Large Bowel Injury Research Articles

Blunt abdominal aortic injury: a Western Trauma Association multicenter study.

Blunt abdominal aortic injury (BAAI) is a rare injury. The objective of the current study was to examine the presentation and management of BAAI at a multi-institutional level. The Western Trauma Association Multi-Center Trials conducted a study of BAAI from 1996 to 2011. Data collected included demographics, injury mechanism, associated injuries, interventions, and complications. Of 392,315 blunt trauma patients, 113 (0.03%) presented with BAAI at 12 major trauma centers (67% male; median age, 38 years; range, 6-88; median Injury Severity Score [ISS], 34; range, 16-75). The leading cause of injury was motor vehicle collisions (60%). Hypotension was documented in 47% of the cases. The most commonly associated injuries were spine fractures (44%) and pneumothorax/hemothorax (42%). Solid organ, small bowel, and large bowel injuries occurred in 38%, 35%, and 28% respectively. BAAI presented as free aortic rupture (32%), pseudoaneurysm (16%), and injuries without aortic external contour abnormality on computed tomography such as large intimal flaps (34%) or intimal tears (18%). Open and endovascular repairs were undertaken as first-choice therapy in 43% and 15% of cases, respectively. Choice of management varied by type of BAAI: 89% of intimal tears were managed nonoperatively, and 96% of aortic ruptures were treated with open repair. Overall mortality was 39%, the majority (68%) occurring in the first 24 hours because of hemorrhage or cardiac arrest. The highest mortality was associated with Zone II aortic ruptures (92%). Follow-up was documented in 38% of live discharges. This is the largest BAAI series reported to date. BAAI presents as a spectrum of injury ranging from minimal aortic injury to aortic rupture. Nonoperative management is successful in uncomplicated cases without external aortic contour abnormality on computed tomography. Highest mortality occurred in free aortic ruptures, suggesting that alternative measures of early noncompressible torso hemorrhage control are warranted. Epidemiologic study, level III; therapeutic study, level IV.

Large bowel injuries during gynecological laparoscopy.

Laparoscopy is one of the most frequently preferred surgical options in gynecological surgery and has advantages over laparotomy, including smaller surgical scars, faster recovery, less pain and earlier return of bowel functions. Generally, it is also accepted as safe and effective and patients tolerate it well. However, it is still an intra-abdominal procedure and has the similar potential risks of laparotomy, including injury of a vital structure, bleeding and infection. Besides the well-known risks of open surgery, laparoscopy also has its own unique risks related to abdominal access methods, pneumoperitoneum created to provide adequate operative space and the energy modalities used during the procedures. Bowel, bladder or major blood vessel injuries and passage of gas into the intravascular space may result from laparoscopic surgical technique. In addition, the risks of aspiration, respiratory dysfunction and cardiovascular dysfunction increase during laparoscopy. Large bowel injuries during laparoscopy are serious complications because 50% of bowel injuries and 60% of visceral injuries are undiagnosed at the time of primary surgery. A missed or delayed diagnosis increases the risk of bowel perforation and consequently sepsis and even death. In this paper, we aim to focus on large bowel injuries that happen during gynecological laparoscopy and review their diagnostic and management options.

Significance of Computed Tomography Finding of Intra‐Abdominal Free Fluid Without Solid Organ Injury after Blunt Abdominal Trauma: Time for Laparotomy on Demand

