Incidence Of Bowel Injury Research Articles

SAFETY OF THE OPTICAL TROCAR AS A METHOD OF 1st LAPAROSCOPIC ACCESS VS DIRECT TROCAR, VERESS AND HASSON NEEDLE

Background: Laparoscopic surgery is a surgical procedure by which access to the abdomino-pelvic cavity is obtained through small incisions. The incidence of bowel injury is estimated at 0.5% and of injury to major blood vessels (iliac, aorta, cava) at the time of access at 1%. Theoretical benets of optical trocar access include immediate and/or early recognition of injury, as well as failed entry, on the assumption that the layers of the abdominal wall are observed with the optical trocar until access has been achieved. To determine whether the optical trocar is a saferObjective: laparoscopic access method compared to the other techniques with direct trocar, Veress needle and Hasson open technique. Material and Methods: Observational, analytical, prospective cohort study with four arms. The study included women over 18 years of age who attended the gynaecology and laparoscopic surgery department of the Hospital Ángeles del Pedregal. The number of attempts and access time, as well as the presence of complications were quantied. Results and Conclusions: Trocar access had an advantage over the other techniques, both in access time and lower incidence of complications. The number of attempts to enter the cavity was similar to the open technique. We can conclude that the optical trocar technique is safer than the other techniques even over the open technique (Hasson).

Optimal timing of laparoscopic cholecystectomy post-endoscopic retrograde cholangiography and common bile duct clearance: A prospective observational study.

Background:The treatment of patients with cholelithiasis with common bile duct (CBD) stones is CBD clearance with cholecystectomy. While traditional teachings advocate waiting for 4–6-week post-endoscopic retrograde cholangiography (ERCP) with CBD clearance, recent studies favour an early laparoscopic cholecystectomy (LC). Hence, this study was conducted to evaluate the optimal timing of LC post-ERCP.Methods:We conducted a prospective observational study between March 2017 and October 2018. Patients diagnosed with cholelithiasis and CBS stones on ultrasonography or computed tomography were included. They were assigned to one of two groups (<2 weeks and >2 weeks) based on the time interval between ERCP and subsequent LC. Chi-square test was used to analyse the intraoperative and post-operative outcomes between the two study groups,Results:One hundred and forty patients were included in the study of which 69 underwent an early LC (<2 weeks). There was a significant decrease in the blood loss and incidence of bowel injury in the early group. Calots triangle was better defined and critical view of safety was achieved more in the patients who underwent an early LC. This resulted in a significantly lower incidence of drain placement and length of hospital stay in those patients who underwent an early LC.Conclusion:A delay of 2 weeks after ERCP makes the LC more difficult and is associated with a longer hospital stay. We advocate LC within 2 weeks of ERCP whenever feasible.

Jain Point: To Study the Efficacy and Safety in Previous Upper Abdominal Scars

Study Objective To study the safety of Jain Point, the left lateral port, in previous surgery cases especially upper abdomen scars. Design All laparoscopic entries made through the Jain Point, which has already been established to be free of adhesions and data analyzed retrospectively for previous surgery cases, especially scars in upper quadrant of abdomen. Setting Tertiary care referral centre. Patients or Participants We had 8059 patients enrolled in this study from Jan 2011 to March 2021. A full decade of developing and using this point. 2345 patients had one or multiple previous surgeries out of which 106 were having upper abdomen scars. Interventions Jain Point is located is 10-13 cm left and lateral to umbilicus. In all cases, first blind entry of veress needle and 5 mm trocar was made from this point, which continued as main working port throughout the surgery. Measurements and Main Results Special emphasis in this study was on entry in patients with upper quadrant surgical scars. We took note of major intra-operative or post-operative complication. Out of 8059, 2345 patients had previous surgeries, single or multiple. 1229 patients had open surgeries and 1116 had combination of laparoscopic and open procedures. 106 patients had upper abdominal scars or extension of long vertical scars. There was no bowel injury in upper abdominal scars, only one injury noted in a transverse scar at level of umbilicus for childhood Koch's. The incidence of bowel injury at Jain point was 0.04%, 1 in 2345 cases. There were no other major complications noted. Conclusion In previous upper abdominal scars, where entry is deemed more challenging by conventional non-umbilical, upper abdomen ports, namely Lee Haung and Palmer's, our study suggests Jain Point is a safe alternative being more lateral and lower at para-umbilical position. To study the safety of Jain Point, the left lateral port, in previous surgery cases especially upper abdomen scars. All laparoscopic entries made through the Jain Point, which has already been established to be free of adhesions and data analyzed retrospectively for previous surgery cases, especially scars in upper quadrant of abdomen. Tertiary care referral centre. We had 8059 patients enrolled in this study from Jan 2011 to March 2021. A full decade of developing and using this point. 2345 patients had one or multiple previous surgeries out of which 106 were having upper abdomen scars. Jain Point is located is 10-13 cm left and lateral to umbilicus. In all cases, first blind entry of veress needle and 5 mm trocar was made from this point, which continued as main working port throughout the surgery. Special emphasis in this study was on entry in patients with upper quadrant surgical scars. We took note of major intra-operative or post-operative complication. Out of 8059, 2345 patients had previous surgeries, single or multiple. 1229 patients had open surgeries and 1116 had combination of laparoscopic and open procedures. 106 patients had upper abdominal scars or extension of long vertical scars. There was no bowel injury in upper abdominal scars, only one injury noted in a transverse scar at level of umbilicus for childhood Koch's. The incidence of bowel injury at Jain point was 0.04%, 1 in 2345 cases. There were no other major complications noted. In previous upper abdominal scars, where entry is deemed more challenging by conventional non-umbilical, upper abdomen ports, namely Lee Haung and Palmer's, our study suggests Jain Point is a safe alternative being more lateral and lower at para-umbilical position.

