Title: Intraoperative Bowel Injury During Hysterectomy
Abstract: Journal of Gynecologic SurgeryVol. 37, No. 3 Special Topic: Major Intraoperative Injuries During HysterectomyFree AccessIntraoperative Bowel Injury During HysterectomyIvana Barouhas, Youssef Mouhayar, and Jean-Marie StephanIvana BarouhasDepartment of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA.Search for more papers by this author, Youssef MouhayarDepartment of Obstetrics and Gynecology, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA.Search for more papers by this author, and Jean-Marie StephanAddress correspondence to: Jean-Marie Stephan, MD, 60 E Scott Street, Apartment 303, Chicago, IL, 60610, USA E-mail Address: [email protected] of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA.Search for more papers by this authorPublished Online:31 May 2021https://doi.org/10.1089/gyn.2020.0230AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail IntroductionBowel injury is a rare but serious complication of gynecologic surgery. This kind of injury has been reported in 0.1%–1.0% of women undergoing hysterectomies and can carry a high rate of morbidity and mortality, particularly when diagnosed postoperatively.1 Furthermore, delayed diagnosis of bowel injury following gynecologic surgery is a significant cause of litigation in the United States.2 The incidence of this complication is increased in patients with histories of prior abdominal surgeries.3 Injuries can happen regardless of surgical approach, with the majority being associated with abdominal access, and the remaining accounted for by bowel dissection during lysis of adhesions, thermal injuries, and improper tissue handling.4 It is estimated that up to 41% of bowel injuries are unrecognized at the time of surgery, with 1 of 31 unrecognized bowel injuries resulting in death.4 This review highlights risk factors associated with bowel injury during hysterectomy, and techniques for prevention of this complication. In addition, intraoperative and postoperative recognition and management are discussed and long-term outcomes are summarized.Risk FactorsThe risk for bowel injury during hysterectomy varies based on surgical approach, indication, technique, and patient factors. A retrospective study of more than 150,000 women undergoing hysterectomy for benign indications found that the abdominal approach to hysterectomy was associated with tenfold increased risk of bowel injury, compared with the vaginal approach, while the laparoscopic/robotic approach was associated with threefold increased odds.5 Vaginal hysterectomy is performed in a carefully selected group of patients and is the preferred route when technically feasible.6Not surprisingly, higher rates of gastrointestinal (GI) injuries have also been attributed to the presence of malignancy, as invasive tumors can severely distort or even invade the pelvic anatomy and associated intestinal tract. With robotic hysterectomies in particular, investigators reported a higher rate of bowel injuries in malignant cases, with an incidence of 1 in 156, compared to 1 in 262 for benign indications.7 This increased rate of GI injuries has also been noted in cases of endometriosis and in the presence of large fibroids.5Patients with histories of multiple abdominal surgeries and, therefore, higher burdens of adhesive disease are at higher risk of intraoperative visceral damage during hysterectomy; the greater the extent and density of intra-abdominal scar, the greater the technical challenge in the identification of planes of dissection and exposure to the pelvic organs.3 Of note, a 2019 systematic review and meta-analysis of 26 studies found that any history of cesarean section conferred an increased risk of intraoperative bowel injury during hysterectomy with an odds ratio (OR) of 1.83.8 Adhesions within the posterior cul-de-sac increase the risk of rectosigmoid damage during vaginal hysterectomy.9 Interestingly, most studies fail to show conclusive evidence of increased risk of bowel injury during hysterectomy with increasing body mass index.10PreventionOpportunities for the prevention of iatrogenic bowel injury exist throughout the surgical process of hysterectomy, from the initial planning stages through the actual dissection. A common concern among gynecologic surgeons is suspected differences in risk of bowel injuries among routes of hysterectomy. As mentioned above, the data regarding this are not conclusive because multiple efforts in the literature to demonstrate such differences have been unsuccessful. This may be due to the overall low rates of complications, including visceral injury, and the fact that many of the trials included in published reviews might not have been sufficiently statistically powered to detect significant differences in adverse-event rates.Nonetheless, the aforementioned increased risk of bowel injury during vaginal hysterectomy in cases of obliterated posterior cul-de-sac merits consideration.9 Incorporation of a careful pelvic examination to assess for the likelihood of this anatomical finding and to evaluate uterine size and mobility can help guide the choice of route of hysterectomy. One can anticipate that poor uterine mobility on examination; evidence of nodularity in the posterior cul-de-sac or along the uterosacral ligaments; or history of diverticulitis, severe endometriosis, ruptured appendicitis, or posterior culdeplasty are likely to increase the risk of rectosigmoid injury during attempted vaginal hysterectomy.Patient positioning and perioperative care also present opportunities for reduction of bowel-injury risk. In all laparoscopic