Optimal management of patients with intra-abdominal free fluid found on computed tomography (CT) scan without solid organ injury remains controversial. The purpose of this study was to determine the significance of CT scan findings of free fluid in the management of blunt abdominal trauma patients who otherwise have no indications for laparotomy. During the 3-year study period, all patients presenting with blunt abdominal trauma who underwent abdominal CT examination were retrospectively reviewed. All hemodynamically stable patients who presented with abdominal free fluid without solid organ injury on CT scan were analyzed for radiological interpretation, clinical management, operative findings, and outcome. A total of 122 patients were included in the study, 91 % of whom were males. The mean age of the patients was 33 ± 12 years. A total of 34 patients underwent exploratory laparotomy, 31 of whom had therapeutic interventions. Small bowel injuries were found in 12 patients, large bowel injuries in ten, and mesenteric injuries in seven patients. One patient had combined small and large bowel injury, and one had traumatic gangrenous appendix. In the remaining three patients, laparotomy was non-therapeutic. A total of 36 patients had associated pelvic fractures and 33 had multiple lumbar transverse process fractures. Detection of intra-peritoneal fluid by CT scan is inaccurate for prediction of bowel injury or need for surgery. However, the correlation between CT scan findings and clinical course is important for optimal diagnosis of bowel and mesenteric injuries.

Erratum to: Incidence, risk, management, and outcomes of iatrogenic full-thickness large bowel injury associated with 56,882 colonoscopies in 14 Lithuanian hospitals

Erratum to: Incidence, risk, management, and outcomes of iatrogenic full-thickness large bowel injury associated with 56,882 colonoscopies in 14 Lithuanian hospitals

Reply to Letter re: Non-target Embolization or Local Effect of Infarction?

Dear Sir, We thank the authors for their interest in our case report. The cause of perforation of transverse colon 3 months after uterine artery embolization cannot be established for certain, but the fact that the perforated colon is stuck down to the large necrotic fundal fibroid suggest that direct, local inflammatory involvement is likely. Smallor large-bowel injury from uterine artery embolization is surprisingly rare even for large fibroid uterus but a few cases have been reported previously [1, 2]. We maintain that the risk of such complication is higher if a large serosal fibroid on the fundus of uterus is present, as in this case. If there is colonic infarction at the time of uterine artery embolization, it is not clear why the patient would have bowel perforation 3 months later, when there is a relative absence of symptoms of ischaemic bowel injury in the interim. Finally, we are not advocating early laparotomy for all cases but where there is sufficient clinical concern and risk factors for bowel injury are present, even if imaging is normal, the risks of laparotomy may be outweighed by the benefits. As in the present case, where irrespective of the mechanism of large bowel injury, there seems to be no other way of treating such a catastrophic complication.

CO2 Laparoskopisi Sırasında İntraoperatif Barsak Yaralanmalarının Tanısı İçin Rektal Kateterizasyon: Deneysel Bir Çalışma

Only 35.7% of the bowel injuries occurred during CO2 laparoscopy is noticeable intra-operatively. Although air insufflations into the rectum is suggested to identify this injuries, increased risk of contamination of the abdominal cavity by bowel contents makes this procedure abolished. In this experimental study we aimed to evaluate the role of rectal catheterization in the diagnosis of small or unnoticed injuries of the intestines during CO2 laparoscopy. Pneumoperitoneum was created at a pressure level of 12 mmHg in seven white, New Zealand female rabbits. An eight G urinary catheter connected tightly to a urine bag was introduced into the rectum. The descending colon was perforated with the tip of a 21 G needle. Timely CO2 use and the change of urine bag volume were recorded. Methylene blue was used to demonstrate flow into the bag. Significant amounts of gas accumulated in the urinary bag following the perforation of the large bowel and methylene blue flowed into the catheter. Thus, transanal placement of a catheter connected to a urinary bag may help in the diagnosis of small or unnoticed large bowel injuries during laparoscopy.

