During the past four decades, gynecologic laparoscopy has evolved from a limited method of access used for diagnosis and sterilization to an advanced operative approach that frequently serves as a substitute for laparotomy. As of 2009, 20% of the 600,000 hysterectomies performed in the United States were done laparoscopically.1 The advantages of laparoscopy over laparotomy include less postoperative pain, shorter hospital stays, and reduced blood loss.2–4 However, complications may arise during initial abdominal access, port placement, dissection, or use of electrosurgery.
Bowel injury is thought to be a rare complication of laparoscopy but carries a high rate of morbidity and mortality, particularly when diagnosed postoperatively.5 Some studies suggest that the mortality rate associated with delayed diagnosis bowel injury may be as high as 21%.6,7 Furthermore, laparoscopy-associated bowel injury is a significant cause of litigation in the United States.8 Despite several decades of experience with laparoscopy, the rate of bowel injury is not well defined with widely varying rates reported.5,9 We undertook a systematic review to evaluate the incidence, presentation, mortality, cause, and location of injury within the gastrointestinal tract associated with gynecologic laparoscopy.
The PubMed Central, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched in duplicate by two reviewers (N.C.L. and A.B.S.) to identify studies reporting the incidence of bowel injury in gynecologic laparoscopy. The PubMed Central search was conducted using two sets of MeSH headings: 1) “laparoscopy,” “gynecologic surgical procedures,” and “intraoperative complications or postoperative complications”; and 2) “laparoscopy,” “intestinal perforation,” and “gynecologic surgical procedures.” A similar search strategy was used for EMBASE. The databases were searched without restriction on date of publication or study design. Additional relevant articles that did not appear in the database searches were garnered from the references of included papers.
This systematic review was conducted in accordance with Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies.10 The aim of the review was to evaluate the incidence of bowel injury in gynecologic laparoscopy as well as the clinical presentation, mortality rate, cause, and location of injury within the gastrointestinal tract. Eligibility for inclusion was limited to papers written in English that reported the incidence of laparoscopic bowel injury. Studies were excluded if they were not in English or duplicated data already included in the review. The quality of the enrolled studies was evaluated by two reviewers in duplicate (N.C.L. and A.B.S.) using the Newcastle-Ottawa Quality Assessment Scale (see the Appendix, available online at http://links.lww.com/AOG/A638).
Each abstract obtained through the electronic databases was evaluated for relevance, and the full text of each relevant abstract was obtained and evaluated for inclusion. Data were obtained and extracted by two reviewers in duplicate (N.C.L. and A.B.S.). The definition of bowel injury in these studies varied from serosal abrasion to full enterotomy. Because bowel injury was infrequently defined and serosal injury and enterotomy were rarely distinguished, we do not distinguish between the types of bowel injuries for the purpose of this review.
Comparisons of categorical variables, including rates of bowel injury by year and study type (prospective compared with retrospective), were performed using Fisher's exact test. Additionally, rates of bowel injury in studies that explicitly defined bowel injury to include both serosal injuries and enterotomies were compared with rates in those studies that did not specify the definition of bowel injury using Fisher's exact test. P values <.05 were considered significant. Ninety-five percent confidence intervals (CIs) were calculated using the Wilson method for calculating CIs for proportions.11 Analyses were conducted using Stata 13.
Study selection is outlined in Figure 1. A total of 324 abstracts and 236 full-text articles were reviewed for eligibility. The literature review identified 90 studies meeting inclusion criteria (Table 1).6,7,9,12–99 The studies were published between 1972 and 2014 and reflect an international pool of experience with gynecologic laparoscopy. Among them were 60 retrospective and 27 prospective studies. A total of 474,063 laparoscopies were reported, including 230,033 sterilizations, 54,181 hysterectomies, 3,885 myomectomies, 496 sacrocolpopexies, and nine cytoreductions for ovarian cancer. An additional 50,437 laparoscopies were classified as “diagnostic” or “minor” without further description, and 52,992 laparoscopies were characterized as “major” or “advanced.”
