Avoiding and repairing bowel injury in gynecologic surgery

Bowel prep regimen

When injuries are most likely

Intestinal injuries during gynecologic surgery usually involve the small bowel and can be minor, such as a serosal tear or a small, full-thickness laceration—or major, involving a devitalized bowel loop or its mesentery.

Bowel injury may occur during a variety of surgical procedures. One study showed that most injuries occur during adhesiolysis or entry into the peritoneal cavity. A smaller but substantial number of cases occur during “less extensive” procedures such as uterine curettage and laparoscopy.⁶

Upon entering the peritoneal cavity, keep in mind the possibility of injuring an adherent loop of bowel. Because of its anatomical relationships to the pelvic viscera, portions of the bowel may become involved in adhesions, which can lead to extremely challenging pelvic dissections in conditions such as endometriosis or severe pelvic infection. Dissection of pelvic adhesions is a common cause of bowel injury, because bowel loops are retracted deeply downward by adhesive bands, and the limited pelvic space hampers visualization and gentle adhesiolysis.

At special risk for bowel injury are women who have undergone prior abdominal operations or who are obese. In a series of 270 general surgery patients undergoing reoperation,⁷ 52 (19%) sustained inadvertent enterotomy. These patients had undergone a mean of 3.3 previous laparotomies and had a higher body mass index (mean of 25.5 versus 21.9).

Age may be another risk factor, since patients with enterotomies were 60 years or older.⁷

Injury during laparoscopy. Inadvertent bowel injuries may occur during laparoscopic procedures, especially at the time of trocar insertion or manipulation of pelvic structures.⁵ One device that helps prevent these injuries is the optical trocar (Visiport, US Surgical, Norwalk, Conn), which allows physicians to visualize the layers of the abdominal wall as penetration occurs.

We also routinely direct anesthesia personnel to insert a nasogastric tube at the beginning of laparoscopic procedures to facilitate decompression of the stomach and small bowel.

The risks of electrosurgery. Electrocautery used for tubal ligation, pelvic dissection, or hemostasis may injure the bowel if the surgeon is not careful. Thermal injury due to unipolar cautery is particularly ominous because the extent of injury is greater than what can be grossly observed. The incidence of this type of injury can be reduced using bipolar cautery devices, as well as clips or bands for tubal ligation.

Injury as a result of uterine perforation is unlikely, but can occur. If perforation occurs during dilation and curettage, bowel laceration may result, particularly adhesions are present between the uterus and bowel loops. In extremely rare instances, a loop of bowel may be pulled through a perforation into the uterine cavity or vagina, requiring laparotomy for reduction and repair. Caution is advised during curettage, especially in a gravid uterus, to prevent this potentially catastrophic event.

Avoid the temptation to lyse opaque adhesions using blunt dissection, as serosal tears and enterotomies may occur.

Adhesiolysis: Plan on a lengthy, meticulous procedure

Adhesions are a common cause of pelvic pain, infertility, and bowel obstruction, and their presence may make it difficult to carry out the intended surgical procedure. Adhesiolysis may be necessary to mobilize loops of bowel tightly adherent to pelvic structures, to provide sufficient exposure of the surgical field and prevent subsequent bowel obstruction.

The extent of adhesions does not necessarily correlate with clinical symptoms.

Adhesions may be of the thin, filmy, “friendly” variety or dense, thick bands.

How adhesions occur. When tissue is injured, fibrin is deposited on the peritoneal and serosal surfaces. The extent to which this fibrin is infiltrated with fibroblasts and the degree of subsequent fibrosis determine adhesion density. Any process that impairs fibrinolysis tends to delay resolution of adhesions.

Contributing factors. Adhesions are commonly encountered in pelvic surgery and may be observed in 50% to 90% of patients who have undergone previous surgery.⁸

Obese patients also are more susceptible to adhesions. Other contributing factors include pelvic infection, bleeding, irradiation, chemical irritants, and conditions such as endometriosis.

Lysis technique. Apply gentle, controlled traction—as well as countertraction—on the bowel loops to facilitate isolation and dissection with sharp Metzenbaum scissors or a scalpel. (Forceful traction or rough handling of bowel loops may cause a breach in the bowel wall with subsequent spillage of intestinal contents.)