Incidence, risk, management, and outcomes of iatrogenic full-thickness large bowel injury associated with 56,882 colonoscopies in 14 Lithuanian hospitals

The primary goal of this hospital-based retrospective multicenter case series study was to determine the incidence of large bowel full-thickness injury associated with colonoscopy in Lithuania. We assessed characteristics of patients who were treated as a result of this complication; management and outcomes were the secondary goals of this study. The medical records of patients with iatrogenic large bowel perforations resulting from colonoscopy within the period January 1, 2007, to December 31, 2011, were retrospectively reviewed. Representatives of 14 Lithuanian public and private hospitals participated in the survey. A total of 56,882 colonoscopies were performed. Forty patients (23 female and 17 male patients) were reported to have iatrogenic full-thickness large bowel injury. Diagnostic and therapeutic colonoscopies resulted in perforation for 28 of 49,795 patients and 12 of 7,087 patients, respectively. A mean age of 70 years and a female preponderance for this complication was revealed. Sigmoid colon and rectosigmoid junction was perforated in 28 patients. All patients underwent surgical management, either primary repair (70.0 %) or bowel resection (30.0 %). Postoperative complications were diagnosed in 15 patients. Immediate treatment resulted in fewer intestinal resections and shorter hospital stays (p < 0.05). Smoking [odds ratio (OR) 14.4, 95 % confidence interval (CI) 1.16-179.8] and a large size perforation site (15 ± 10 vs. 8 ± 5 mm; OR 1.19, 95 % CI 1.03-1.38) were risk factors for developing a postoperative complication after curative surgery. Six patients died. All deaths were related to diagnostic colonoscopy. Total incidence of large bowel full-thickness injury in Lithuanian hospitals is 0.07 %. Incidence of this complication after diagnostic and therapeutic colonoscopies is 0.056 and 0.169 %, respectively. The most common site of perforation is sigmoid colon and rectosigmoid junction, at 70 %. Risk rises when colonoscopy is performed in low-volume practice centers. Urgent surgical management resulted in overall mortality rate of 15.0 % and morbidity of 37.5 %.

Management of Large Bowel Injury During Laparoscopic Surgery

Management of Large Bowel Injury During Laparoscopic Surgery

Factors associated with complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy

To identify risk factors for complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy (LAVH). Retrospective study. Tertiary referral hospital. All 2012 consecutive women who underwent LAVH for non-malignant diseases in a single institution. Retrospective study. Operative complications and conversion to laparotomy. Most of the LAVHs were successful, but conversion to laparotomy was required in 97 women (4.8%) because of pelvic adhesion (n= 71), large uterine size (n= 18) or bowel injury (n= 8). There were 45 women (2.2%) with complications (bladder injury, 26; bowel injury, 9; vascular injury, 9; and ureteral injury, 1). A history of previous cesarean section (twice or more) was a significant risk factor for complications [odds ratio (OR) 3.38]. A body mass index ≥30 kg/m(2) (OR 2.98), history of previous myomectomy (OR 6.19) and uterine weight ≥500 g (OR 3.24) independently influenced the risk of conversion to laparotomy. Risk factors identified in this study include a history of previous cesarean section (twice or more) and myomectomy, body mass index ≥30 kg/m(2) and uterine weight ≥500 g. The findings may be useful in counseling women preoperatively about the potential complications of LAVH.

Laparoendoscopic single site surgery in urology: A single centre experience

OBJECTIVE:To analyze our experience of 87 cases with single port surgery, which is also known as laparoendoscopic single site surgery (LESS).MATERIALS AND METHODS:Case records of all LESS procedures performed between December 2007 and June 2010 were analysed. The procedures performed were donor nephrectomy (n=45), simple nephrectomy (n=27), radical nephrectomy (n=5), pyeloplasty (n=9), and ureteroneocystostomy (n=1). Parameters analysed were operating room (OR) time, estimated blood loss (EBL), visual analogue score (VAS), and complications in all patients undergoing LESS procedure and additionally, warm ischaemia time (WIT) and graft outcome in patients undergoing LESS donor nephrectomy. In reconstructive procedures, the functional assessment was performed with a diuretic renogram at 6 months.RESULTS:In LESS donor nephrectomy, the mean WIT was 6.9 ± 1.9 min. Mean serum creatinine in recipients at 1 month was 0.96 ± 0.21 mg%. We encountered one instance each of renal artery injury, renal vein injury, large bowel injury, minor cortical laceration at the upper pole and two instances of diaphragmatic injury. In LESS simple nephrectomy, the average OR time was 148.7 ± 52.2 min and hospital stay was 3.7 ± 1.2 days. There was one instance of large bowel injury during specimen retrieval. In LESS radical nephrectomy, the average OR time was 202.5 ± 35.7 min and average hospital stay was 4.2 ± 1.3 days. 6 patients of LESS pyeloplasty completed follow up with a diuretic renogram showing a good drainage. LESS ureteroneocystostomy could also be performed successfully without any complications.CONCLUSION:LESS surgery can be accomplished safely in nephrectomy and reconstructive procedures such as pyeloplasty and ureteroneocystostomy with equivalent outcomes as standard laparoscopy and with added benefits of cosmesis and quicker convalescence. LESS donor nephrectomy is a technically feasible procedure; current status of procedure needs to be proved with randomised controlled studies.

