

Prevention is the best strategy

As the opening case demonstrates, major vessel injury can occur without warning and cause cascading problems that can lead to permanent disability—even death. Because most serious vessel injuries occur during entry into the anterior abdominal wall, careful attention to entry techniques and the patient’s unique circumstances (obesity, presence of adhesions) can go a long way toward averting injury. Vigilance for the possibility of injury is also important throughout the procedure. When injury does occur, it is critical to call for help as soon as possible and to have safeguards in place to manage it.

We want to hear from you! Tell us what you think.

CASE: Abdominal entry leads to life-threatening injury

A 50-year-old woman with a BMI of 25 kg/m², a strong family history of breast and ovarian cancer, and a confirmed BRCA mutation was scheduled for prophylactic bilateral salpingo-oophorectomy via robotic laparoscopy on November 26, 2009. At the time of the procedure, the gynecologic surgeon selected a site for the camera trocar that was several centimeters above the umbilicus. After making a transverse incision, he inserted a Veress needle and insufflated the abdomen with CO₂ gas until intra-abdominal pressure reached 17 mm Hg. He then thrust an 11-inch disposable trocar through the anterior abdominal wall, attached the camera to the laparoscope, confirmed proper intraperitoneal placement, and inserted two additional trocars under direct vision.

Shortly after these actions, the anesthesiologist reported that the patient’s blood pressure had dropped precipitously, along with end tidal CO₂. The surgeon examined the peritoneal cavity and discovered blood in the right paracolic gutter. The anesthesiologist advised the surgeon that he could no longer detect the patient’s blood pressure; electrocardiography revealed pulseless electrical activity.

The surgical team began chest compressions, evacuated the pneumoperitoneum, and removed all trocars. Blood was noted on the camera trocar, and the device was secured by the OR staff. The surgeon performed an emergent laparotomy, making the incision within 4 minutes of the beginning of CPR. Exploration revealed a large retroperitoneal hematoma above the area of the aortic bifurcation and inferior vena cava.

General and vascular surgeons were called. The general surgeon opened the retroperitoneum and found an extreme amount of clotted and unclotted blood. The vascular surgeon described the initial injury as a 1.5-cm laceration of the distal aorta, just above the bifurcation. A cell saver was requested and recorded blood loss of 12,000 mL.

The vascular surgeon clamped the aorta proximally; he also clamped both common iliac arteries. He then repaired the lacerations on the aorta using 5-0 Prolene suture (Ethicon). The aorta was significantly narrowed, however, so the surgeon decided to replace the distal aorta, which he then resected and repaired using a 14-mm Dacron graft (DuPont).

Further inspection revealed continuing retroperitoneal bleeding. The vascular surgeon found and repaired a laceration of the inferior mesenteric vein. He also clipped multiple small veins to stop bleeding.

When a hole in the transverse colon was identified, the general surgeon—who had left the operating table—rescrubbed to repair it. He also discovered an injury to the mesentery of the transverse colon and repaired both wounds, resecting the perforated segment. The divided, stapled colon was dropped back into the abdomen because the bowel was dusky. Despite an epinephrine drip, the patient was hypotensive and coagulopathic. The abdomen was packed and covered with sterile cassette film, with towels covering the open wound.

The patient was taken to the postanesthesia care unit in guarded condition and was subsequently transferred to the ICU, where her blood pressure dropped again. She was returned to the OR, where the packs were removed and a bleeding right common iliac artery was repaired using 5-0 Prolene suture. The next day, she underwent bilateral salpingo-oophorectomy with a transverse colon colostomy.

Because of the colon injury, the vascular surgeon believed that the Dacron graft had been contaminated. On December 1, the graft was taken down, a left femoral-vein autograft was harvested, and a reconstructive conduit was created for the terminal aorta. The patient underwent three additional procedures to place mesh into the abdominal wall. When the mesh became infected, it was removed.

The patient remained in the hospital for 1 month, after which she was transferred to a long-term care facility. She suffered permanent neurologic injuries because of prolonged hypoxia and continues to require supportive care.

How could this catastrophe have been avoided?

Traumatic injury to the great retroperitoneal vessels is an emergent and life-threatening event. During gynecologic laparoscopy, it is most likely to occur during entry into the anterior abdominal wall.

Most laparoscopic procedures require entry into the anterior abdominal wall for placement of a trocar and a sleeve that serves as a portal for insertion of the endoscope. Secondary ports provide entry points for manipulative and operative tools.