A total of 604 bowel injuries were reported for a combined incidence of 1 in 769 (0.13%, 95% CI 0.12–0.14%). Rates of bowel injury varied by procedure, year, study methodology, and by definition of bowel injury. The rate of injury ranged from 1 in 3,333 (0.03%, 95% CI 0.01–0.03%) for laparoscopic sterilization to 1 in 256 (0.39%, 95% CI 0.34–0.45%) for hysterectomy (Table 2). Rates of bowel injury for a single procedure (laparoscopic hysterectomy) were compared before 2000 and after 2000. Rates reported before 2000 (1/222 [0.45%]) were higher than those reported after 2000 (1:294, 0.34%) (relative risk [RR] 0.75, 95% CI 0.57–0.98, P=.03). There was also a significant difference in the rate of bowel injury among studies (including all procedure types) that explicitly defined bowel injury to include serosal injuries and enterotomies, 1 in 416 (0.24%), compared with studies that did not clearly define bowel injury (1/833 [0.12%]) (RR 0.47, 95% CI 0.38–0.59, P<.001). Finally, there was a significant difference in the incidence of bowel injury identified by prospective (1/666 [0.15%]) and retrospective (1/909 [0.11%]) studies (RR 0.78, 95% CI 0.63–0.96, P=.02).
Twenty-nine studies describing 354 bowel injuries reported the location of the injury within the gastrointestinal tract (Table 3). The small intestine was the most frequently damaged region with 166 (47%, 95% CI 42–52%) injuries followed by the colon with 106 (30%, 95% CI 25–35%) injuries, the rectum with 62 (18%, 95% CI 14–22%) injuries, and the stomach with 20 injuries (6%, 95% CI 4–9%).
An additional 30 studies evaluating 366 bowel injuries described the laparoscopic instruments responsible for the damage (Table 4). The majority of bowel injuries occurred during initial abdominal access obtained using a Veress needle or trocar placement (201 injuries [55%], 95% CI 50–60%). Electrosurgery was causative factor in 105 (29%, 95% CI 24–34%) bowel injuries. 42 (11%, 95% CI 9–15%) injuries occurred intraoperatively during dissection or lysis of adhesions as a result of an unknown instrument, and 15 (4.1%, 95% CI 3–7%) occurred as a result of the grasping forceps or scissors (Table 4).
Bowel injury was managed primarily by laparotomy (Table 5). The management of laparoscopic bowel injury was described in 40 studies reporting 307 injuries. Among these, 247 (80%, 95% CI 76–84%) injuries were managed with laparotomy, including conversion of the initial laparoscopic procedure. Some injuries discovered intraoperatively were repaired laparoscopically (23 injuries [8%], 95% CI 5–11%), and a remarkably small fraction (seven injuries [2%], 95% CI 1–5%) were managed expectantly. Among the injuries treated laparoscopically, two required reoperation with laparotomy. An additional 30 injuries (10%, 95% CI 7–14%) were managed without laparotomy, but the mode of treatment was not specified.
Among the 375 bowel injuries for which time of injury was reported, the diagnosis was delayed in 154 of 375 cases (41%, 95% CI 36–46%). The median time to diagnosis for delayed injuries was 3 days but varied from 1 to 13 days. The presenting signs and symptoms of bowel injury were described in 19 cases (Fig. 2) and most frequently included peritonitis (9/19), abdominal pain (8/19), fever (8/19), and abdominal distension (6/19). Two patients presented with rectovaginal fistulas, and one had an abdominal abscess. Leukocytosis (2/19) and leukopenia (1/19) were infrequently reported. Two patients were reported to be in septic shock on presentation, one of whom developed acute respiratory distress syndrome.
Among 604 bowel injuries, five deaths were reported for an overall mortality rate of 1 in 125 (0.8%, 95% CI 0.36–1.9%) cases. However, only 42 studies explicitly mentioned mortality as an outcome. Furthermore, all of the deaths reported in these series occurred as a result of delayed recognition of bowel injury (n=154), making the mortality rate for unrecognized bowel injury 5 in 154 or 1 in 31 (3.2%, 95% CI 1–7%). There were no deaths associated with intraoperatively diagnosed bowel injury.
