Complications of Gynecologic Laparoscopic Surgery
9/1/2009 - Robert S. Schenken, MD
Editor: Christopher M. Zahn, MD
REVISED PEARL - February 2015
Complications of gynecologic laparoscopy occur in 3 to 6 per 1000 cases, proportional to the complexity of the case. Approximately one-third to one-half occurs during initial access. There is no clear safety advantage associated with any specific entry technique (open, Veress needle, or direct trocar entry). Approximately one-fourth of all injuries and one-half of bowel injuries are recognized postoperatively. Risk factors 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 1000 laparoscopies, and may be associated with mortality. The majority occur with abdominal entry. Injuries may involve abdominal wall vessels (particularly the inferior epigastric vessels with lateral trocar placement), omentum, mesenteric vessels, middle sacral artery, iliac vessels, inferior vena cava and aorta. Delayed bleeding from trocar sites may occur when the tamponade by the trocar or pneumoperitoneum are removed. Retroperitoneal bleeding may also be masked. 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, exploration, and repair; assistance from vascular surgeons is often beneficial. Several techniques are described to control inferior epigastric injury, including balloon tamponade using a Foley catheter, suture ligation, or fascial closure devices. Cautery is ineffective.
Bowel injuries represent nearly half of all major complications; a significant proportion may be unrecognized. Approximately half are associated with abdominal entry, with the small bowel most commonly affected. The large bowl 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 for very small wounds such as puncture wounds from a Veress needle. Full-thickness injuries require repair, typically in two layers. Thermal injuries may be more difficult to recognize, and may require oversewing or resection depending on the extent of the injury. Bowel injury should be suspected if the patient’s postoperative course does not steadily improve, especially in the presence of persistent nausea, emesis, abdominal pain, distention, and fever. Free intra-abdominal air on abdominal radiography is not helpful for diagnosis. Repeat laparoscopy or laparotomy should be considered when there is a suspected bowel injury.
Bladder injury is most commonly associated with suprapubic trocar insertion or dissection at the time of hysterectomy. 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, with attention to avoiding ureteral compromise. Ureteral injuries may not be identified intraoperatively. If a ureteral injury is identified, repair may range from stenting (minor injuries) to mobilization, resection, reanastomosis, or reimplantation, depending on the extent and location of the injury.
The frequency of trocar site bowel herniation is approximately 1%. Ten mm or larger trocar sites require fascial closure; however, herniation may still occur. Wound infection is rare.
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Initial approval 9/2009; Revised 2/2015; Reaffirmed 7/2016
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