The most critical entry point is primary placement of the viewing device. Secondary trocars are always inserted under direct visualization; therefore, they carry a lower risk of inflicting injury to underlying viscera and vessels.

Practice safe entry

In the early days of laparoscopy, only one method of entry existed. Over time, however, several other techniques have been devised.

The initial method—still widely utilized—is known as the closed or blind technique. The surgeon creates a pneumoperitoneum with the use of a needle that is 18 gauge to 2.5 mm in diameter; the needle is placed through a subumbilical incision. Once intraperitoneal placement is confirmed, CO₂ gas is infused into the peritoneal cavity until the abdomen is tympanic to percussion (usually at pressures of 14 to 18 mm Hg).

Next, the surgeon aims the trocar toward the uterus at a 45° angle, maintaining the device in the midline. Entry is confirmed by opening the trocar’s trap-door valve and witnessing a rush of CO₂ gas.

Another entry technique—the open technique—is used almost universally by general surgeons. The procedure is a type of microlaparotomy. After making the subumbilical incision, the fascia of the abdominal wall is pierced and the peritoneum is grasped and opened bluntly or sharply. Once the edges of the peritoneum are secured, a blunt trocar (Hasson trocar) is inserted. Then the trocar is removed, leaving the sleeve in place to accept the laparoscope.

Another entry variation, called direct entry, employs no pneumoperitoneum. In this approach, the surgeon grabs the anterior abdominal wall, sharply elevating it, and directly thrusts the reusable or disposable trocar into the abdominal cavity.

An extensive review of entry techniques has been published elsewhere.¹

Many complications arise from entry techniques and devices

A survey of Australian gynecologists about entry techniques found that 73% of respondents used a Veress needle and pneumoperitoneum for entry and that 83% used a location other than the infraumbilical site when periumbilical adhesions were suspected. Twenty-one percent had experienced a major retroperitoneal vascular injury, but 33% lacked a plan to manage such injuries.²

In their review of entry techniques, Vilos and colleagues asserted that Veress-needle insertion should be accompanied by pneumoperitoneal pressures of 20 to 30 mm Hg rather than a predetermined volume of CO₂ gas.¹ They also recommended insertion in the left upper quadrant when periumbilical adhesions are suspected or when insufflation at the umbilicus fails three times.

Newer entry devices include the optical-view trocar and the radially expanding trocar. The first consists of a plastic, conically tipped instrument that is optically clear. At least hypothetically, this device permits the surgeon to view each layer of the abdominal wall as he or she thrusts the device under “direct vision” into the abdominal cavity.

The radially expanding trocar is inserted over a Veress needle into the abdominal cavity. Its initial diameter is only 3 mm; once the instrument is in place, however, a blunt plastic trocar and sleeve are pushed into the mesh-like, radially expanding tube until it reaches 11 to 12 mm in diameter. The blunt trocar is then removed, leaving the plastic sheath and mesh material in place to accept the laparoscope. One key advantage of this device is the mesh component, which resists slippage or movement as the laparoscope is moved in and out of the sheath.

Vilos and colleagues concluded that open entry was neither superior nor inferior to other entry techniques and that direct entry without pneumoperitoneum may be as safe as Veress-needle techniques and associated with a lower risk of gas embolism. They also reported that shielded trocars are not associated with fewer visceral or vascular injuries and that visual-entry trocars lack superiority, compared with other devices, for the prevention of visceral or vascular injuries.¹

Other review articles about entry techniques similarly found no objective evidence that any single technique is superior.³ However, data are conflicting on the safety of the optical trocar, compared with other trocars, with some data showing marginal advantages and others demonstrating no difference.^4-6

Follow a few key entry guidelines

In 1990, Yuzpe reported a mail-in survey of 800 practicing ObGyns in Canada on the topic of pneumoperitoneum and trocar injuries.⁷ Of the 407 physicians who responded, 16.7% reported that the pneumoperitoneum needle caused a visceral or major vessel injury, and 16.5% attributed the injury to the primary trocar. Among 109 vessel injuries, 31 were caused by the pneumoperitoneum needle, and 28 of 104 injuries were caused by the primary trocar.

To be safe, Veress needle and primary trocar entry require critical attention to the angle and direction of the thrust relative to the abdominal cavity (FIGURE, page 24). For example, if the Veress needle or the sharp tip of the trocar deviate to the right or left of the midline during entry into the abdomen, injury to the iliac vessels is a clear risk.

Most laparoscopic surgeons stand on the left-hand side of the patient and face her feet. Trocar deviation for a right-handed person tends to vector to the right, especially when a twisting motion is utilized. Correct alignment of the primary trocar is straight down the middle of the lower abdomen on a virtual or real line drawn from the center of the navel to the center of the symphysis.

