In one memorable case, a primary trocar penetrated the omentum, injuring several underlying structures. In its transit, the trocar passed through both the anterior and posterior walls of the duodenum and finally entered the superior mesenteric artery. The gynecologic surgeon performing the laparoscopic tubal ligation failed to recognize any of these injuries. The patient went into shock in the recovery room and was returned to the operating room. Fortunately, a transplant surgeon from a neighboring theater was immediately available to consult and repair the damage.
Another danger: intestinal ischemic necrosis
Abnormalities in splanchnic blood flow are sometimes caused by elevations in intra-abdominal pressure. Caldwell and Ricotta inflated the abdomens of nine dogs and reported a significant reduction of blood flow to omentum, stomach, duodenum, jejunum, ileum, colon, pancreas, liver, and spleen, but not to the adrenal glands.2 The splanchnic flow reductions essentially shunted blood away from abdominal viscera with auto-transfusion to the heart, lungs, and systemic circulation.
Eleftheriadis and colleagues studied 16 women randomized to laparoscopic versus open cholecystectomy.3 Significant depression of the hepatic microcirculation during the period of CO2 gas insufflation was noted in the laparoscopy cohort but not in the control group. Gastric mucosal ischemia also was observed in the laparoscopy group.
Several case reports of catastrophic intestinal ischemia have appeared in the literature (1994–1995).4-7 These articles have mainly involved laparoscopic upper abdominal operations in elderly people.
Recently, however, Hasson and colleagues reported a case of possible ischemic necrosis of the small intestine following laparoscopic adhesiolysis and bipolar myolysis.8 The authors emphasized that CO2 pneumoperitoneum reduces splanchnic blood flow, predisposing the patient to ischemia, but that ischemia with infarction requires an underlying vasculopathy or inciting factors such as traction on a short mesentery, atherosclerosis, or thrombosis.
A high index of suspicion for bowel ischemia following laparoscopic surgery should occur when, postoperatively, a patient experiences inordinately severe abdominal pain associated with tachypnea, tachycardia, and alterations in the WBC count. A paucity of physical abdominal signs in the early phases of this disorder should alert the clinician to the possibility of bowel ischemia.
Diagnosing and treating ischemia
A CT scan with contrast can suggest ischemia, but angiography is usually required for definitive diagnosis.
Treatment begins with infusion of papaverine into the intestinal vasculature via angiography cannula. In some cases, anticoagulation may be indicated. Surgery by laparotomy is clearly indicated for patients who fail to respond to vasodilatation measures.
This condition can be ameliorated by intermittent intraoperative decompression of the abdomen. Avoiding prolonged CO2 pneumoperitoneum and a lengthy laparoscopic operation also may diminish the risk of intestinal ischemia.