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9/1/2009

Complications of Gynecologic Laparoscopic Surgery

Author: Robert S. Schenken, MD

Editor: Abimbola O. Famuyide MBBS, FRCOG, FACOG

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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 are multiple approaches to achieve intraabominal entry. Although there seems to be no significant outcome differences, there may be an increase incidence of minor complications such as subcutaneous emphysema, preperitoneal insufflation, omental injury, and omental emphysema  with the Veress needle technique. The open technique is also associated with successful entry more often.  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 1,000 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 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 for very small injuries 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.  When bowel injury is likely, repeat laparoscopy or laparotomy should be performed without delay.

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.

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.

Shirk GJ, Johns A, Redwine DB. Complications of laparoscopic surgery: How to avoid them and how to repair them. J Minim Invasive Gynecol. 2006 Jul-Aug;13(4):352-9; quiz 360-1.

 

Initial approval September 2009 ; Revised February 2015; Reaffirmed November 2017; Reaffirmed  July 2016; Revised May 2019

 

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