An entry angle of 45° to 60° will carry the needle or trocar toward the bladder or uterus and away from the aorta and left common iliac vein. In contrast, a 90° thrust will aim the device dangerously toward the great vessels. A slightly upward and right-sided deviation from the subumbilical entry will place the needle and trocar in the direction of the inferior vena cava and right common iliac vessels. A 90° entry with deviation to the left will position the entry device at the inferior mesenteric vessels and the left common iliac vessels.

Primary abdominal entry
An entry angle of 45° to 60°, regardless of whether a needle or trocar is used, will carry the device toward the bladder or uterus and away from the aorta and left common iliac vein.In a review of access complications associated with laparoscopy, including major vascular injuries, Philips and Amaral listed variables responsible for large-vessel injury; they also documented the incidence of such injuries associated with laparoscopic cholecystectomy.⁸ They recommended that the patient be placed in the Trendelenburg position and that the needle or trocar be inserted at a 45° angle that stays within the midline; they also concluded that the trocar should be placed when pneumoperitoneal pressures exceed 20 mm Hg. They advised against direct insertion in patients with a history of pelvic surgery as well as in thin patients.

Place secondary trocars under direct visualization

Secondary trocars should always be placed under direct, visually controlled entry and, at least hypothetically, should never injure any great vessel. Nevertheless, secondary trocars do sometimes cause injury, most often as a result of extreme lateral entry near the inguinal ligament. The vessels at risk are the external iliac artery and vein.

Injuries are also invariably associated with adhesiolysis and anatomic problems. Precise knowledge of pelvic anatomy is not only a requisite for pelvic surgery in general but also for laparoscopic surgery, in which the operative view is less clear than it is in open procedures.

Know the risks associated with operative tools

Suturing and knot tying are not easy maneuvers during laparoscopic procedures and add significant operative time. Although they are performed more easily when robotics is utilized, few gynecologists are skilled practitioners. As a result, accessory instruments have been developed to prevent and control bleeding during laparoscopic operations. These devices include monopolar and bipolar instruments, lasers, ultrasonic tools, and stapling devices.

Avoid monopolar electrosurgery

This modality should be avoided whenever possible because the risk of injury is significantly higher than with bipolar electrosurgery. The key disadvantages of monopolar energy are high-frequency leaks; low-frequency currents; direct, indirect, and capacitative coupling; and return-electrode failures. None of these problems are common with bipolar techniques.

However, all electrosurgical devices carry a risk of thermal injury through direct tissue contact and conduction of heat to neighboring tissues and structures.

A full discussion of the physics and tissue actions of electrosurgical devices may be found elsewhere.⁹

CO₂ is the safest laser

A variety of lasers have been used in laparoscopic surgery. The neodymium–YAG, KTP-532, and CO₂ lasers have been used most frequently for gynecologic operations.

Because of its wavelength, the CO₂ laser is the safest device for intra-abdominal use. Advantages include precision and control. In addition, the CO₂ laser is absorbed by water very effectively. As a result, hydrodissection techniques can facilitate effective backstopping of the laser beam in strategic locations, thereby preventing injury to surrounding structures.

Laser energy is not conducted through tissue in the same way that electrosurgical energy is conducted. Therefore, the laser is ideal for vaporizing endometrial implants and cutting adhesions.

Beware of heat generated by the ultrasonic shears

This device, known more commonly as the Harmonic Scalpel (Ethicon), employs high-frequency sound waves to shear and coagulate tissue and prevent bleeding. It does not require conduction through tissues but does require contact with tissues. Because friction produces heat, these devices can become hot enough to inflict unintended burns on tissues that are inadvertently touched by the hot tip or by heat transmitted from the operative site by thermal conduction.

Stapler may inadvertently involve adjacent structures

This laparoscopic device has the advantage of not requiring or emitting energy other than the mechanical force of the operator’s hand. Disadvantages associated with the stapler center on the inadvertent inclusion of other structures within the jaws of the instrument. In addition, the staplers themselves tend to be large and somewhat unwieldy in close quarters, adding to the risk of stapling nearby viscera.

Further information on the physics and actions of lasers, ultrasonic shears, and staplers is available.^10,11

Obesity may increase the risk of major vessel injury

A recent study by Baggish found obesity to be a high-risk circumstance for major vessel injury.¹² In the study, 22 of 31 women who sustained injury were overweight or obese, with a BMI ranging from 26 to 30 kg/m².