Method for safe Verres needle entry at the umbilicus, with modification for first trocar entry to reduce the complication rate of first entry.

Background:Initial intraperitoneal access and first trocar entry are responsible for nearly half of all complications of laparoscopic surgery. The purpose of this article is to detail our method of initial intraperitoneal access with Veress needle and first trocar at the umbilicus used over the past 28 years.Patients and Methods:Since 1990, a single surgeon performed laparoscopic surgery in 7600 patients. From 1992 onward, 6975 patients underwent laparoscopic surgery. On assessment, 739 cases (10.6%) were found unsuitable for Veress needle entry at the umbilicus. The remaining, 6236, patients form the study group for this article. Every patient was operated in the identical, repetitive manner. Every detail was considered important. The method of the first trocar entry is modified to minimise complications of this manoeuvre.Results:The average time from cleaning umbilicus again to Veress needle tip in peritoneum was 1 min 40 s (25 s–7 min). Out of the 4228 patients in whom no adhesions were observed at first trocar entry (Group 1), the Veress needle insertion was successful at first attempt in 3829 (90.5%) patients, at second attempt in 322 (7.6%) and at third attempt in 30 (0.7%). In the 2008 patients with significant adhesions observed after first trocar entry (Group 2), successful insertion of the Veress needle was achieved at first attempt in 1700 (84.6%) patients, at second attempt in 182 (9%) and at third attempt in 19 (0.9%). In this group, there was one bowel injury (0.05%) and 3 (0.15%) minor vascular injuries. There was no mortality in either group. In the overall series, the Veress needle was successfully introduced in 6082 of the 6236 patients (97.5%) and 154 patients (2.4%) failed Veress needle entry. The incidence of bowel injury in the series was 0.016% and that of minor vascular injuries was 0.048%.Conclusions:Initial intraperitoneal access must be performed with utmost caution after adequate training and proctorship. This paper stresses with meticulous attention to every detail, this safe, method of initial intraperitoneal access leads to low complication rates.

A network meta-analysis of comparison of operative time and complications of laparoscopy, laparotomy, and laparoscopic-assisted vaginal hysterectomy for endometrial carcinoma.

The endometrial carcinoma (EC) is the most frequently occurring female genital cancer. The authors performed this network meta-analysis to compare operative time and the incidence of bowel injury and wound infection of 3 operative approaches (laparoscopy, laparotomy, and laparoscopic-assisted vaginal hysterectomy [LAVH]) in the treatment of EC. The Cochrane Library, PubMed, and Embase databases were searched. Randomized controlled trials (RCTs) for EC from the day of databases establishment to February 2017 were included. Direct and indirect evidences were combined to calculate the combined weighted mean difference (WMD) or odd ratio values and the surface under the cumulative ranking curve (SUCRA) value of 3 operative approaches in the treatment of EC. A total of 9 qualified RCTs were included into the study. The results showed that laparotomy had a shorter-operative time than LAVH (WMD = -40.36, 95% confidence interval = -75.03 to -2.57). However, there was no significant difference in the incidence of bowel injury and wound infection among 3 operative approaches. Besides, the SUCRA values indicated that laparotomy had the shortest operative time but the incidence of bowel injury and wound infection was relatively higher. The results from this study indicate that laparotomy had highest incidence of bowel injury and wound infection but shortest operative time among 3 operative approaches in the treatment of EC.

