Complications - Sigma resection, laparoscopic

Anastomotic Insufficiency:

If the water test is positive, in the case of a small and easily accessible insufficiency, an oversewing can be attempted. In this case, the creation of a protective ileostomy should be considered. In case of doubt, the re-establishment of the anastomosis should be performed.

Organ Injury:

• Injury to the Spleen: Coagulation with bipolar current, ultrasonic scissors, possibly applying a hemostatic agent or fibrin glue. A laparotomy is only necessary in exceptional cases.
• Injury to the Pancreas: In case of bleeding, proceed similarly to spleen injuries. Here, the placement of an Easy-Flow drainage is recommended to drain secretions in case of a pancreatic fistula.
• Injuries to the Intestine: With appropriate expertise, laparoscopic oversewing is possible.
• Thermal damage using bipolar scissors or ultrasonic dissector, especially in the area of the left flexure.
• Vascular Injury: Bleeding from smaller vessels can usually be controlled using bipolar current or ultrasonic scissors and possibly by clipping.
  Injuries to large vessels (e.g., aorta, vena cava) require immediate laparotomy.
• Injury to the Ureter: In case of superficial injuries, laparoscopic oversewing can be attempted; otherwise, a small laparotomy directly over the injury site is recommended to suture the ureter under direct vision. In any case, the insertion of a ureteral stent is indicated.
• Injury to the Vagina: Accidental entrapment of the vagina during the use of the stapling device can lead to the formation of rectovaginal fistulas.

It should be noted that in situations without sufficient anatomical overview, a laparotomy is indicated.

Anastomotic Insufficiency:
Any deviation from the normal postoperative course should suggest anastomotic insufficiency. In cases of justified suspicion, timely diagnostic laparoscopy/laparotomy should be pursued. Small insufficiencies without generalized peritonitis can be sutured laparoscopically. However, in this case, the creation of a protective ileostomy is mandatory.
In cases of larger anastomotic insufficiencies with generalized peritonitis, discontinuity resection is indicated. Furthermore, intensive medical care with appropriate treatment of peritonitis or sepsis is carried out.

Intra-abdominal Abscess:
Smaller abscesses without clinical or paraclinical signs of infection, diagnosed incidentally, should be observed over time and do not necessarily require surgical or interventional therapy. However, intra-abdominal abscesses can be indirect signs of anastomotic insufficiency. Therefore, in the presence of intra-abdominal abscesses, an endoscopic exclusion of suture leakage is necessary.
In the presence of signs of infection, interventional drainage of the abscess is the method of choice. This can be performed sonographically or CT-guided, depending on location and expertise.
In cases of progressive sepsis, in addition to supportive therapy (intensive care, antibiotic therapy), surgical source control should be pursued.

Bleeding:
Postoperatively, there may be a perianal discharge of small amounts of older blood. In cases of increasing perianal discharge of blood or the occurrence of fresh perianal bleeding, an endoscopic examination should be performed. If bleeding is present in the area of the anastomosis, primary endoscopic hemostasis using a clip is indicated. Only in exceptional cases is a revision surgery necessary. Close monitoring of plasma hemoglobin and coagulation status is mandatory.
In cases of bloody secretion through the indwelling drain, monitoring of hemoglobin and coagulation is also indicated. Depending on the extent of bleeding, the clinical condition, and the hemoglobin level, transfusion of red blood cell concentrates or surgical revision is indicated.

Intestinal Atony:
Postoperative intestinal atony is prevented by the routine administration of parasympathomimetics. Additionally, a rapid dietary build-up combined with quick mobilization of patients promotes bowel activity.