Obesity increases the risk of major vessel injury because of the greater elasticity of the anterior abdominal wall. As force secondary to the downward thrust of the trocar is placed on the abdominal wall, it is pushed inward in the direction of the posterior wall. In contrast, thin women have rigid abdominal walls with minimal elasticity, so the force of the trocar thrust does not create significant displacement.

Baggish also found that disposable trocars accounted for 90% of major vascular injuries and that use of long trocars accounted for 43% of deaths.¹²

Injury and death are rare but real risks

In a multicenter study in France over 9 years, investigators reviewed 29,966 diagnostic and operative laparoscopic procedures and found a mortality rate of 3.33 deaths for every 100,000 laparoscopies and an overall complication rate of 4.64 complications for every 1,000 procedures.¹³ They found the complication rate to be significantly correlated with the complexity of the procedure (P = .0001). One in three complications (34.1%; n = 43) occurred during set-up, and one in four (28.6%) were not identified intraoperatively.¹³

The risk of great vessel injury associated with laparoscopy most frequently quoted is 0.5 injury for every 1,000 procedures.¹⁴ A multicenter study reported the prevalence of this complication to be 1.05 injuries per 1,000 procedures.¹⁵

The mortality rate associated with major vessel injury has been reported in several studies to range from 8% to 17%.^14-17

Two articles measured the distance from various points on the anterior abdominal wall to the great retroperitoneal vessels during laparoscopic operations; they also measured the force required for the trocar to penetrate the abdominal wall.^18,19 They found significant differences in the distance from the site of primary trocar insertion to the aorta and iliac vessels, depending on the BMI of the patient. In women with a BMI below 25 kg/m², the mean distance to the aorta was 11.21 cm. In women with a BMI of 25 to 30, it was 14.14 cm, and in women with a BMI over 30, it was 15.14 cm. They also found variations in the mean thickness of the abdominal wall, which was 3.48 cm, 3.85 cm, and 5.05 cm in women with a BMI of less than 25, 25–30, and more than 30, respectively.

As for the force required for entry, investigators found that disposable cutting trocars can traverse the anterior abdominal wall with less force and less time, compared with reusable trocars and optical viewing devices.^18,19

Another study measured the thickness of the abdominal wall and the distance to the great vessels by magnetic resonance imaging or computed tomography.²⁰ However, this study was not performed during laparoscopy with pneumoperitoneum in place.

As previously mentioned, Baggish reported on 31 cases of major-vessel injury associated with laparoscopic operations involving 49 major-vessel injuries. Twenty-eight injuries occurred as a result of entry techniques: 26 occurred during primary trocar insertion, and two were related to secondary trocar thrusts.¹² Four injuries and three deaths were associated with use of an 11-inch disposable trocar.

Of the injuries associated with primary trocar insertion, 10 occurred during direct insertion and 26 after creation of pneumoperitoneum. Open laparoscopy was performed in two cases.¹² The TABLE details the number of vessels injured and the sites of injury in this study.

Seven women (23%) died as a direct result of venous injury. Collateral injury to other structures was observed in 16 cases. Blood loss ranged from 1,000 mL to 7,000 mL.¹²

Sites of major vessel injury in one study of gynecologic laparoscopy

Avoid these common errors

The most common errors in gynecologic laparoscopy include:

• delayed diagnosis
• failure to act on a visible retroperitoneal hematoma
• failure to cross-match adequate supplies of blood and blood products
• failure to adequately transfuse blood and blood products
• clamping the large damaged vessel
• opening the abdomen via Pfannenstiel incision
• failure to call for a vascular surgeon in a timely manner.

Recommended interventions

When a major vascular injury occurs, a well-informed surgeon will take the following measures:

• call for a vascular surgeon immediately. (Baggish found that there was a substantial delay in getting a vascular surgeon to the operating table in four of 31 cases.¹²)
• open the abdomen via a midline incision
• use a sponge stick to apply direct pressure to the bleeding vessel
• obtain an emergency type and cross-match and order a minimum of 6 U of blood plus fresh frozen plasma
• obtain a baseline complete blood count, platelet count, fibrinogen level, and test for fibrin-split products
• advise the anesthesiologist to seek additional help
• call for additional OR nursing personnel
• assign one circulator to run stats and record critical data.^21-33

Prevention is the best strategy

As the opening case demonstrates, major vessel injury can occur without warning and cause cascading problems that can lead to permanent disability—even death. Because most serious vessel injuries occur during entry into the anterior abdominal wall, careful attention to entry techniques and the patient’s unique circumstances (obesity, presence of adhesions) can go a long way toward averting injury. Vigilance for the possibility of injury is also important throughout the procedure. When injury does occur, it is critical to call for help as soon as possible and to have safeguards in place to manage it.