Inadvertent suprapubic gastrostomy: Report of a unique complication of blind percutaneous suprapubic trocar cystostomy

Emergency percutaneous trocar suprapubic cystostomy is a common surgical procedure for acute urinary retention. Although uncommon it can be associated with a few complications. The most dangerous complication is iatrogenic bowel injury. Literature shows reported cases of small and large bowel injuries. We report a case of inadvertent placement of suprapubic catheter into a dilated and ptotic stomach. This is the first reported case of this complication of suprapubic cystostomy.

Management of Gunshot Pelvic Fractures With Bowel Injury: Is Fracture Debridement Necessary?

Low-velocity pelvic gunshot injuries occur commonly in urban trauma centers, occasionally involving concomitant intestinal viscus injury leading to potential fracture site contamination. Surgical debridement of the fractures may be necessary to prevent osteomyelitis, although not routinely performed in many centers. The purpose of this study was to determine whether fracture debridement should be done to prevent osteomyelitis in these injuries. A 5-year retrospective review of all patients older than 12 years with low-velocity gunshot pelvic fractures was performed at an urban Level I trauma center. Medical records and radiographs/computed tomographic scans were reviewed, and data regarding fracture location, concomitant intestinal viscus injury, orthopedic surgical intervention, antibiotic treatment, and bone and/or joint infection were recorded. Of a total of 103 patients identified, 19 had expired within 48 hours and were excluded, resulting in a total of 84 study subjects for review. Fifty of 84 patients (59%) had a perforated viscus with 31 large bowel injuries and 30 small bowel injuries. Eighteen patients (21%) had intra-articular fractures, 15 of which involved the hip joint. Orthopedic surgical fracture debridement was done only in intra-articular fractures with retained bullet fragments (seven cases). Deep infection occurred in one patient with a missile injury to the hip joint with concomitant intestinal spillage. Immediate joint debridement was performed in this case, but successful missile fragment removal was not achieved until the second debridement after 48 hours. No infections occurred in any extra-articular fractures, regardless of the presence of intestinal spillage. Extra-articular gunshot pelvic fractures do not require formal orthopedic fracture debridement even in cases with concomitant intestinal viscus injury. However, debridement with bullet removal should be done in cases with intra-articular involvement, particularly if there are retained bullet fragments in the joint, to prevent deep infection.

