by Ceana H. Nezhat, MD, Daniel S. Seidman, MD Farr R. Nezhat, MD, Camran R. Nezhat MD
SURGICAL ANATOMY AND TECHNIQUES
Laparoscopy is an effective tool for the evaluation of patients with chronic pain. Laparoscopic adhesiolysis is associated with significant relief of chronic abdominal pain in more than 80% of patients. Laparoscopic adhesiolysis was also found to be more effective than microsurgical adhesiolysis for infertility. Although complications due to adhesiolysis are rare, there is understandable concern about blunt, sharp, or thermal injury to the bowel. Adhesions are frequently involved between two organs and most often involve the bowel. The possibility of injury during abdominal entry with a Veress needle or trocar exists in patients with or without a previous history of laparotomy.(Figure 1, Figure 2a, Figure 2b) To adequately perform laparoscopic adhesiolysis, three or four abdominal punctures are required - the infraumbilical incision for the operative laparoscope and two to three lower, lateral punctures for introduction of ancillary instruments. Successful insertion depends on adequate skin incision, the trocar’s working condition, proper orientation, and control over the instrument’s force and depth of insertion. Small diameter (<3 mm in diameter) laparoscopy as an alternative to open laparoscopy can be utilized for initial abdominal entry in patients at risk for adhesions. Through the lateral trocar, on the side of the assistant, an atraumatic grasping forceps is inserted to hold the adhesion or involved organ, stretch it, and identify its boundaries and avascular planes. The opposite trocar, on the side of the surgeon, is used for microscissors or the suction-irrigator probe. Dense adhesions are severed first, followed by thin and filmy adhesions. This approach allows for progressive exposure of the pelvic structures. Once the intestines are freed from the adjacent structures, they can be pushed cephalad. In the pelvis, adherent ovaries are freed from the pelvic sidewall, broad ligament, tubes, and uterus. Once the ovaries are lifted from the cul-de-sac and mobilized, all peritubal adhesions are removed. Any bleeding that cannot be controlled with the laser is desiccated using the bipolar or unipolar electrocoagulator to maintain a clear field.
Adhesion formation is a serious concern following pelvic surgery. Adhesion formation at the vaginal cuff and pelvic sidewall usually involves bowel and omentum. This may result in pelvic pain, dyspareunia, small bowel obstruction, and residual ovary syndrome when salpingo-oophorectomy is not performed. Adhesions were identified as the primary cause of chronic pelvic pain in 13-26% of females. Painful coitus is frequently reduced after lysis of pelvic adhesions. In many surveys of postoperative bowel obstruction, abdominal surgery is the leading cause of adhesion formation.
The laparoscopic surgical technique, although associated with less adhesion formation than laparotomy, is still associated with a substantial risk of adhesion formation. This has been estimated in one extensive evaluation of second-look procedures to be 67% after fimbrioplasty and 80% following ovarian cystectomy. Adhesions developed in 40-60% of patients after laparoscopic removal of ectopic pregnancy. A preoperative bowel preparation is necessary in patients with a history of previous laparotomy or with severe endometriosis, as the possibility of adhesion formation and the chances of bowel injury are increased. If a CO2 laser is being utilized to lyse dense adhesions, hydrodissection with the suction-irrigator probe is highly recommended to create tissue planes before dissection (Figure 3). Grasping forceps are also essential for applying traction to the ovary, tube, intestines, or abdominal wall so that a plane of dissection can be identified. Whenever possible, either the adhesions or ovarian ligaments should be grasped instead of the ovarian cortex to minimize trauma. For delicate microscopic procedures such as fimbriolysis and salpingo-ovariolysis, the microscissors or Ultrapulse CO2 laser is preferable, as thermal damage can occur with electrosurgery and the fiber laser (Nd:YAG, KTP, or argon).
Factors which contribute to an increased risk of gastrointestinal injuries include 1) failure to establish an adequate pneumoperitoneum, 2) the use of dull trocars which require excessive force, 3) uncontrolled, sudden entry of sharp instruments, and 4) gastric distention. Poorly controlled or sudden trocar entry can result in rectosigmoid laceration. Gastric distention can displace the transverse colon toward the pelvis, where it can be punctured by the Veress needle or lacerated with the trocar. This complication can be eliminated by using a nasogastric tube intraoperatively.