We want to hear from you! Tell us what you think.

CASE: Abdominal entry leads to life-threatening injury

A 50-year-old woman with a BMI of 25 kg/m², a strong family history of breast and ovarian cancer, and a confirmed BRCA mutation was scheduled for prophylactic bilateral salpingo-oophorectomy via robotic laparoscopy on November 26, 2009. At the time of the procedure, the gynecologic surgeon selected a site for the camera trocar that was several centimeters above the umbilicus. After making a transverse incision, he inserted a Veress needle and insufflated the abdomen with CO₂ gas until intra-abdominal pressure reached 17 mm Hg. He then thrust an 11-inch disposable trocar through the anterior abdominal wall, attached the camera to the laparoscope, confirmed proper intraperitoneal placement, and inserted two additional trocars under direct vision.

Shortly after these actions, the anesthesiologist reported that the patient’s blood pressure had dropped precipitously, along with end tidal CO₂. The surgeon examined the peritoneal cavity and discovered blood in the right paracolic gutter. The anesthesiologist advised the surgeon that he could no longer detect the patient’s blood pressure; electrocardiography revealed pulseless electrical activity.

The surgical team began chest compressions, evacuated the pneumoperitoneum, and removed all trocars. Blood was noted on the camera trocar, and the device was secured by the OR staff. The surgeon performed an emergent laparotomy, making the incision within 4 minutes of the beginning of CPR. Exploration revealed a large retroperitoneal hematoma above the area of the aortic bifurcation and inferior vena cava.

General and vascular surgeons were called. The general surgeon opened the retroperitoneum and found an extreme amount of clotted and unclotted blood. The vascular surgeon described the initial injury as a 1.5-cm laceration of the distal aorta, just above the bifurcation. A cell saver was requested and recorded blood loss of 12,000 mL.

The vascular surgeon clamped the aorta proximally; he also clamped both common iliac arteries. He then repaired the lacerations on the aorta using 5-0 Prolene suture (Ethicon). The aorta was significantly narrowed, however, so the surgeon decided to replace the distal aorta, which he then resected and repaired using a 14-mm Dacron graft (DuPont).

Further inspection revealed continuing retroperitoneal bleeding. The vascular surgeon found and repaired a laceration of the inferior mesenteric vein. He also clipped multiple small veins to stop bleeding.

When a hole in the transverse colon was identified, the general surgeon—who had left the operating table—rescrubbed to repair it. He also discovered an injury to the mesentery of the transverse colon and repaired both wounds, resecting the perforated segment. The divided, stapled colon was dropped back into the abdomen because the bowel was dusky. Despite an epinephrine drip, the patient was hypotensive and coagulopathic. The abdomen was packed and covered with sterile cassette film, with towels covering the open wound.

The patient was taken to the postanesthesia care unit in guarded condition and was subsequently transferred to the ICU, where her blood pressure dropped again. She was returned to the OR, where the packs were removed and a bleeding right common iliac artery was repaired using 5-0 Prolene suture. The next day, she underwent bilateral salpingo-oophorectomy with a transverse colon colostomy.

Because of the colon injury, the vascular surgeon believed that the Dacron graft had been contaminated. On December 1, the graft was taken down, a left femoral-vein autograft was harvested, and a reconstructive conduit was created for the terminal aorta. The patient underwent three additional procedures to place mesh into the abdominal wall. When the mesh became infected, it was removed.

The patient remained in the hospital for 1 month, after which she was transferred to a long-term care facility. She suffered permanent neurologic injuries because of prolonged hypoxia and continues to require supportive care.

How could this catastrophe have been avoided?

Traumatic injury to the great retroperitoneal vessels is an emergent and life-threatening event. During gynecologic laparoscopy, it is most likely to occur during entry into the anterior abdominal wall.

Most laparoscopic procedures require entry into the anterior abdominal wall for placement of a trocar and a sleeve that serves as a portal for insertion of the endoscope. Secondary ports provide entry points for manipulative and operative tools.

The most critical entry point is primary placement of the viewing device. Secondary trocars are always inserted under direct visualization; therefore, they carry a lower risk of inflicting injury to underlying viscera and vessels.

Practice safe entry

In the early days of laparoscopy, only one method of entry existed. Over time, however, several other techniques have been devised.