Laparoscopic Gynae-oncological Procedures: Lessons Learnt After a Single Institution Audit of Complications and Their Management in 567 Consecutive Patients

To retrospectively evaluate the complications of the laparoscopic pelvic surgeries and to formulate the guidelines to avoid them. Retrospective study (Canadian Classification). Advanced Laparoscopic Institute. Nine hundred and seven operated for gynecological malignancies. Laparoscopic surgeries. 567 women suffering from different pelvic conditions were studied in a period of 60months. The median age of the patient was 35 (11-80). Complications occurred in 32 patients (32/567, 5.5%). The overall incidence of urinary tract injury in all the advanced cases at our institute was 2.1% (12/567). The incidence of bowel injury at our center was 1.76%. The incidence of vascular injury at our institute was 1.76% (10/567). Laparoscopic complications are different than those seen following open surgeries. Anticipation, early recognition, and timely intervention help to reduce morbidity. Laparoscopic management of complications is possible. Formulating standard guidelines can help to avoid many such complications.

Laparoscopic Bowel Injury in Retroperitoneal Surgery: Current Incidence and Outcomes

Laparoscopic bowel injury is associated with significant morbidity and mortality when unrecognized. We assessed the incidence and outcomes of bowel injury in a contemporary cohort of patients, and reviewed the literature to examine the impact of experience with time on the incidence and consequences of bowel injury. Between 2006 and 2009 we performed 1,073 laparoscopic surgeries on the upper urinary tract, adrenal gland and retroperitoneal lymph nodes. Patients incurring bowel injury were identified retrospectively. We reviewed complications and management. In a separate literature survey we identified 21 studies on laparoscopic bowel injury from 1993 to 2009. We analyzed etiology, incidence and management. Bowel injury occurred in 8 cases (0.75%), including 6 and 2 identified intraoperatively and postoperatively, respectively. Mechanisms included Veress needle and trocar placement, dissection and thermal injury. Intraoperative management included oversewing the injury, bowel resection and observation. No patient with intraoperatively recognized bowel injury sustained a postoperative adverse event. Patients with unrecognized injury presented in delayed fashion and required multiple procedures to manage the injury. No deaths occurred in this series. Urology series of bowel injury showed a combined 0.65% incidence in 14,447 laparoscopic procedures with 46.7% of injuries unrecognized at surgery. While the incidence of bowel injury has increased with time, the percent of unrecognized bowel injury has dramatically decreased from the early (70.4%) to the more recent (36.9%) laparoscopic era. The incidence of laparoscopic bowel injury has increased in the last 17 years. However, morbidity and mortality have decreased due to immediate recognition and repair.

Major complications and outcome of diagnostic and operative transvaginal hydrolaparoscopy

Transvaginal hydrolaparoscopy (THL) has recently been developed as a less invasive alternative to conventional laparoscopy. There are some reports that described the usefulness and prognostic value of diagnostic THL in infertile women. Moreover, operative THL such as ovarian drilling for unovulatory women with polycystic ovarian syndrome (PCOS) to induce ovulation has also been found to be as effective as that by conventional laparoscopy. The risk of bowel injury and sepsis by transvaginal access with culdoscopy was higher than that with laparoscopy in the previous reports. The purpose of the present study was to examine the risk of diagnostic and operative THL according to two case studies with a literature review. The authors carried out diagnostic or operative THL in 177 infertile women, aged 22-43 years. Major complications during THL and a review of the literature were analyzed. Two cases of bowel injury were diagnosed during diagnostic THL. No complication occurred during operative THL. In total, the incidence of bowel injury was 1.1%. The injuries were diagnosed during THL and treated expectantly under strict conditions in both cases. Ten studies in the literature reported a total of 4232 procedures, including 26 bowel injuries (0.61%) and one perforation of a retroflexed uterus (0.02%). The usefulness of THL for diagnostic and operative purposes is in no doubt. However, informed consent should be obtained and vigilance before and during THL should be maintained, although it can be done on an outpatient clinic basis.