gynecologic procedures, the effect of gravity can be made advantageous for pelvic surgery by using the Trendelenburg position, allowing the intestines to fall into the upper abdomen and away from the operative field. Placement of a gel pad under the patient will improve stability on the operative table and facilitate maximal use of this position.11The type of incision during laparotomy or method of entry during laparoscopy should be chosen in a manner to minimize the risk of bowel injury. During open hysterectomy, the appropriate choice of incision should take into account not only the indication for hysterectomy (benign versus malignant or size of specimen), but also the patient's body habitus, associated conditions, and prior abdominal scars. When utilizing a transverse incision, and a large or bulky uterus or significant adhesions are encountered, the combination of the associated technical difficulty and limited exposure may increase the risk of enterotomy.11 With a vertical incision, gaining entry to the peritoneal cavity above or below a previous scar will often avoid dissecting directly into adherent bowel.3 The possibility of adherent bowel must be anticipated during laparotomy, and careful dissection of the abdominal wall layers from skin to peritoneum is warranted. Particular caution is warranted in the presence of a known incisional hernia.A 2007 review of methods of laparoscopic entry in gynecologic surgery found no evidence that an open entry technique was superior to other methods for reducing bowel injury.12 Separate from the method of initial entry, the choice of entry location is also an important opportunity for reducing the risk of visceral injury. In patients with suspected or known periumbilical adhesions, a left, upper-quadrant laparoscopic entry should be considered. It has also been reported that side-to-side “waggling” of the Veress needle after entry has been associated with increasing the size of a visceral puncture and should therefore be avoided.12 The review also found no evidence that elevating the anterior abdominal wall at the time of Veress insertion, or using shielded trocars or visual entry trocars decreased the rate of complications such as bowel injuries. Ultimately, the type of laparoscopic entry and the instruments used are vehicles of an individual surgeon's skills and should thus be chosen to accommodate the surgeon's capabilities; the most confident and practiced approach will generally be the least dangerous. After successful laparoscopic entry, any additional trocars should be placed under direct visualization.3In laparotomy or laparoscopy, lysis of adhesions near bowels should be conducted with careful sharp dissection where feasible (in avascular adhesions) in order to reduce the opportunity for thermal injury due to electrosurgery. Prevention of intraoperative visceral damage also requires that the surgeon be cognizant of the benefits and hazards of different electrosurgical instruments. Monopolar instruments cause the largest thermal spread and should be used judiciously. One should also use electrocautery on the lowest necessary power setting to dissect efficiently without increasing the risk of injury.9 In addition, care should be taken intraoperatively to avoid direct coupling—the transfer of electrical energy from an electrosurgical device to a second metal instrument—which can result in indirect thermal visceral injury. In the case of intraoperative bleeding, adequate visualization of the field and isolation of nearby structures, including intestines, should be undertaken prior to application of any method of hemostasis, especially electrocautery. Finally, the risk of stomach perforation after a difficult intubation can be decreased using naso- or orogastric suction.3Intraoperative RecognitionIn a review of bowel injury during gynecologic laparoscopy, the most-frequently damaged area of the GI tract was the small intestine.13 A systematic review of GI injury in robotic gynecologic surgery reported the rectum, followed by the colon and, last, the small intestine as the most-common sites of injury.7 However, only a minority of the studies in these reviews actually reported the locations of the injuries. Llarena et al.4 found that the diagnosis of intraoperative bowel injury was delayed by more than 1 day in 40% of cases, and that all subsequent deaths occurred exclusively in cases when the complication was not recognized intraoperatively. The mortality rate for unrecognized bowel injuries in this study was 1 in 31 or 3.2%. It is, therefore, imperative to recognize and identify injuries intraoperatively.As in any laparoscopic surgery, the procedural step most commonly associated with inadvertent enterotomy during laparoscopic hysterectomy is abdominal entry, particularly with primary trocar placement at the umbilicus.3,13 When entry is performed with a Veress needle, the surgeon may utilize certain techniques to assess for inadvertent vascular or visceral puncturing, such as aspiration of an attached syringe, to inspect for blood or bowel contents. An opening insufflation pressure of <10 mm Hg also suggests correct intraperitoneal placement. In addition, a survey of the abdomen immediately after entry should be conducted to evaluate for evidence of GI injury, such as bleeding, visceral insufflation, or leakage of bowel contents. This survey may require not only directed laparoscopic visualization but also careful “running” of the bowel using blunt bowel graspers if significant suspicion for bowel injury exists. The “flat tire test”—filling of the pelvis with irrigation fluid and injection of air into the