The initial method—still widely utilized—is known as the closed or blind technique. The surgeon creates a pneumoperitoneum with the use of a needle that is 18 gauge to 2.5 mm in diameter; the needle is placed through a subumbilical incision. Once intraperitoneal placement is confirmed, CO₂ gas is infused into the peritoneal cavity until the abdomen is tympanic to percussion (usually at pressures of 14 to 18 mm Hg).

Next, the surgeon aims the trocar toward the uterus at a 45° angle, maintaining the device in the midline. Entry is confirmed by opening the trocar’s trap-door valve and witnessing a rush of CO₂ gas.

Another entry technique—the open technique—is used almost universally by general surgeons. The procedure is a type of microlaparotomy. After making the subumbilical incision, the fascia of the abdominal wall is pierced and the peritoneum is grasped and opened bluntly or sharply. Once the edges of the peritoneum are secured, a blunt trocar (Hasson trocar) is inserted. Then the trocar is removed, leaving the sleeve in place to accept the laparoscope.

Another entry variation, called direct entry, employs no pneumoperitoneum. In this approach, the surgeon grabs the anterior abdominal wall, sharply elevating it, and directly thrusts the reusable or disposable trocar into the abdominal cavity.

An extensive review of entry techniques has been published elsewhere.¹

Many complications arise from entry techniques and devices

A survey of Australian gynecologists about entry techniques found that 73% of respondents used a Veress needle and pneumoperitoneum for entry and that 83% used a location other than the infraumbilical site when periumbilical adhesions were suspected. Twenty-one percent had experienced a major retroperitoneal vascular injury, but 33% lacked a plan to manage such injuries.²

In their review of entry techniques, Vilos and colleagues asserted that Veress-needle insertion should be accompanied by pneumoperitoneal pressures of 20 to 30 mm Hg rather than a predetermined volume of CO₂ gas.¹ They also recommended insertion in the left upper quadrant when periumbilical adhesions are suspected or when insufflation at the umbilicus fails three times.

Newer entry devices include the optical-view trocar and the radially expanding trocar. The first consists of a plastic, conically tipped instrument that is optically clear. At least hypothetically, this device permits the surgeon to view each layer of the abdominal wall as he or she thrusts the device under “direct vision” into the abdominal cavity.

The radially expanding trocar is inserted over a Veress needle into the abdominal cavity. Its initial diameter is only 3 mm; once the instrument is in place, however, a blunt plastic trocar and sleeve are pushed into the mesh-like, radially expanding tube until it reaches 11 to 12 mm in diameter. The blunt trocar is then removed, leaving the plastic sheath and mesh material in place to accept the laparoscope. One key advantage of this device is the mesh component, which resists slippage or movement as the laparoscope is moved in and out of the sheath.

Vilos and colleagues concluded that open entry was neither superior nor inferior to other entry techniques and that direct entry without pneumoperitoneum may be as safe as Veress-needle techniques and associated with a lower risk of gas embolism. They also reported that shielded trocars are not associated with fewer visceral or vascular injuries and that visual-entry trocars lack superiority, compared with other devices, for the prevention of visceral or vascular injuries.¹

Other review articles about entry techniques similarly found no objective evidence that any single technique is superior.³ However, data are conflicting on the safety of the optical trocar, compared with other trocars, with some data showing marginal advantages and others demonstrating no difference.^4-6

Follow a few key entry guidelines

In 1990, Yuzpe reported a mail-in survey of 800 practicing ObGyns in Canada on the topic of pneumoperitoneum and trocar injuries.⁷ Of the 407 physicians who responded, 16.7% reported that the pneumoperitoneum needle caused a visceral or major vessel injury, and 16.5% attributed the injury to the primary trocar. Among 109 vessel injuries, 31 were caused by the pneumoperitoneum needle, and 28 of 104 injuries were caused by the primary trocar.

To be safe, Veress needle and primary trocar entry require critical attention to the angle and direction of the thrust relative to the abdominal cavity (FIGURE, page 24). For example, if the Veress needle or the sharp tip of the trocar deviate to the right or left of the midline during entry into the abdomen, injury to the iliac vessels is a clear risk.

Most laparoscopic surgeons stand on the left-hand side of the patient and face her feet. Trocar deviation for a right-handed person tends to vector to the right, especially when a twisting motion is utilized. Correct alignment of the primary trocar is straight down the middle of the lower abdomen on a virtual or real line drawn from the center of the navel to the center of the symphysis.