Can Bowel Injury be Prevented During Laparoscopic Surgery? A Case Report and Literature Review

Summary Objective Laparoscopic gynecologic surgery has gained worldwide popularity in the past few years, but complications of this technique do occur. Bowel injuries, which may occur as a result of the insertion of an insufflation needle or trocar, are a rare complication of laparoscopy. They are generally recognized either immediately or within a few days postoperatively. Case Report We present a case of laparoscopic perforation of the small bowel in a patient who had previously undergone surgery for an ectopic pregnancy and an adhesive ileus. After converting to a laparotomy, a jejunal loop adhesive to the anterior abdominal wall was discovered at the site of the trocar puncture. One puncture hiatus was observed and sutured. The follow-up was uneventful. Conclusion The incidence of bowel injuries occurring during access and surgical procedures significantly decreases with experience. Most importantly, if trocar injury does accidentally occur, laparoscopists must be alert to the possibility, detect it early, take proper action and manage the complications to reduce morbidity and mortality.

Sigmoid capnometry in abdominal aortic aneurysm surgery

A reply EDITOR: We thank Dr Björck for his interest in our work [1] and for giving us the opportunity both to re-emphasize points made in our paper and to correct a reference mistake in the published version. We first apologize to Dr Björck for the reference error in the third paragraph of the discussion part where reference 10 should in fact be reference 19. Furthermore, we share Dr Björck's point of view that sigmoid tonometry monitoring in surgery for aortic aneurysm is best indicated in high-risk patients. In our study, patients included were at high risk with a Parsonnet score ≥4; six of our patients had a combined history of myocardial necrosis and severe chronic obstructive bronchopulmonary disease. The surgical procedure was also particularly difficult as attested by long surgical and clamping times. All these factors explain our high frequency of ischaemic colitis. These patients were selected voluntarily because the main objective of our study was to compare the sigmoid-to-arterial PCO2 gap with the mucosal aspect as assessed by colonoscopy, which is the reference diagnostic tool of ischaemic colitis. It was interesting to observe that patients with the highest PCO2 gap were those who developed the most severe postoperative ischaemic colitis. However, our study was not powerful enough to determine the limits of the PCO2 gap, thus not allowing us to distinguish a normal from an ischaemic intestinal mucosa. In our practice, we do not argue about the sole regional PCO2 but we compare it with arterial PCO2 since tissue PCO2 concentration is dependent on the PCO2 of the perfusing arterial blood. A regional-to-arterial PCO2 gap >4 kPa provides sufficient information suggesting bowel mucosal low flow associated with O2 uptake-to-supply dependency [2], a state known as dysoxia. In this study [1], endoscopically proven ischaemic colitis was shown for PCO2 gaps >6-8 kPa. This leads us to think that a sigmoid PCO2 >15 kPa, an upper technical limit with the Tonocap® as emphasized by Björck [3], is so high, that the intestinal mucosa obviously suffers from dysoxia, preventing any doubt or interpretation. We emphasize furthermore that in our hands PrCO2 rarely goes beyond 10-12 kPa [1]. We would like to point out that trends - rather than absolute PCO2 or pHi - much better reflect any underlying regional PCO2. Therefore, a high PCO2 gap, which persists after aortic declamping without any improvement in the initial postoperative period, will alert the clinicians to perform a colonoscopy. For this reason, automatic measurements of PCO2 are certainly of great help. We agree with Dr Björck that sigmoid capnometry in aortic surgery will be mostly valuable in high-risk patients, whereas further prospective and multicentre studies are required to determine the lower limit of the PCO2 gap associated with colitis dysoxia and the influence of therapeutic correction of a high PCO2 gap on the incidence of bowel injury. G. Lebuffe B. Vallet Department of Anaesthesia and Intensive Care Medicine; University Hospital; Claude Huriez Hospital; Lille, France

