Complications - Left hemicolectomy, ArtiSential-assisted

• Intraoperative complications arise from unintentional injury to anatomically adjacent structures.
• The frequency generally ranges from 2 to 12% in colon procedures.

Note: Known risk factors for intraoperative injury to adjacent structures include:

• Obesity
• Previous surgeries
• Adhesive abdomen
• Emergency procedure
• T4 tumor or extensive accompanying inflammation

1.)  Bowel Injury:

• Frequency 1-3%, necessary adhesiolysis increases the risk to 4-13%
• Possible Injury Patterns:
  • Superficial serosal injuries
  • Transmural lesions of the bowel wall
  • Thermal damage to the bowel wall using monopolar/bipolar scissors or ultrasonic dissector, especially in the area of the left flexure.
  • Mesenteric tears with subsequent ischemia of the dependent bowel segment
  • Injury from trocar placement or Veress needle
• Prevention:
  • In recurrent procedures, incision as far as possible outside the scar
  • Open insertion of the first trocar after previous surgeries via a mini-laparotomy
  • Grasping the bowel as much as possible in the area of the taeniae or appendices epiploicae only with atraumatic grasping forceps under vision
  • No blind coagulations, careful, targeted preparation with ultrasonic scissors/bipolar sealing instruments

Note: Ultrasonic scissors and bipolar sealing devices can cause thermal damage several seconds after active use.

• Procedure upon Recognition:
  • Laparoscopic suturing for serosal lesions and smaller defects
  • For larger defects >1/2 of the circumference or meso-near lesions: laparoscopic or possibly open resection and anastomosis

2.)  Spleen Injury

• Injury Mechanism: Traction on the colon or greater omentum during mobilization of the left flexure typically results in inferior or medial superficial capsular lesions.
• Prevention: Mobilization of the left flexure with great care and under good setting of the situs. Omental adhesions to the splenic capsule should be released early.
• Procedure upon Recognition:
  • Coagulation with bipolar current (bipolar forceps), possibly applying hemostatic agents (Tachosil, Flowseal, etc.) or fibrin glue.
  • A spleen-preserving therapy should always be pursued, as it is associated with a lower complication rate than splenectomy.

Note: A laparotomy is only necessary in exceptional cases.

3.)  Pancreas Injury

• Injury Mechanism: During mobilization of the left flexure and also during the care of the inferior mesenteric vein, preparation is close to the pancreatic tail and the lower edge of the pancreas, so that injury can occur in the course of this.
• Procedure upon Recognition:
  • In case of bleeding, proceed similarly to spleen injuries. Coagulation with bipolar current (bipolar forceps) or laparoscopic suturing, possibly applying a hemostatic agent (Tachosil, Flowseal, etc.) or fibrin glue.
  • For parenchymal injuries, it is recommended to place a drain to be able to drain secretions in case of a pancreatic fistula and to prevent postoperative behavior.

4.)  Ureter Injury

• Injury Mechanism: During mobilization of the sigmoid, due to its close anatomical relationship, injury to the ureter can occur. In addition to sharp partial or complete transections, electrical injuries are also possible.
• Prevention:
  • Preservation of the Gerota fascia
  • Secure identification of the ureter
  • Possibly use of ICG for better visualization

NOTE: Special caution is required 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.  

• Intraoperative Diagnosis
  • Visual examination
• Therapy
  • Stenting and suturing for short-segment injuries

Note: For superficial injuries, laparoscopic suturing can be performed; otherwise, a small laparotomy is recommended in direct projection onto the injury site to 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).

5.)  Intraoperative Bleeding

• Risk Factors:
  • Obesity
  • Altered anatomy due to previous surgeries, inflammations, and tumors
  • Emergency procedures
• Symptoms/Clinic: Depending on the size of the injured vessel and the associated blood loss, variable clinical manifestations from intraoperatively inconspicuous courses to acute shock symptoms (hemorrhagic shock) are possible.
• Diagnosis: Intraoperative visual identification of the bleeding source
• Prevention:
  • Identification of surgical or patient-related risk factors for bleeding complications
  • Use of ICG for identification of vascular structures
• Therapy
  • Temporary bleeding control by compression with a laparoscopic atraumatic instrument
  • Informing the surgical team and anesthesia
  • Creating the best possible material and personnel situation surgically (vascular surgeon, second experienced surgeon) as well as anesthesiologically (senior physician, blood units, volume, etc.)
  • Transfusion if transfusion criteria are met
• Surgical Tactics
  • Bleeding from smaller vessels can usually be controlled using bipolar current or ultrasonic scissors and possibly by clipping.
  • With appropriate expertise, small to medium vessels can also be sutured laparoscopically.
  • For injuries to large vessels (e.g., aorta, vena cava), immediate laparotomy is indicated. Inform anesthesia and provide blood units, possibly involve a vascular surgeon and prepare a vascular tray, create anatomical overview, repair the vessel defect.
  • Injury to muscular or epigastric vessels in the abdominal wall during trocar placement: Compression, possibly over a filled bladder catheter. U-sutures above and below the trocar insertion site. In case of doubt, enlarge the incision site and directly encircle, especially in obese abdominal walls.

