- Typical risk factors for intraoperative injuries include:
- Obesity
- Altered anatomy due to previous surgeries, inflammations, and tumors
- Emergency interventions
Bowel Injury
- Minor 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 re-serosed.
Splenic Injury
- A spleen-preserving therapy should always be pursued, as it is associated with a lower complication rate than splenectomy.
- Electrocoagulation of capsule defects; hemostatic patches; compression and patience
- For deeper lesions, place the spleen in a resorbable plastic mesh bag, achieving continuous tissue compression. As a last resort, splenectomy.
Pancreatic Injury
- Fine over-and-over ligatures to prevent pancreatic fistulas!
- It is advisable to place a drain to allow secretion drainage in case of a pancreatic fistula.
Ureteral Injury
- This can be avoided by carefully ensuring that only the mesosigmoid is mobilized laterally.
- Furthermore, the ureter should be identified, but extensive exposure should be avoided to protect the nerve plexus in this region. Slinging should also be avoided.
- In cases of previous surgeries and adhesions due to inflammation or tumors with disruption of anatomical layers in the pelvis, preoperative stenting of the ureter can be considered to facilitate its identification.
- Conservative treatment for superficial lesions.
- Incomplete injuries are stented (double-J catheter) and closed with direct suturing.
- 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
- Risk constellation with tumor growth beyond boundaries, inflammation, previous surgeries, or post-radiation.
- Treatment: No indiscriminate attempts at over-and-over suturing, but controlled vascular suturing or initially sustained compression.
- In other cases, recognition and localization of the bleeding source, primary bleeding control by compression or clamping, informing anesthesia and providing blood products, possibly involving a vascular surgeon and preparing a vascular sieve, creating anatomical overview, repairing the vascular defect.
Bleeding from the Sacral Plexus
- This very serious complication, which can quickly become life-threatening, is avoided by preparing very precisely in the mesorectal displacement layer.
- If bleeding does occur, it is generally not possible to control it with over-and-over sutures (exception: bleeding after injury to the internal or external iliac vein). It is more advisable to apply pressure for several minutes as an immediate hemostatic measure. If more extensive bleeding occurs, it is recommended to quickly transect the rectum under temporary compression with a stapling device and tamponade the pelvis.