In this review of 474,063 gynecologic laparoscopies, bowel injury occurred in 1 in 769 cases. The incidence of injury varied across 90 studies, from 0 to 1 in 4.5.27,32,35,71 Rates of injury differed as a result of inconsistencies in the definition of bowel injury, failure to stratify injury rates by procedure complexity, and differences in study design. We noted a higher rate of bowel injury in prospective as compared with retrospective studies, suggesting that retrospective studies may be underestimating the true incidence of injury.
Because bowel injury was inconsistently defined, some studies report both serosal abrasion and perforation, whereas others describe only enterotomy. A French study of 29,966 laparoscopies, in which the rate of bowel injury was 0.12%, reported bowel injury as a complication only if it required laparotomy and excluded injures repaired intraoperatively.18 Notably, the rate of injury was higher in studies that defined bowel injury to include both serosal injuries and enterotomies than in studies that did not clearly define bowel injury, suggesting that serosal injuries are underreported. Additionally, injuries repaired intraoperatively may be underreported. Two of the largest retrospective series in the review, the Finnish studies, which together evaluated 102,812 laparoscopies, reported a remarkably low rate of bowel injury at 0.06–0.07% and a high proportion of delayed diagnosis (82%).33,34 This rate of delayed diagnosis is substantially higher than our rate of 42%, indicating that the rate of intraoperatively repaired injuries may be underestimated.6,7,33,34,41,100 These findings highlight the need for prospective studies evaluating the incidence of laparoscopic complications that clearly define bowel injury.
Obtaining abdominal access is a high-risk segment of laparoscopic procedures. Approximately 55% of bowel injuries occurred during abdominal access and insufflation, either as a result of the Veress needle or a trocar. The International Society for Gynecologic Endoscopy survey found that although bowel injury occurred less frequently among experienced surgeons, the risk of injury during abdominal access was unrelated to experience.7,100 In a study of trocar-associated injuries reported to the U.S. Food and Drug Administration, bowel injury was second only to major vascular injury as the leading cause of trocar-associated death after laparoscopy and was more likely than vascular injury to go undetected during surgery.101 A recent systematic review of 28 randomized controlled trials found no difference in major vascular or visceral complications between the open Hassan technique and the closed Veress needle approach102; however, the open-entry technique resulted in fewer failed entries.103 It has been suggested that the open technique may facilitate intraoperative diagnosis of bowel injury, reducing mortality associated with delayed recognition.75,104 Unproven strategies for preventing complications associated with abdominal access include evaluating the primary trocar site from a secondary port and inspecting the bowel underneath the primary entry site for damage, particularly in the presence of adhesions.104 Knowledge of laparoscopic access techniques is critical for avoiding complications associated with abdominal entry.
Delayed diagnosis of bowel injury results in significant morbidity and mortality and is an important cause of litigation in the United States.8 We found that 41% of bowel injuries went unrecognized at the time of surgery. Electrosurgery, which accounted for 29% of bowel injuries in our review, has frequently been implicated as the causative factor in late-presenting bowel injuries.33,105 Limited information is available about the presentation of postoperatively diagnosed laparoscopic bowel injuries; however, the presentation often differs from the classical picture of peritonitis, possibly as a result of minimal stimulation of acute phase reactants by laparoscopy compared with laparotomy.100,106,107 In this series, leukocytosis, ileus, and septic appearance were infrequently reported, particularly when the small bowel had been injured.
Managing bowel injury frequently requires laparotomy, although several studies support the safety of intraoperative laparoscopic repair.108–110 Bowel injuries diagnosed postoperatively almost always require laparotomy, because the entire abdomen must be evaluated.105,106 Approximately 80% of bowel injuries in the reviewed series were managed with laparotomy and 8% were managed laparoscopically. Despite the notion that injuries such as from a Veress needle can be observed expectantly, we would advise caution given that we identified only six cases in 46 years of literature.
In this series, five deaths were reported after a delay in diagnosis of bowel injury, for a mortality rate of 1 in 31. Prior studies have reported the mortality rate after delayed diagnosis to be as high as 21%.6,7,100,105 There were no deaths associated with intraoperatively diagnosed injuries; however, deaths may be underreported, because only 29 of 90 studies explicitly mentioned mortality as an outcome. These results highlight the need for prospective data regarding mortality rates after laparoscopic bowel injury.
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