Current management of large bowel injuries and factors influencing outcome

Background Colonic and intra-peritoneal rectal injuries may be managed by primary repair and extra-peritoneal rectal injuries by diverting colostomy. This study was undertaken to document our experience with this approach and to identify factors which might impact on outcome. Patients and methods Prospective study of all patients treated for colon and rectal injuries in one surgical ward at King Edward VIII hospital, Durban, over a 7-year period (1998–2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented. Results Of 488 patients undergoing laparotomy, 177 (36%) had injuries to the colon and rectum with age 29.8 ± 10.9 years. Injury mechanisms were firearms (118) stabs (54) and blunt trauma (5). Delay before laparotomy was 10 ± 9.3 h. Complication and mortality rates were 36% and 17%, respectively. 68 patients (38%) required ICU management. Shock on admission and increased transfusion requirements were associated with a significantly increased mortality. Patients with delay ≤12 h before laparotomy had a higher mortality rate than those with delay >12 h. The mortality rate increased with the number of associated injuries and it was higher the higher the Injury Severity Score (ISS); it was similar for stabs, firearms and blunt trauma. Hospital stay was 9.5 ± 9.2 days. Conclusion We reaffirm that primary repair is appropriate for colonic and intra-peritoneal rectal injuries and that extra-peritoneal rectal injuries require diverting colostomy. Shock on admission, increased blood transfusion requirements, associated organ injury and severity of the injury were associated with high mortality.

Evaluation of the Outcomes of Electrosurgical Induced Bowel Injury Treated with Tissue Glue/Sealant Versus Sutured Repair in a Rabbit Model

Bowel injury is an uncommon, although potentially devastating, intraoperative laparoscopic complication. Questions have been raised about the possible use of a tissue adhesive to repair injured bowel. We compared glued repair and sutured repair of both large bowel (LB) and small bowel (SB) electrosurgical injuries in a rabbit model. Pneumoperitoneum was obtained, and four laparoscopic ports were placed in each of 48 New Zealand rabbits. The hook electrode was used in a specified manner to create an equal number of uniform full-thickness injuries to either the SB or the LB. Laparoscopic repair was performed with a 3-0 silk Lembert suture (LS), fibrin glue (FG), or BioGlue (BG), or repair was not performed (i.e., no repair, NR); the animals were monitored for 3 weeks. Adverse clinical outcomes and findings at laparotomy were recorded. Pathologic assessment included an objective scaled evaluation of the intensity of the inflammatory response and degree of healing. In the SB injury group, deteriorating clinical condition necessitated early euthanasia in one animal repaired with FG, one animal repaired with BG, and two animals with NR. LS repair animals had no adverse clinical outcomes. The LB injury group had no adverse clinical outcomes regardless of the method of repair, including the control group. Of the animals that survived for 3 weeks, the animals repaired with BG had more intraabdominal adhesions (100%) than LS (33%), FG (55%), and NR (50%) (p = 0.001). The pathologic assessment revealed that BG induced a more intense inflammatory response (p < 0.05). In the rabbit, suture repair of an electrosurgical SB injury appears to have improved outcomes when compared with a glued repair. In contrast, LB injury responded well to any form of treatment. The data suggest that suture is superior to biological glues when dealing with a laparoscopic electrosurgical bowel injury.

Renal Gunshot Wounds: Clinical Management and Outcome

To analyze our experience with renal gunshot wounds (GSW). We analyzed our prospective trauma database for patients with renal GSW. Two hundred one patients (206 renal units) with renal GSW were collected from our database. Preoperative imaging (1-shot intravenous pyelogram, dedicated intravenous pyelogram, or computed tomography) was performed in 68.7% (n = 140). Gross or microscopic (>5 red blood cell/high power field) hematuria was present in 88.7%. Injury to other organs was present in 96.5% (194 of 201), with >1 organ involved in 74.6% (other than kidney). The liver was the most commonly injured organ. Using the American Association for the Surgery of Trauma grading system, there were 46 grade 1 (G1), 21 G2, 62 G3, 51 G4, and 26 G5 injuries. The trend to observe without renal exploration has not changed significantly during the past three decades (1978-1989 = 32.8%, 1990-1999 = 39%, 2000-2007 = 30.4%). Ninety-five renal units (excluding nephrectomy) underwent repair with associated small or large bowel injuries without any known complications, including 14 patients with mesh used during renal repair. The renal salvage rate was 85.4% (n = 176 of 206) with two delayed nephrectomy procedures for persistent bleeding after initial repair. The total number of nephrectomy procedures was 30 of 206 renal units. Postoperative imaging was obtained in 32.8% (55 of 201) patients, and there were no known cases of postinjury hypertension. Overall survival was 90.6% (182 of 201), with 2 intraoperative and 17 postoperative deaths. There were no postoperative infections related to renal reconstruction. Isolation of renal vessels was obtained in all patients before opening Gerota's fascia with no deaths secondary to urologic intervention. Selective observation and various operative techniques can yield high renal salvage rates approximating 85% after GSW.