An entry angle of 45° to 60° will carry the needle or trocar toward the bladder or uterus and away from the aorta and left common iliac vein. In contrast, a 90° thrust will aim the device dangerously toward the great vessels. A slightly upward and right-sided deviation from the subumbilical entry will place the needle and trocar in the direction of the inferior vena cava and right common iliac vessels. A 90° entry with deviation to the left will position the entry device at the inferior mesenteric vessels and the left common iliac vessels.

Primary abdominal entry
An entry angle of 45° to 60°, regardless of whether a needle or trocar is used, will carry the device toward the bladder or uterus and away from the aorta and left common iliac vein.In a review of access complications associated with laparoscopy, including major vascular injuries, Philips and Amaral listed variables responsible for large-vessel injury; they also documented the incidence of such injuries associated with laparoscopic cholecystectomy.⁸ They recommended that the patient be placed in the Trendelenburg position and that the needle or trocar be inserted at a 45° angle that stays within the midline; they also concluded that the trocar should be placed when pneumoperitoneal pressures exceed 20 mm Hg. They advised against direct insertion in patients with a history of pelvic surgery as well as in thin patients.

Place secondary trocars under direct visualization

Secondary trocars should always be placed under direct, visually controlled entry and, at least hypothetically, should never injure any great vessel. Nevertheless, secondary trocars do sometimes cause injury, most often as a result of extreme lateral entry near the inguinal ligament. The vessels at risk are the external iliac artery and vein.

Injuries are also invariably associated with adhesiolysis and anatomic problems. Precise knowledge of pelvic anatomy is not only a requisite for pelvic surgery in general but also for laparoscopic surgery, in which the operative view is less clear than it is in open procedures.

Know the risks associated with operative tools

Suturing and knot tying are not easy maneuvers during laparoscopic procedures and add significant operative time. Although they are performed more easily when robotics is utilized, few gynecologists are skilled practitioners. As a result, accessory instruments have been developed to prevent and control bleeding during laparoscopic operations. These devices include monopolar and bipolar instruments, lasers, ultrasonic tools, and stapling devices.

Avoid monopolar electrosurgery

This modality should be avoided whenever possible because the risk of injury is significantly higher than with bipolar electrosurgery. The key disadvantages of monopolar energy are high-frequency leaks; low-frequency currents; direct, indirect, and capacitative coupling; and return-electrode failures. None of these problems are common with bipolar techniques.

However, all electrosurgical devices carry a risk of thermal injury through direct tissue contact and conduction of heat to neighboring tissues and structures.

A full discussion of the physics and tissue actions of electrosurgical devices may be found elsewhere.⁹

CO₂ is the safest laser

A variety of lasers have been used in laparoscopic surgery. The neodymium–YAG, KTP-532, and CO₂ lasers have been used most frequently for gynecologic operations.

Because of its wavelength, the CO₂ laser is the safest device for intra-abdominal use. Advantages include precision and control. In addition, the CO₂ laser is absorbed by water very effectively. As a result, hydrodissection techniques can facilitate effective backstopping of the laser beam in strategic locations, thereby preventing injury to surrounding structures.

Laser energy is not conducted through tissue in the same way that electrosurgical energy is conducted. Therefore, the laser is ideal for vaporizing endometrial implants and cutting adhesions.

Beware of heat generated by the ultrasonic shears

This device, known more commonly as the Harmonic Scalpel (Ethicon), employs high-frequency sound waves to shear and coagulate tissue and prevent bleeding. It does not require conduction through tissues but does require contact with tissues. Because friction produces heat, these devices can become hot enough to inflict unintended burns on tissues that are inadvertently touched by the hot tip or by heat transmitted from the operative site by thermal conduction.

Stapler may inadvertently involve adjacent structures

This laparoscopic device has the advantage of not requiring or emitting energy other than the mechanical force of the operator’s hand. Disadvantages associated with the stapler center on the inadvertent inclusion of other structures within the jaws of the instrument. In addition, the staplers themselves tend to be large and somewhat unwieldy in close quarters, adding to the risk of stapling nearby viscera.

Further information on the physics and actions of lasers, ultrasonic shears, and staplers is available.^10,11

Obesity may increase the risk of major vessel injury

A recent study by Baggish found obesity to be a high-risk circumstance for major vessel injury.¹² In the study, 22 of 31 women who sustained injury were overweight or obese, with a BMI ranging from 26 to 30 kg/m².

Obesity increases the risk of major vessel injury because of the greater elasticity of the anterior abdominal wall. As force secondary to the downward thrust of the trocar is placed on the abdominal wall, it is pushed inward in the direction of the posterior wall. In contrast, thin women have rigid abdominal walls with minimal elasticity, so the force of the trocar thrust does not create significant displacement.

