- Intraoperative complications arise from unintended injury to anatomically adjacent structures.
- The frequency is generally between 2 and 12 % for colon procedures
Caution: Known risk factors for intraoperative injury to adjacent structures are:
- Obesity
- Previous operations
- Adhesive abdomen
- Emergency procedure
- T4 tumor or extensive concomitant inflammation
Intestinal injury:
- Frequency 1 - 3 %, a necessary adhesiolysis increases the risk to 4 - 13 %
- Possible injury patterns:
- Superficial serosal injuries
- Transmural lesions of the intestinal wall
- Thermal damage to the intestinal wall using bipolar scissors or ultrasound dissector, especially in the area of the left flexure.
- Mesenteric tears with subsequent ischemia of the dependent intestinal segment
- Injury by the trocar system, Veress needle
- Prevention:
- In recurrent procedures, incision as far as possible outside the scar
- Open insertion of the first trocar after previous operations
- 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, targeted preparation with ultrasound scissors/bipolar sealing instruments
Caution: Ultrasound scissors and bipolar sealing devices can still cause thermal damage several seconds after active use.
- Procedure upon recognition:
- Robotic oversewing for serosal lesions and smaller defects
- For larger defects >1/2 of the circumference or for lesions close to the mesentery: robotically assisted resection and anastomosis
Splenic injury
- Injury mechanism: Traction on the colon or greater omentum during mobilization of the left flexure typically leads to superficial capsular lesions located inferiorly or medially.
- Prevention: Mobilization of the left flexure with great care and under good exposure of the site. Omental adhesions to the splenic capsule should be released early.
- Procedure upon recognition:
- Coagulation with bipolar current (bipolar forceps), if necessary apply hemostypticum (Tachosil, Flowseal etc.) or apply fibrin glue.
- Spleen-preserving therapy should always be aimed for, as it is associated with a lower complication rate than splenectomy.
Note: A laparotomy is only necessary in exceptional cases.
Pancreatic injury
- Injury mechanism: During mobilization of the left flexure and also during management 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 splenic injuries. Coagulation with bipolar current (bipolar forceps), if necessary apply hemostypticum (Tachosil, Flowseal etc.) or apply fibrin glue.
- For parenchymal injuries, placement of a drain is recommended to drain the secretion in case of possible pancreatic fistula and to prevent postoperative complications
Ureteral injury
- Injury mechanism: During mobilization of the sigmoid, injury to the ureter can occur due to its close anatomical relationship. In addition to sharp partial or complete transections, electrical injuries are also possible
- Prevention:
- Preservation of the Gerota fascia
- Secure identification of the ureter
- Use of ICG for better visualization
CAUTION in previous operations and inflammation- or tumor-related adhesions with disruption of the anatomical layers in the pelvis. Preoperative stenting of the ureter should be considered to facilitate its identification.
- Intraoperative diagnostics
- Visual examination
- Therapy
- Stenting and oversewing for short-segment injuries
Note: For superficial injuries, laparoscopic oversewing can be attempted; otherwise, a small laparotomy in direct projection to the injury site is recommended to suture the ureter openly under vision. In any case, insertion of a ureteral stent is indicated.
- Extensive injuries or partial resections require complex urological reconstructions (diversion, implantation on the opposite side, psoas hitch plasty).
Intraoperative bleeding
- Risk factors:
- Obesity
- Altered anatomy due to previous operations, inflammations and tumors
- Emergency procedures
- Symptoms/clinical presentation: Depending on the size of the injured vessel and the associated blood loss, from intraoperatively unremarkable courses to acute shock symptoms (hemorrhagic shock) possible.
- Diagnostics: Intraoperative visual identification of the bleeding source
- Prevention:
- Identification of surgical or patient-related risk factors for bleeding complications
- Use of ICG to identify vascular structures
- Therapy
- Temporary bleeding control by compression with laparoscopic/robotic atraumatic instruments
- Inform OR team and anesthesia
- Create the best possible material and personnel situation surgically (vascular surgeon, second experienced surgeon) as well as anesthesiologically (senior physician, RBCs, volume, etc.)
- Transfusion if transfusion criteria are met
- Surgical tactics
- Injury to muscular or epigastric vessels in the abdominal wall during trocar placement: Compression, if necessary via a filled bladder catheter. U-stitches above and below the trocar insertion site. In case of doubt, extension of the incision site and direct ligation, especially in obese abdominal walls.
- Bleeding from smaller vessels can usually be stopped using bipolar current or ultrasound scissors and, if necessary, by clipping.
- For 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.
CAUTION: Uncontrolled use of the suction device, especially in venous injuries, can significantly but almost imperceptibly increase blood loss. Therefore, compression until readiness for management is established and only then management of the injury under targeted use of the suction device
Intraoperative anastomotic leakage
- Diagnostics: Perform an intraoperative leak test as a hydropneumatic leak test or as a test with diluted methylene blue solution.
- Therapy: If the leak test is abnormal, oversewing can be attempted for small and easily accessible insufficiencies. In case of doubt, the anastomosis should be recreated. In principle, creation of a protective ileostomy should be considered in case of intraoperative leakage.