The rectosigmoid can be injured if the depth of penetration by endometriosis is underestimated (Figure 3) or the cul-de-sac is obliterated. When the rectum is adherent to the posterior aspect of the cervix or uterosacral ligaments, blunt dissection may lacerate the rectum. Sharp dissection with scissors or the CO2 laser is recommended. The combination of high-power superpulse or ultrapulse CO2 laser and hydrodissection is relatively safe for working around the bowel.
When the cul-de-sac is dissected, identification of the vagina and rectum is facilitated by placing a probe or an assistant’s finger in both the vagina and rectum. Dissection should begin lateral to the uterosacral ligaments, where anatomy is less distorted, and proceed toward the obliterated cul-de-sac. Similarly, when posterior culdotomy is performed for tissue removal or during laparoscopic hysterectomy, correct identification of vagina and rectum is important.
Preoperative detection of adhesions is difficult and the overall sensitivity of imaging with ultrasound is poor. However, the patient’s history of previous surgery, endometriosis, or pelvic inflammatory disease (PID) can help predict the likelihood of encountering adhesions during laparoscopy. Once complications of adhesions have occurred, a high degree of awareness may be necessary for prompt diagnosis.
Electrical injuries to the bowel are not always apparent intraoperatively or their appearance leads the surgeon to choose conservative management. If the area of blanching on the intestinal serosa exceeds 5 mm, the extent of thermal damage will probably exceed the apparent damage, and therapy should be instituted immediately. The actual area of injury can extend up to 5 cm from the apparent injury.
If the small bowel has been lacerated by a trocar, the surgeon may initially view a mucosal surface or notice a foul smell when the laparoscope is inserted. Small bowel contents may be observed leaking from a laceration, or a hematoma may be present on the small bowel serosa.
Injuries involving the small and large bowel may not be recognized at the time of surgery and symptoms may not become apparent until the third or fourth postoperative day. Patients generally present with lower abdominal pain, fever, nausea and anorexia. By the 5th or 6th postoperative day, symptoms include fever, severe abdominal pain, nausea, vomiting, constipation, increased white blood cell count and peritonitis. Radiographs reveal multiple air/fluid levels or air under the diaphragm.
Perforation of the large bowel with the Veress needle can sometimes be recognized by the saline aspiration test; recovery of brownish fluid is pathognomonic. Fecal odor may be detected. If large bowel entry is suspected based on these two tests, the needle should be promptly withdrawn and another sterile Veress needle reinserted. Once the laparoscope is inserted, the entry site should be sought and examined. Because of the high bacterial concentration, minor leaks of fecal material into the peritoneal cavity can be the source of serious infection. The underwater examination is recommended following the treatment of severe endometriosis and adhesions of the rectum and rectosigmoid colon.
The major concern following adhesiolysis is subsequent reformation of the adhesions. Currently, the most promising preventive measure seems to be the laparoscopic insertion of either an oxidized cellulose absorbable adhesion barrier or a Gore-Tex surgical membrane. The most common severe complication associated with adhesions is small bowel injury, the severity of which is related to the extent of damage and the time lapsed before the injury is discovered. Sharp trocar injuries to the bowel can be limited to the serosa or deep, involving the entire wall. Small punctures or superficial lacerations seal readily and require no further treatment assuming that careful inspection of the affected bowel reveals no leakage of bowel contents or bleeding. Small (< 5 mm) superficial lacerations need to be inspected to assure that only the serosa is involved. In these cases, the patient may be treated conservatively and discharged the day of surgery with dietary instructions and orders to report any untoward reaction.
Patients with obvious peritoneal soiling require special attention. Laparoscopic repair should only be performed by an experienced laparoscopist. The bowel should be inspected on both sides to detect through-and-through injuries, especially if produced by a trocar. If only one entry is found and repaired, peritonitis may develop postoperatively. If the laparoscope has been inserted through the bowel laceration and laparotomy is performed, leaving the trocar in place allows the defect to be readily identified and closed by a purse-string suture as the laparoscope is withdrawn (so as to minimize peritoneal contamination).
