Typical risk factors for intraoperative injuries are:
- Obesity
- Altered anatomy due to previous surgeries, inflammations, and tumors
- Emergency interventions
Anastomotic insufficiency
If the water leakage test is positive, an oversewing can be attempted in the case of a small and easily accessible insufficiency. In this case, the creation of a protective ileostomy should be considered. If in doubt, a new anastomosis should be performed.
Bowel injury 1-3%, an adhesiolysis increases the risk to 3.8–13.6%
Possible injury patterns:
- Superficial serosal injuries
- Transmural lesions of the intestinal wall
- Thermal damage to the intestinal wall using bipolar scissors or ultrasonic dissector, especially in the area of the left flexure.
- Mesenteric tears with subsequent ischemia of the dependent intestinal segment
Prevention by:
- In recurrent procedures, incision as far away from the scar as possible
- Open insertion of the first trocar
- Grasping the intestine as much as possible in the area of the taeniae or appendices epiploicae only with atraumatic grasping forceps under vision.
- No blind coagulations, careful handling with the tip of ultrasonic scissors, which can cause thermal damage even seconds after active use.
Therapy:
- With appropriate expertise, laparoscopic oversewing is possible.
- Larger defects usually require conversion with resection near the intestinal wall and anastomosis.
Spleen injury
Injury mechanism:
Due to traction on the colon or greater omentum during mobilization of the left flexure, inferior or medial superficial capsular lesions typically occur.
Prevention:
Mobilization of the flexure with great care and under good setting of the situs. Omental adhesions to the splenic capsule should be released early. Laparoscopic operations reduce the number of splenic injuries.
Therapy:
- A spleen-preserving therapy should always be aimed for, as it is associated with a lower complication rate than splenectomy.
- Coagulation with bipolar current, if necessary, apply hemostatic agent (see Medical Equipment tab) or fibrin glue. A laparotomy is only necessary in exceptional cases.
Pancreatic injury
In case of bleeding, proceed similarly to splenic injuries.
In case of parenchymal injuries, the placement of a drain is recommended to be able to drain the secretion in case of a pancreatic fistula.
Ureteral injury
Prevention by:
- Preservation of the Gerota's fascia
- Secure identification of the ureter
- Caution in previous surgeries and inflammation- or tumor-related adhesions with disruption of anatomical layers in the pelvis. Preoperative stenting of the ureter should be considered to facilitate its identification.
Therapy:
- In superficial injuries, laparoscopic oversewing can be attempted; otherwise, a small laparotomy in direct projection onto the injury site is recommended to openly suture the ureter under vision. In any case, the insertion of a ureteral stent is indicated.
- Extensive injuries or partial resections require complex urological reconstructions (diversion, contralateral implantation, psoas hitch procedure).
Vascular injury/bleeding
- Injury to muscular or epigastric vessels in the abdominal wall during trocar placement. Compression, if necessary, over a filled bladder catheter. U-sutures above and below the trocar insertion site. In case of doubt, enlargement of the incision site and direct suturing, especially in obese abdominal walls.
- Bleeding from smaller vessels can usually be controlled using bipolar current or ultrasonic scissors and, if necessary, by clipping.
- In case of injuries to large vessels (e.g., aorta, vena cava), immediate laparotomy is indicated. Inform anesthesia and provide blood products, if necessary, involve a vascular surgeon and prepare a vascular tray, create anatomical overview, repair the vascular defect.
Vaginal injury
Accidental entrapment of the vagina when using the stapler device can lead to the formation of rectovaginal fistulas.
It should be noted that in situations without sufficient anatomical overview, a laparotomy is indicated.