NOTE: Uncontrolled use of the suction device, especially in venous injuries, can significantly but almost imperceptibly increase blood loss. Therefore, apply compression until ready and then use the suction device in a targeted manner to care for the injury.

6.)  Intraoperative Leakage of the Anastomosis

• Prevention:
  • Anastomosis creation tension-free and well-perfused (use of ICG)
  • Extend the spike of the endoluminal stapler in the center of the linear staple line
• Diagnosis: Perform an intraoperative test of the anastomosis as a hydropneumatic leak test or as a test with diluted methylene blue solution.
• Therapy:
  • If the leak test is conspicuous, suturing can be performed for small and easily accessible insufficiencies.
  • In case of doubt, re-establish the anastomosis.
  • Possibly consider creating a protective ileostomy in case of intraoperative leakage

Note: Prevention of postoperative complications:

The ERAS protocol and fast-track surgery aim to accelerate postoperative recovery and to reduce the incidence and severity of postoperative complications.

The main objectives are the reduction of postoperative pain, postoperative intestinal atony with nausea, vomiting and constipation, as well as infections. In elective colon surgery, studies have demonstrated a reduction of up to 40%.

1) Anastomotic leak (following elective colon/rectal resections, approx. 3–12%)

Definition: Dehiscence of the suture line between two bowel segments with leakage of intraluminal fluid/air. Anastomotic leakage represents the most severe complication after colorectal cancer resections.

Significance: Leading cause of postoperative sepsis after colorectal surgery; associated with high morbidity and mortality.

Prevention:

• Tension-free anastomosis
• Optimal anastomotic technique
• Adequate perfusion of the bowel ends
• Intraoperative leak test
• Restrictive intra- and perioperative fluid management

Note: Indocyanine green (ICG) fluorescence angiography of the colon, with objective assessment of perfusion at the anastomotic ends, is recommended to lower the risk.

Clinical presentation: Ranges from asymptomatic to septic shock; typically postoperative day 4–10.

• Abdominal pain
• Peritonitis
• Elevated inflammatory markers, esp. rising CRP
• Postoperative fever
• Bowel obstruction up to paralytic ileus
• Sepsis and shock
• Cloudy/discolored/feculent drainage fluid
• Clinical deterioration

Diagnostics:

• Laboratory: inflammatory markers (WBC, CRP, possibly IL-6, PCT), drain fluid: amylase/lipase
• Ultrasound, with guided puncture if fluid present
• CT with rectal contrast
• Endoscopy
• Diagnostic laparoscopy

Caution: Any deviation from the expected postoperative course should raise suspicion of an anastomotic leak. In case of reasonable suspicion, obtain contrast-enhanced CT with rectal filling or perform partial (flexible) endoscopy without delay.

Therapy:

• Conservative: In select patients with mild clinical course and adequate drainage, particularly with a diverting stoma
• Antibiotics (e.g., piperacillin–tazobactam, meropenem)
• Dietary restriction/elemental diet if no stoma in place
• IV fluids as needed
• Parenteral nutrition if required
• Close clinical monitoring
• Interventional:
• Endosponge for low rectal leaks
• Endoscopic clip closure (in select cases)
• Surgical: Always indicated with clinical deterioration, sepsis, or undrained collection
• Oversewing of small defects + drainage
• Re-anastomosis in larger defects (>25% of circumference) + drainage
• Consider protective stoma
• Take-down of anastomosis with creation of a Hartmann’s procedure + drainage
• Critical care: Full sepsis management with broad-spectrum antibiotics, fluid and electrolyte replacement, and organ support if failure occurs.

