One-Hundred and Thirty Small- and Large-Bowel Injuries Associated with Gynecologic Laparoscopic Operations

One-hundred and thirty cases of laparoscopically associated intestinal perforations are reported in this paper. This series consisted of 81 small intestinal and 49 large intestinal injuries. Seventy-seven percent of the former and 41% of the latter were entry-related, that is, trocar-associated injuries, whereas 59% of large bowel and 23% of small bowel injuries were associated with the operative procedure. The majority of injuries were diagnosed postoperatively, and 70% of small bowel and 51% of large bowel perforations were diagnosed late. The most useful laboratory studies leading to the correct diagnosis were the computed axial tomography scan with contrast and the complete blood count with differential. Many of the patients experienced unnecessary delays before an exploratory laparotomy procedure was undertaken. Because of the delay, sepsis intervened in every colonic perforation, and in 50% of small bowel perforations when the diagnosis was delayed >48 hours. Many of the patients had collateral complications, including abscess formation, wound infection, pleural effusion, and colostomy. Complex laparoscopic operations, especially in the presence of moderate to severe adhesions and particularly following prior abdominal surgery, are at the highest risk relative to intestinal injuries. The gynecologic surgeon must always be aware that the normal sequence of events following laparoscopic surgery should be that of steady improvement. When that pathway is aberrant, the surgeon must, first and foremost, consider a major laparoscopically associated injury.