Nine Cases of Bowel Injury during 3,472 Laparoscopies

The incidence and consequences of bowel injuries during laparoscopies, including the potential need for laparotomy and possible ileostomy, must be understood by both the surgeon and patient before embarking upon any surgical procedure. The risk of bowel injury has been reported to be between 0.5 and 1.8/1,000 laparoscopies; those injuries that require laparotomy have had a risk of 0.88 to 1.09/1,000 cited. Incidences may be dependent upon the practice of the surgeons involved. A review of the practice of a single gynaecologist, performing mostly advanced laparoscopic procedures in a tertiary level centre, was undertaken. All the cases over a 13-year period were reviewed and are reported. The incidence of bowel injury was 2.6/1,000 cases (0.3%), including Veress needle and trocar injuries. Repairs requiring laparotomy had an incidence of 1.4/1,000 cases. These rates may reflect the specialized referral practice of the surgeon involved and the number of advanced laparoscopic cases performed, but it also may reflect the reality of the practice of gynaecological laparoscopy over the past 13 years. Avant d’entreprendre une intervention chirurgicale quelconque, les chirurgiens et leurs patientes doivent tous deux être conscients de l’incidence et des conséquences des lésions intestinales durant la laparoscopie, y compris la possibilité de devoir pratiquer une laparotomie, et même une iléostomie. On a établi le risque de lésions intestinales liées aux laparoscopies, de 0,5 à 1,8/1000 et le taux d’atteintes nécessitant une laparotomie, de 0,88 à 1,09. Il se peut que ces cas soient liés aux pratiques des chirurgiens. Dans un centre de soins tertiaires, on a passé en revue les pratiques d’un gynécologue qui pratiquait surtout des laparoscopies avancées. On a examiné tous les cas, sur une période de 13 ans, et on les a tous inclus dans cette étude. L’incidence de lésions intestinales a été de 2,6/1000 cas (0,3 %),y compris les atteintes dues à l’aiguille de Veress et au trocart. Les réparations exigeant une laparotomie ont eu une incidence de 1,4/1000 cas. Il se peut que ces taux soient attribuables au fait que le chirurgien intervenant est un spécialiste vers qui on dirige des cas plus difficiles, et au nombre d’interventions laparoscopiques avancées qu’il pratique. Il se peut aussi qu’ils soient une réflexion de la réalité de la pratique de la laparoscopie gynécologique durant ces 13 années.

Intraperitoneal P-32 is not an effective consolidation therapy after a negative second-look laparotomy for epithelial carcinoma of the ovary

Thirty-four patients with epithelial carcinoma of the ovary were entered into a trial of adjuvant intraperitoneal P-32 following induction chemotherapy and a negative second-look laparotomy. The breakdown by initial Stage was Stage IC, 5; Stage II, 3; Stage III optimal, 22; and Stage III suboptimal, 4. Previous treatment consisted of 4–12 cycles (median 6) of cisplatin or carboplatin-based combination chemotherapy. Fifteen millicuries of P-32 were instilled via a Tenckhoff catheter placed at the time of second-look laparotomy. Because of a 22% incidence of bowel injury in the first 23 patients, the P-32 dose was reduced to 12 mCi in the last 11 patients. To date, there have been no bowel injuries at the lower dose. Eighteen of the 34 (53%) patients have relapsed with a median time to relapse of 20 months and a median follow-up for all patients of 31 months. There has been no difference in the relapse rate between a dose of 12 and 15 mCi. Intraperitoneal P-32 does not appear to reduce the relapse rate following a negative second-look laparotomy. The incidence of bowel injury is dose dependent and is higher than that seen in patients treated as an adjuvant following initial surgery without subsequent chemotherapy or second-look laparotomy.

Pelvic complications after interstitial and external beam irradiation of urologic and gynecologic malignancy.

AbstractPelvic malignancies comprise 19% and 28% of all malignancies in the female and male, respectively. The majority of gynecologic and urologie pelvic malignancies are treated with radiation therapy either alone or in combination with surgery either as definitive or palliative therapy. The pelvic organs, therefore, are at risk for injury by pelvic radiation. We have reviewed our experience and that of the literature with regard to the incidence of injury associated with pelvic irradiation and give recommendations for management. The most frequent and severe complications occur in association with cystectomy performed for carcinoma of the bladder that has failed definitive radiation therapy and in association with radiotherapeutic and surgical treatment of carcinoma of the cervix. We have found an 11% incidence of bowel injury following planned integrated preoperative radiation followed by cystectomy. In our experience, bowel and urinary complications secondary to external beam radiation or125I brachytherapy for definitive treatment of carcinoma of the prostate are very similar. The morbidity of external beam radiation therapy has been reduced using a triple‐course fractionated protocol. Rectal ulceration requiring colostomy has occurred in approximately 3% of patients treated with external beam or interstitial125I therapy. Surgical correction of rectal fistulas using vascularized flaps has been successful after125I injury but has not been possible after external beam injury. Urethral complications associated with definitive external beam radiation therapy for carcinoma of the prostate are most often associated with prior transurethral resection. They can be significantly reduced by withholding initiation of therapy for 4–6 weeks after completion of transurethral resection.