The process by which the presumptive diagnosis is made is the most important issue in this article. The shorter the process, the lower the patient’s morbidity, and vice versa.
Look for steady improvement. Worry when it is absent
After any laparoscopic operation, the postoperative course should be one of steady clinical improvement. When a patient deviates from this model, the foremost presumptive diagnosis should be laparoscopy-associated injury, and the intestine should top the list of organs that may be injured. Other diagnoses should be subordinate to the principal presumptive diagnosis; these include ileus, bowel obstruction, pulmonary embolus, gastroenteritis, and hematoma, to name a few.
I do not mean to imply that a potentially life-threatening complication such as pulmonary embolus should not be ruled in or out, but that the necessary imaging should be performed in a timely fashion. The abdominal-pelvic CT scan will offer clues to the presence of free air, free fluid, air-fluid levels, and foreign bodies. It also is useful in detecting intra-abdominal—specifically, subphrenic—abscess. If necessary, a VQ scan or spiral CT scan can then be performed without delaying the diagnosis of the primary intra-abdominal catastrophe responsible for the pulmonary symptoms.
In the opening case, before making an improbable presumptive diagnosis, the surgeon should have questioned why an otherwise healthy woman would coincidentally develop gastroenteritis after laparoscopic surgery. The same can be said for diagnoses of intestinal obstruction or vascular thrombosis involving the intestinal blood supply.
Typical presentation of the injured patient
An injured patient does not experience daily improvement and a return to normal activity. Instead, the postoperative period is marked by persistent and worsening pain, often compounded by nausea or vomiting, or both. The patient may complain of fever, chills, weakness, or simply not feeling normal. Breathing may be labored. As time elapses, the symptoms become worse.
Reports of more than one visit to an emergency care facility are not uncommon. When examined, the patient exhibits direct or rebound tenderness, or both. The abdomen may or may not be distended, but usually is increased in girth. Bowel sounds are diminished or absent.
Vital signs initially reveal normal, low-grade, or subnormal temperature, and tachycardia, tachypnea, and normal blood pressure are typical. As time and sepsis progress, however, fever and hypotension develop. Most other symptoms and signs become progressively more abnormal in direct proportion to the length of time the diagnosis is delayed.
Seminal laboratory values for sepsis include a lower than normal white blood cell (WBC) count, elevated immature white-cell elements (e.g., “bandemia”), elevated liver chemistries, and an elevated serum creatinine level.
Mortality is most often the result of overwhelming and prolonged sepsis, leading to multiorgan failure, bleeding diathesis, and adult respiratory distress syndrome.
Among 130 laparoscopic surgical cases complicated by bowel injury and reported by Baggish, sepsis was diagnosed in 100% of colonic perforations and 50% of small-bowel perforations when the diagnosis was delayed more than 48 hours after surgery.1
TABLE 1 lists the signs and frequency of sepsis in these 100 cases, and TABLE 2 collates the signs and symptoms that were observed. Peritoneal cultures obtained at the time of exploratory laparotomy revealed multiple organisms (polymicrobial) in 60% of cases.
TABLE 1
Frequency of signs of sepsis among 130 patients with colon or small-bowel injury
| Sign | Colon (49 patients) | Small bowel (81 patients) |
|---|---|---|
| Normal or subnormal temperature | 30* | 41* |
| Fever | 19 | 40 |
| Tachycardia | 31 | 44 |
| Tachypnea | 30 | 40 |
| Hypotension | 21 | 15 |
| Anemia | 38 | 51 |
| Depressed WBC count | 20 | 18 |
| Elevated WBC count | 24 | 32 |
| Bandemia | 25 | 30 |
| Elevated creatinine and blood urea nitrogen levels | 12 | 5 |
| *Number of patients. | ||
| Source: Baggish1 | ||
Watch for signs and symptoms of intestinal injury
| Symptom | Sign |
|---|---|
| Abdominal pain | Direct or rebound tenderness |
| Bloating | Abdominal distension |
| Nausea, vomiting | Diminished bowel sounds |
| Fever, chills | Elevated or subnormal temperature |
| Difficulty breathing | Tachypnea, tachycardia |
| Weakness | Pallor, hypotension, diminished consciousness |
| Source: Baggish1 | |
Concurrent injuries to neighboring structures
A number of collateral injuries may occur in conjunction with intestinal perforation, depending on the location of the trauma. The most dangerous combination includes indirect laceration of one of the major retroperitoneal vessels. A through-and-through perforation of the cecum can also involve one or more of the right iliac vessels. A trocar perforation of the ileum may continue directly into the presacral space or pass above it and penetrate the left common iliac vein or aorta. Similarly, perforation of the sigmoid colon may penetrate the left iliac vessels.
Careful inspection of the posterior peritoneum for tears and evidence of retroperitoneal hematoma is required to avoid missing a serious collateral injury. More likely, however, is a penetrating injury to the small bowel presenting with collateral mesenteric damage and compromise of the blood supply of an entire segment of bowel. The ureter and bladder may also be injured when dissection along the pelvic sidewall, or a trocar thrust, deviates to the right or left of midline. In thin patients, the stomach may be perforated as well as the small intestine or transverse colon.