2) Missed intraoperative bowel injury

Clinical presentation: 

• Similar variability as anastomotic leak, often with insidious course
• Abnormal drainage output
• Elevated inflammatory markers
• Abdominal pain
• Sepsis

Prevention:

• Trocar placement under direct vision
• Use of atraumatic instruments for bowel handling
• Dissection only under direct visualization
• Insertion/removal of instruments under vision
• Avoid unnecessary traction on bowel; grasp at taeniae or appendices epiploicae
• Avoid abrupt movements
• Complete inspection of bowel after extensive adhesiolysis before closure

Diagnostics: Contrast-enhanced CT showing contrast extravasation and/or free air

Therapy: Surgical revision with oversewing or segmental resection and re-anastomosis.

3) Intraabdominal abscess

Incidence: 1–12%

Diagnostics: Ultrasound or CT imaging

Therapy: Depends on clinical condition

Small, incidental abscesses without systemic signs may be observed.

Caution: Intraabdominal abscesses can be indirect evidence of anastomotic leak → always rule out dehiscence.

With systemic infection: image-guided drainage (ultrasound- or CT-guided).

With progressive sepsis: operative source control plus supportive ICU therapy and antibiotics.

4) Surgical site infection (4–30% depending on definition and follow-up)

Classification (CDC):

A1: Superficial (skin/subcutaneous)

A2: Deep (involving fascia and muscle)

A3: Organ/space infections

Prevention: Antibiotic prophylaxis ≤30 min before incision; repeat dosing after 4h for long procedures or in contaminated wounds; first dressing change after 48h; avoid hypothermia.

Therapy: Wound opening and irrigation; empirical antibiotics effective against E. coli and S. aureus after culture; debridement of necrotic tissue; vacuum-assisted closure for large wounds with cavities.

5) Postoperative ileus (intestinal atony)

Incidence: up to 25%

Prevention: ERAS/fast-track concepts with early mobilization and early oral intake

Therapy: Stepwise management

• Chewing gum
• Laxatives
• Metoclopramide/erythromycin
• Neostigmine
• Methylnaltrexone if opioid-induced
• Diluted contrast medium

6) Postoperative hemorrhage

Incidence: 0.5–3%

Management depends on location:

• Peranal bleeding:
• Small amounts of old blood may be expected.
• Increasing or fresh bleeding → endoscopy with hemostasis (clips preferred for anastomotic bleeding).
• Surgical revision only in exceptional cases.
• Monitor hemoglobin and coagulation closely.
• Intraabdominal bleeding:
• Signs: bloody drain output, abdominal pain, distension, hemodynamic instability
• Diagnostics: labs (Hb/Hct, coagulation), ultrasound, possibly CT with contrast
• Therapy:
• Non-surgical bleeding: optimize coagulation, transfusion as needed
• Surgical bleeding: emergency reoperation

7) Anastomotic stricture

Symptoms: Irregular bowel movements, paradoxical diarrhea, subileus, abdominal pain

Therapy: Endoscopic dilation first; if unsuccessful, surgical re-anastomosis.

8) Incisional and trocar-site hernia

Incidence: 5–16% (esp. extraction sites, trocar hernias)

Therapy: Elective repair (usually mesh-based) ≥6 months after index surgery, unless symptomatic.

9) Missed intraoperative ureteral injury

Symptoms: Non-specific; flank pain, urinoma, fever, sepsis, reduced urine output with major leak, hydronephrosis if ligated, hematuria

Note: Mild hematuria may be normal in patients with indwelling ureteral stents.

Warning sign: Large volumes of clear fluid via drains + low urine output.

Diagnostics: Creatinine in drain fluid, serum renal parameters, ultrasound, CT urography or IV urography

Therapy:

Minor injuries: laparoscopic repair with stenting

Major injuries/partial resection: open repair with stent; in complex cases, reconstructive urology (reimplantation, psoas-hitch, etc.).

10) Fascial dehiscence (burst abdomen) at retrieval incision

Incidence: Rare after minimally invasive surgery

Types: Incomplete (skin intact) vs. complete (intestines/omentum visible)

Timing: Typically postoperative day 3–9

Diagnostics: Persistent wound drainage, clinical inspection, ultrasound, possibly CT

Therapy: Surgical revision with fascial closure after excluding intraabdominal pathology

Caution: Fascial dehiscence often indicates underlying intraabdominal pathology (e.g., anastomotic leak) → always rule out.

11) Other complications: e.g., nerve injury (impotentia coeundi)

12) General medical complications:

• Deep vein thrombosis / pulmonary embolism
• Pneumonia
• Cardiac events
• Urinary tract infection
• Stroke