Small bowel should be repaired in 1 or 2 layers by placing an initial row of interrupted sutures of 2-0 Vicryl to approximate the mucosa and muscularis. A reinforcing layer of 3-0 silk Lembert sutures is used to approximate the muscularis and serosal edges. All lacerations should be closed transversely to minimize the occurrence of stricture and stenosis of the bowel lumen. This closure is appropriate only if the laceration is less than one-half the diameter of the bowel. If the laceration exceeds one-half the diameter of the lumen, segmental resection and anastomosis should be performed. If the mesenteric blood supply is interrupted by the puncture, a resection must be performed regardless of the size or the length of the laceration. For those surgeons who are not familiar with bowel repair and its postoperative care, consultation with a general or colorectal surgeon is appropriate whenever significant bowel trauma occurs. Small bowel injuries caused by trocars, CO2 laser, or sharp scissors can be repaired laparoscopically in one layer using 3-0 silk or 4-0 polydioxanone. Injuries less than 2 cm (small or large bowel) may be repaired transversely or longitudinally; however, injuries over 2 cm should be repaired transversely. Following is a simple technique to repair bowel injuries caused by sharp instruments or the CO2 laser if the perforation is less than 1 cm: After the edge of the perforation is thoroughly trimmed of any debris, a 4-0 polydioxanone or 0 polyglactin suture is used in cm intervals in an interrupted fashion to approximate and close the defect. To evaluate the repair, the abdomen and posterior cul-de-sac are filled with lactated Ringer’s solution. A sigmoidoscope is used to insufflate the bowel, which is pushed under the fluid. The presence of air bubbles indicates inadequate repair.
Following repair of a bowel laceration, the entire abdomen is irrigated. A nasogastric tube is usually not necessary. The patient is not given anything by mouth until she passes flatus.
When possible bowel laceration becomes apparent after the patient has been discharged, conservative management is successful in patients who have not developed peritonitis. In-hospital management consists of hydration, nothing by mouth and close observation with white blood count and physical exam. Wheeless reported that over one-half the patients treated conservatively required no surgical intervention. Those whose condition deteriorated during observation underwent laparotomy and had no complications attributable to delayed surgery.
Immediate surgical intervention by laparoscopy or possible laparotomy may be indicated in patients who present with fever, severe abdominal pain, nausea, vomiting, obstipation or peritonitis, or in those whose clinical condition worsens. Surgical considerations for managing bowel injuries discovered postoperatively differ somewhat from those discovered and managed intraoperatively. The damaged bowel must be repaired or resected. In addition, resection of all necrotic tissue in the pelvis is mandatory even if this requires a hysterectomy and bilateral salpingo-oophorectomy. If burned or necrotic tissue has been bathed in intestinal contents and blood or serum is not excised, a pelvic abscess will develop.
Wheeless presented a 7-point plan to manage patients with peritonitis secondary to bowel perforation:
1) preoperative stabilization with fluids, electrolytes
and nasogastric suction,
2) exploratory laparotomy with repair or resection
of the injured bowel,
3) resection of all necrotic tissue,
4) copious and repeated saline lavage of the
5) pelvic drainage using a closed drainage system,
6) aggressive antibiotic therapy,
7) embolus prophylaxis with mini-dose heparin
(5,000 units TID).
For small colonic wounds associated with minimal contamination, primary suture closure has been the accepted therapy. In addition, copious lavage of the peritoneal cavity, broad spectrum antibiotics and drainage are essential in minimizing the risk of infection.
Electrical injury to the right colon is managed by resecting the injured segment and primary anastomosis. Diverting ileostomy facilitates healing and reduces morbidity and mortality. Injury to the descending colon, sigmoid or rectum in an unprepared bowel usually is not managed by primary closure or resection with primary anastomosis. Diverting colostomy with resection of the injured portion is traditionally performed. However, we believe this may be an over-treatment.
Colonic lacerations in prepared bowel can be repaired laparoscopically after excising endometriosis nodules and identifying the extent of the laceration. A single-layered repair using 2-0 silk, 4-0 polydioxanone, or 0 polyglactin sutures is used.
The knowledge that the bowel can be repaired successfully by laparoscopic techniques in the properly prepared patient should increase the confidence of the surgeon operating in the deep pelvis.
In a recent study of 48 post-hysterectomy patients presenting with chronic pelvic pain and found to have severe bowel adhesions, the complications were as follows. Intraoperative complications (n=3; 6.2%) included an enterotomy in one patient and bladder injury in two. All were repaired laparoscopically with no conversions to laparotomy. Postoperative complications (n=3; 6.2%) included one ileus which required a two-day hospital admission, one pelvic abscess requiring readmission and second-look laparoscopy. Of the 23 patients followed for more than 24 months, 11 (47.8%) required from 1 to 3 subsequent surgeries. Complete pain relief was reported by 10 (43.5%) of the women, 8 of whom had not required further surgery. Twelve (57.1%) of the 21 patients followed for 6 to 12 months reported complete pain relief.
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