During observation over the next 2 days, she remains afebrile and tachycardic, but her shortness of breath becomes progressively worse. Neither spiral CT nor lower-extremity Doppler suggests pulmonary embolism or deep venous thrombosis. Supplemental oxygen, aggressive pain management, albuterol, ipratropium, and acetylcysteine are initiated after pulmonary consultation.
The patient tolerates a regular diet on postoperative day 3 and has a bowel movement on day 5. However, the same day she begins vomiting and reports worsening abdominal pain. CT imaging of the abdomen and pelvis reveals free air in the abdomen and loculated fluid with air bubbles suspicious for intra-abdominal infection and perforated bowel.
Exploratory laparotomy reveals diffuse feculent peritonitis, as well as food particles and contrast media. There is a perforation in the antimesenteric side of the ileum approximately 1.5 feet proximal to the ileocecal valve. This perforation measures approximately 1 cm in diameter and is freely spilling intestinal contents. Small bowel resection is performed to treat the perforation.
Following the surgery, the patient recovers slowly.
Could the bowel perforation have been detected sooner?
Intestinal tract injury is a serious complication, particularly with postoperative diagnosis.15 Damage can occur during insertion of the Veress needle or trocar when the bowel is immobilized by adhesions, or during enterolysis.16 Unrecognized thermal injury can cause delayed bowel injury.
Small-bowel damage often occurs during uncontrolled insertion of the Veress needle or primary umbilical trocar. It also may result from sharp dissection or thermal injury.17,18 Abrasions and lacerations can occur if traction is exerted on the bowel using serrated graspers. When adhesions are dense and tissue planes poorly defined, the risk of laceration due to energy sources or sharp dissection increases.
Be cautious during bowel manipulation. Avoid blunt dissection. Be especially careful when the small bowel is adherent to the anterior abdominal wall (FIGURE 2A), particularly during evaluation of patients with a history of bowel resection, exploratory laparotomy for trauma-related peritonitis, or tumor debulking.
Remove the primary and ancillary cannulas under direct visualization with the laparoscope to prevent formation of a vacuum that can draw bowel into the incision and cause herniation.19
FIGURE 2 Adherent bowel, minor bleeding
A: Veress needle pressure measurements are persistently elevated before primary trocar insertion in this patient, raising the suspicion of adhesive disease from earlier surgery. As a result, the primary trocar is relocated to the left upper quadrant. Inspection confirms that small bowel is adherent to the anterior abdominal wall.
FIGURE 2 Adherent bowel, minor bleeding
B: After the small-bowel adhesions are dissected off the anterior abdominal wall via laparoscopy, a small hematoma is discovered, likely caused by the Veress needle. The patient is managed conservatively and recovers.
The value of open laparoscopy
In open laparoscopy, an abdominal incision is made into the peritoneal cavity so that the trocar can be placed under direct vision, after which the abdomen is insufflated. This approach can prevent bowel injury only when the adhesions and attachments are to the anterior abdominal wall and away from the entry site. When the attachment lies directly beneath the umbilicus, however, open laparoscopy is no guarantee against injury.
When bowel adhesions are severe, use alternative trocar sites such as the left upper quadrant (Palmer’s point) for the Veress needle and primary trocars.5,20,21
The likelihood of perforation can be reduced with preoperative bowel prep when there is a risk of bowel adhesions.
Identifying bowel injury
We recommend routine inspection of the structures beneath the primary trocar upon insertion of the laparoscope to look for injury to the bowel, mesentery, or vascular structures. If adhesions are found, evaluate the area carefully to rule out injury to the bowel or omentum. It may be necessary to change the position of the laparoscope to assess the patient.
Trauma to the intestinal tract can be mechanical or electrical in nature, and each type of trauma creates a distinctive, characteristic pattern. Thermal injury can be subtle and present as simple blanching or a distinct burn and charring. A small hole or obvious tear in the bowel wall can be the result of mechanical injury.22
Benign-appearing, superficial thermal bowel injuries may be managed conservatively.22 Minimal serosal burns (smaller than 5 mm in diameter) can be managed expectantly. Immediate surgical intervention is needed if the area of blanching on the intestinal serosa exceeds 5 mm in diameter or if the burn appears to involve more than the serosa.23
Small-bowel injuries that escape notice intraoperatively generally become apparent 2 to 4 days later, when the patient develops fever, nausea, lower abdominal pain, and anorexia. On postoperative day 5 or 6, the white blood cell (WBC) count rises and earlier symptoms may become worse. Radiography may reveal multiple air and fluid levels—another sign of bowel injury. Be aware that if the patient has clinical symptoms of gastrointestinal injury, even if the WBC count is normal, exploratory laparoscopy or laparotomy is necessary for accurate diagnosis.