One-Hundred and Thirty Small- and Large-Bowel Injuries Associated with Gynecologic Laparoscopic Operations

One-hundred and thirty cases of laparoscopically associated intestinal perforations are reported in this paper. This series consisted of 81 small intestinal and 49 large intestinal injuries. Seventy-seven percent of the former and 41% of the latter were entry-related, that is, trocar-associated injuries, whereas 59% of large bowel and 23% of small bowel injuries were associated with the operative procedure. The majority of injuries were diagnosed postoperatively, and 70% of small bowel and 51% of large bowel perforations were diagnosed late. The most useful laboratory studies leading to the correct diagnosis were the computed axial tomography scan with contrast and the complete blood count with differential. Many of the patients experienced unnecessary delays before an exploratory laparotomy procedure was undertaken. Because of the delay, sepsis intervened in every colonic perforation, and in 50% of small bowel perforations when the diagnosis was delayed >48 hours. Many of the patients had collateral comp...

Optical-Access Visual Obturator Trocar Entry into Desufflated Abdomen During Laparoscopy: Assessment After 96 Cases

The introduction of optical-access laparoscopic trocars was met with enthusiasm and the impression that these devices provide safer access with decreased complication rates. However, serious complications have been reported. We retrospectively reviewed our first 96 consecutive cases (17 radical prostatectomies, 2 sacrocolpopexies, 6 adrenalectomies, and 71 renal procedures), performed between October 2001 and April 2003, of optical-access laparoscopic trocar placement as initial entry into the desufflated abdomen. After creating a 12-mm periumbilical or lateral-rectus incision, the 12-mm Endopath Bladeless visual obturator trocar (Ethicon Endosurgery, Cincinnati, OH) was inserted into the peritoneum while carefully observing the separation of the layers of fascia, muscle, and peritoneum. There were no vascular injuries. However, we observed 2 (2.1%) large-bowel injuries: a seromuscular injury and a through-and-through enterotomy of the mid-descending colon. In both cases, the visual obturator was placed lateral to the left rectus muscle, and the large colon was noted to be adherent to the anterior abdominal wall. The bowel injuries were repaired in two layers (running 3-0 Vicryl for the mucosa and 3-0 silk for the seromuscular layer). The operations were completed without open conversion and with uneventful recovery. Direct placement of an optical-access visual obturator trocar into the desufflated abdomen carries the potential for significant injury. Our current practice is to place the visual trocar after Veress-needle peritoneal insufflation.

