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9/1/2009

Complications of Gynecologic Laparoscopic Surgery

Complications of gynecologic laparoscopy occur in 3 to 6 per 1000 cases.  Approximately one-third to one-half of complications occur during initial access. Evidence is insufficient to support the use of one laparoscopic entry technique over another, although direct trocar entry seems to have lower rates of failed entry than the Veress needle. Approximately one-fourth of all injuries are recognized postoperatively.  Risk factors for injury include prior abdominal surgery, endometriosis, pelvic infection, bowel distention, large pelvic masses, adhesions, cardiopulmonary disease and diaphragmatic hernias.

Complications related to the pneumoperitoneum include subcutaneous emphysema and, less commonly, pneumomediastinum and pneumothorax.  Subcutaneous emphysema is usually self-limited.  Gas embolism and cardiac arrhythmia from excessive absorption of CO2 are extremely rare, but potentially fatal.

The reported rate of vascular injury is 0.1 to 6.4 per 1,000 laparoscopies, with the majority occurring during abdominal entry.  Injuries may involve abdominal wall, intraperitoneal, or retroperitoneal vessels. Delayed bleeding from trocar sites may occur when the tamponade by the trocar or pneumoperitoneum are removed.  Clinically stable hematomas may be observed; expanding hematomas require exploration and suture ligation.  Minimal bleeding from omental and pelvic vessels may be controlled with fulguration or suturing.  Injury to major vessels requires the initial application of pressure, abdominal exploration, and repair; assistance from vascular surgeons is recommended.  Several techniques are described to control inferior epigastric injury, including balloon tamponade using a Foley catheter, suture ligation, or fascial closure devices. 

Bowel injuries represent nearly half of all major complications and are often unrecognized.  The small bowel is most commonly affected with entry injuries.  The large bowel is most commonly injured after entry.  Perforation of the stomach may occur with an upper abdominal or umbilical site insertion, especially if the stomach is not decompressed.  Management of an intraoperatively recognized injury may involve expectant management or suture of Veress injuries.  Larger injuries require repair, typically in two layers.  Thermal injuries may be more difficult to recognize, and diagnosis may lag by several days. Thermal injury repair may require oversewing or resection depending on the extent of the injury.  Bowel injury should be suspected in the presence of persistent nausea, emesis, abdominal pain, distention, or fever.  When bowel injury is likely, surgical exploration should be performed.

Bladder injury is most commonly associated with suprapubic trocar insertion or dissection at the time of hysterectomy, typically at the bladder dome.  Signs of a bladder injury include blood and gas in the Foley bag.  Injuries may be confirmed by retrograde filling of the bladder with dye.  Small bladder injuries may be managed expectantly with bladder drainage; larger and thermal-associated injuries require layered repair.  Ureteral injuries may not be identified intraoperatively.  Ureteral injury may be stenting or surgical repair depending on severity and location of injury.

The frequency of trocar site bowel herniation is approximately 1%.  Ten millimeter or larger trocar sites require fascial closure; however, herniation may still occur with smaller trocar sites.  Wound infection is rare and risk is further reduced with appropriate use of prophylactic antibiotics when indicated, sterile technique, and use of bags during specimen removal via a trochar site.

Further Reading:

Makai G, Isaacson K. Complications of gynecologic laparoscopy. Clin Obstet Gynecol. 2009 Sep;52(3):401-11. doi: 10.1097/GRF.0b013e3181b0c080.

Jiang X, Anderson C, Schnatz PF. The safety of direct trocar versus Veress needle for laparoscopic entry: a meta-analysis of randomized clinical trials. J Laparoendosc Adv Surg Tech A. 2012 May;22(4):362-70. doi: 10.1089/lap.2011.0432. Epub 2012 Mar 16.

Glaser L, Milad M. Bowel and Bladder Injury Repair and Follow-up After Gynecologic Surgery. Obstetrics & Gynecology 133(2):p 313-322, February 2019.

Ahmad G, Baker J, Finnerty J, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2019 Jan 18;1(1):CD006583. doi: 10.1002/14651858.CD006583.pub5. PMID: 30657163; PMCID: PMC6353066.

Initial approval September 2009; Revised February 2015; Reaffirmed November 2017; Reaffirmed July 2016; Revised May 2019, Revised March 2022, Reaffirmed March 2024

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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