Baggish also found that disposable trocars accounted for 90% of major vascular injuries and that use of long trocars accounted for 43% of deaths.¹²

Injury and death are rare but real risks

In a multicenter study in France over 9 years, investigators reviewed 29,966 diagnostic and operative laparoscopic procedures and found a mortality rate of 3.33 deaths for every 100,000 laparoscopies and an overall complication rate of 4.64 complications for every 1,000 procedures.¹³ They found the complication rate to be significantly correlated with the complexity of the procedure (P = .0001). One in three complications (34.1%; n = 43) occurred during set-up, and one in four (28.6%) were not identified intraoperatively.¹³

The risk of great vessel injury associated with laparoscopy most frequently quoted is 0.5 injury for every 1,000 procedures.¹⁴ A multicenter study reported the prevalence of this complication to be 1.05 injuries per 1,000 procedures.¹⁵

The mortality rate associated with major vessel injury has been reported in several studies to range from 8% to 17%.^14-17

Two articles measured the distance from various points on the anterior abdominal wall to the great retroperitoneal vessels during laparoscopic operations; they also measured the force required for the trocar to penetrate the abdominal wall.^18,19 They found significant differences in the distance from the site of primary trocar insertion to the aorta and iliac vessels, depending on the BMI of the patient. In women with a BMI below 25 kg/m², the mean distance to the aorta was 11.21 cm. In women with a BMI of 25 to 30, it was 14.14 cm, and in women with a BMI over 30, it was 15.14 cm. They also found variations in the mean thickness of the abdominal wall, which was 3.48 cm, 3.85 cm, and 5.05 cm in women with a BMI of less than 25, 25–30, and more than 30, respectively.

As for the force required for entry, investigators found that disposable cutting trocars can traverse the anterior abdominal wall with less force and less time, compared with reusable trocars and optical viewing devices.^18,19

Another study measured the thickness of the abdominal wall and the distance to the great vessels by magnetic resonance imaging or computed tomography.²⁰ However, this study was not performed during laparoscopy with pneumoperitoneum in place.

As previously mentioned, Baggish reported on 31 cases of major-vessel injury associated with laparoscopic operations involving 49 major-vessel injuries. Twenty-eight injuries occurred as a result of entry techniques: 26 occurred during primary trocar insertion, and two were related to secondary trocar thrusts.¹² Four injuries and three deaths were associated with use of an 11-inch disposable trocar.

Of the injuries associated with primary trocar insertion, 10 occurred during direct insertion and 26 after creation of pneumoperitoneum. Open laparoscopy was performed in two cases.¹² The TABLE details the number of vessels injured and the sites of injury in this study.

Seven women (23%) died as a direct result of venous injury. Collateral injury to other structures was observed in 16 cases. Blood loss ranged from 1,000 mL to 7,000 mL.¹²

Sites of major vessel injury in one study of gynecologic laparoscopy

Avoid these common errors

The most common errors in gynecologic laparoscopy include:

• delayed diagnosis
• failure to act on a visible retroperitoneal hematoma
• failure to cross-match adequate supplies of blood and blood products
• failure to adequately transfuse blood and blood products
• clamping the large damaged vessel
• opening the abdomen via Pfannenstiel incision
• failure to call for a vascular surgeon in a timely manner.

Recommended interventions

When a major vascular injury occurs, a well-informed surgeon will take the following measures:

• call for a vascular surgeon immediately. (Baggish found that there was a substantial delay in getting a vascular surgeon to the operating table in four of 31 cases.¹²)
• open the abdomen via a midline incision
• use a sponge stick to apply direct pressure to the bleeding vessel
• obtain an emergency type and cross-match and order a minimum of 6 U of blood plus fresh frozen plasma
• obtain a baseline complete blood count, platelet count, fibrinogen level, and test for fibrin-split products
• advise the anesthesiologist to seek additional help
• call for additional OR nursing personnel
• assign one circulator to run stats and record critical data.^21-33

Prevention is the best strategy

As the opening case demonstrates, major vessel injury can occur without warning and cause cascading problems that can lead to permanent disability—even death. Because most serious vessel injuries occur during entry into the anterior abdominal wall, careful attention to entry techniques and the patient’s unique circumstances (obesity, presence of adhesions) can go a long way toward averting injury. Vigilance for the possibility of injury is also important throughout the procedure. When injury does occur, it is critical to call for help as soon as possible and to have safeguards in place to manage it.

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