Typical risk factors for intraoperative injuries are:
- Obesity
- Altered anatomy due to previous surgeries, inflammations, and tumors
- Emergency interventions
Bowel injury 1-3%, adhesiolysis increases the risk to 3.8 – 13.6%
Possible injury patterns:
- Superficial serosal injuries
- Transmural lesions of the bowel wall
- Thermal damage to the bowel wall
- Mesenteric tears with subsequent ischemia of the dependent bowel segment
Treatment:
- Smaller lesions are sutured.
- Larger defects with poorly defined edges are sparingly excised and sutured, or a bowel wall resection with anastomosis is performed.
- Serosal defects should be generously reserosized.
Spleen injury
Injury mechanism: Traction on the colon or greater omentum during mobilization of the left flexure typically results in inferior or medially located superficial capsular lesions.
Prevention: Mobilization of the flexure with great care and under good visualization of the site. Omental adhesions to the splenic capsule should be resolved early.
Treatment:
- A spleen-preserving therapy should always be pursued, as it is associated with a lower complication rate than splenectomy.
- Electrocoagulation of capsular defects; hemostatic patches; compression and patience
- For deeper lesions, placing the spleen in a resorbable plastic mesh bag achieves continuous tissue compression.
Pancreatic injury
In case of bleeding, proceed similarly to spleen injuries.
For parenchymal injuries, drainage is recommended to divert secretions in case of a pancreatic fistula.
Ureteral injury
Prevention by:
- Preservation of Gerota's fascia
- Caution in cases of previous surgeries and inflammation- or tumor-induced adhesions with disruption of anatomical layers in the pelvis. Preoperative stenting of the ureter should be considered to facilitate its identification.
- Secure visualization of the ureter before transecting the bowel.
Treatment:
- Conservative treatment for superficial lesions.
- Incomplete injuries are stented (double-J catheter) and closed with direct suture.
- For complete transections, a watertight and tension-free anastomosis with ureteral stenting is performed.
- Extensive injuries or partial resections require complex urological reconstructions (diversion, contralateral implantation, psoas hitch procedure).
Vascular injury/bleeding
Risk constellation in cases of tumor growth beyond boundaries, inflammation, previous surgeries, or post-radiation.
Treatment: No indiscriminate attempts at oversewing but rather recognition and localization of the bleeding source, primary bleeding control through compression or clamping, informing anesthesia and providing blood products, possibly involving a vascular surgeon and preparing a vascular tray, creating anatomical overview, repair of the vascular defect.