The Role of Intraoperative Proctosigmoidoscopy in Laparoscopic Pelvic Surgery

Study Objective To report the outcome of rigid sigmoidoscopy during operative laparoscopy in patients at high risk for rectosigmoid and large bowel injury. Design Prospective patient database with retrospective chart review (Canadian Task Force classification II-3). Setting Referral practice and tertiary medical center. Patients Two hundred sixty-two women with rectosigmoid endometriosis and adhesions. Interventions Rigid sigmoidoscopy during laparoscopy. At the end of surgery, proctosigmoidoscopy was performed to evaluate intraluminal abnormality or rectosigmoid injury. The pelvis was then filled with isotonic fluid to observe laparoscopically for air leakage. Measurements and Main Results Sigmoidoscopy was performed due to a lesion involving the rectum or sigmoid in 60.7%, large bowel in 11.1%, and posterior cul-de-sac in 28.2% of patients. During laparoscopy, endometriosis was found in 30.5%, adhesions in 20.2%, and both in 43.5%. Four women (1.5%) had bowel injury identified during sigmoidoscopy; all bowel injuries were treated by intracorporeal laparoscopic suturing. One incomplete repair was detected by sigmoidoscopy. In one woman (0.4%) a rectal polyp was detected. Conclusion Bowel injury is one of the most serious complications of laparoscopy. Early detection and prompt intraoperative management are essential to prevent a potentially catastrophic outcome. Sigmoidoscopy is a relatively easy procedure and aids during laparoscopy in the diagnosis of bowel perforation and in assessment of bowel wall invasion and potential stricture caused by endometriosis. It is a safe procedure even when performed immediately after extensive laparoscopic surgical treatment of rectosigmoid endometriosis and adhesions.

Fundamentals of Peritoneal Access

The art of laparoscopic surgery is anticipating requirements for completing contemplated procedures. Patient safety and technical efficacy are inextricably linked to how carefully the patient is evaluated preoperatively. Choosing the best method for accessing the peritoneal cavity depends on patient phenotype, abdominal wall morphology, and anatomic configuration of underlying vital anatomy. Since no particular method is necessarily the safest approach for every patient, it is incumbent on every laparoscopic surgeon to be well-versed in alternative procedures for insufflation and entry into the peritoneal cavity. The laparoscopic surgeon must be forever mindful that most life-threatening surgical accidents to small and large bowel as well as to retroperitoneal vessels occur during insertion of the Veress needle and primary cannula. Review of a nationwide analysis of access-related complications in Finland revealed 256 complications during more than 70,000 laparoscopic procedures performed over 4 years; the frequency of bowel perforation was 0.1%, including 20 small and 16 large bowel injuries caused by either an umbilical trocar or Veress needle. 1 Injury to iliac vessels and aorta occurred in five patients. Complications during 1033 laparoscopic surgeries performed at one center over 6 years had an overall rate of 3%, of which 23.5% occurred during Veress needle or first trocar insertion. 2 A group in Switzerland prospectively followed 14,243 patients over 2 years and found 22 trocar and 4 Veress needle injuries (0.18%), including 19 injuries to large and

Laparoscopic Bowel Injuries: Forty Litigated Gynaecological Cases in Canada

Objective: To review the clinical circumstances and the clinical and legal outcomes of 40 laparoscopic bowel injuries that were litigated in Canada.Design: Retrospective review of 40 litigated cases of laparoscopic bowel injury, from 1990 to the end of 1998, provided by the Canadian Medical Protective Association (CMPA).Measurements and Main Results: The laparoscopy was performed for diagnosis (n = 13), tubal occlusion (n = 15), and as an operative therapeutic procedure (n = 12). Injuries were related to the initial peritoneal entry in 22 (55%) women (19 during the closed technique and 3 with the open technique). Of these, the injury was due to the primary trocar (n = 17), scalpel (n = 1), Veress needle (n = 1),Veress needle or undetermined (n = 2), and fascial suture (n = 1). The small bowel was injured in 9 of 11 entries by the trocar during diagnostic laparoscopy and in 6 of 14 tubal occlusions. Five injuries in the tubal occlusion group were attributed to “cautery.” The injury was recognized intra-operatively in 55% of cases. The clinical outcome was uncomplicated in 85% of patients. There was no difference in clinical outcome between small versus large bowel injuries and between intra-operative versus post-operative diagnosis of the injury. The litigation outcome was favourable to the physician in 75% of cases. Recognition was delayed in 45% of cases and this was associated with 67% of the litigation outcomes unfavourable to physicians.Conclusions: (1) The initial laparoscopic entry into the peritoneal cavity remains the major contributor to bowel injury in laparoscopic surgery. (2) The open (Hasson) technique does not prevent bowel injuries. (3) Delayed recognition was a major factor in assessment of liability.