rectum, followed by inspection for air bubbles—can aid in detection of rectosigmoid perforation. Alternatively, proctosigmoidoscopy can be used when such a complication is highly suspected.3 Postoperatively, persistent pyrexia, tachycardia, abdominal pain, or sepsis should raise the index of suspicion for a bowel injury.ManagementManagement of an intraoperative GI injury varies with route of hysterectomy, and conversion to laparotomy is sometimes required when an enterotomy is identified during minimally invasive surgery. Depending on the extent and location of the injury, repair can be undertaken via primary closure, resection with reanastomosis, or resection with temporary diversion to stoma. Consideration should be given to the provision of additional antibiotic prophylaxis, especially in cases of extensive large bowel injury with leakage of stool into the peritoneal cavity.32Straightforward puncture injuries with the Veress needle to the small or large bowel generally require no further intervention unless complicated by bleeding. However, any injury of >5 mm involving the full thickness of the bowel wall must be repaired. Placing the suture line perpendicular to the long axis of the intestine prevents narrowing of the bowel lumen. The repair is usually done in 1 or 2 layers. If performed in 2 layers, the first consists of a delayed absorbable layer reapproximating the intestinal mucosa and muscularis, followed by a second serosal layer of 3-0 interrupted silk suture.3 Bowel resection is recommended if the enterotomy is larger than half of the diameter of the small intestine lumen or if there is the potential for vascular compromise.3 In the event of a large or deep thermal injury involving not only tissue immediately adjacent to the electrosurgical instrument but also tissue damaged by thermal spread, it has been suggested that resection with a wide margin is necessary in order to remove all potential sites of necrosis.9Iatrogenic colonic injury is generally a more serious complication than small-bowel damage and is thus treated more aggressively. If small, a colonic laceration can be managed with reapproximation with a suture perpendicular to the long axis as described above for the small bowel. A large colonic defect, or one with delayed recognition, may require resection and diversion to colostomy. Management of all intraoperative injuries to the colon should involve broad-spectrum antibiotic prophylaxis and copious peritoneal irrigation.3Long-Term OutcomesBeyond the substantial challenge of initial postoperative recovery, the potential for long-term morbidity in patients who have bowel injuries during hysterectomy warrants careful follow-up. In one population-based study of more than 22,000 women who underwent hysterectomy for benign indications in Sweden between 2000 and 2014,14 there was a statistically significant increase in risk of subsequent fistula formation in cases of intraoperative organ injuries, compared to cases without such injuries (7% versus 0.4%; adjusted OR: 15.29; 95% confidence interval: 9.81–23.85). In that study, a higher proportion of women with organ injury at the time of hysterectomy also reported subjective general deterioration in health 1 year after surgery, compared to those without organ injury.14ConclusionsBowel injury is a rare but serious complication of hysterectomy. Patients with histories of prior abdominal surgery or other causes of adhesions or with distortion of the pelvic anatomy (endometriosis, large fibroids, or gynecologic malignancy) are at higher risk for this morbid event. This review identified conflicting data regarding the risk of GI injury according to route of hysterectomy, but the fact that this complication occurs most commonly during abdominal access has been well-established. Prevention of bowel injury requires careful entry into the abdominal cavity and a rigorous understanding of the lowest-risk techniques of dissection, particularly during lysis of adhesions and with the use of electrocautery. Prompt recognition is imperative and can be achieved with a timely survey of the abdominal organs upon peritoneal entry, close attention to detail during dissection of or near the bowel, and adjunctive intraoperative tests as indicated. Initial management varies according to the specific GI location of injury and its extent. Appropriate postoperative care requires anticipation of short- and long-term morbidity, such as a leak or fistula formation, and monitoring for a negative impact on general health and quality of life.Author Disclosure StatementNo financial conflicts of interest exist. Funding InformationNo funding was received for this article.References1. Härkki-Sirén P, Sjöberg J, Mäkinen J, et al. Finnish national register of laparoscopic hysterectomies: A review and complications of 1165 operations. Am J Obstet Gynecol 1997;176(1[pt1]):118. Crossref, Medline, Google Scholar2. Walden PA, Zeybek B, Phelps JY. 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Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 37Issue 3Jun 2021 InformationCopyright 2021, Mary Ann Liebert, Inc., publishersTo cite this article:Ivana Barouhas, Youssef Mouhayar, and Jean-Marie Stephan.Intraoperative Bowel Injury During Hysterectomy.Journal of Gynecologic Surgery.Jun 2021.197-199.http://doi.org/10.1089/gyn.2020.0230Published in Volume: 37 Issue 3: May 31, 2021Online Ahead of Print:May 5, 2021Keywordsbowel injuryhysterectomybowel perforationPDF download
Publication Year: 2021
Publication Date: 2021-06-01
Language: en
Type: article
Indexed In: ['crossref']
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