Damage caused by a sharp tipped obturator or trocar is usually more serious than needle injury. Inadvertent gastric entry usually is associated with stomach distention because of aerophagia, difficult or improper intubation, or mask induction with inhalation anesthetic. Most often the injury is created by the trocar-cannula system used for primary access. Ancillary cannulas may result in visceral injury, although placement of these cannulas under direct vision helps reduce the risk of injury. The risk of gastric perforation can be minimized with the selective use of preoperative nasogastric or oral gastric suction when left upper-quadrant entries are used or when the intubation was difficult. Open laparoscopy likely has little impact on the risk for gastrointestinal complications, particularly those related to adhesions to the anterior abdominal wall from previous surgery. For high-risk patients, left upper quadrant needle and trocar-cannula insertion with a properly decompressed stomach may be preferable (119–122).
If the trocar of a primary cannula penetrates the bowel, the condition is usually diagnosed when the mucosal lining of the gastrointestinal tract is visualized. If the large bowel is entered, a feculent odor may be noted. However, the injury may not be recognized immediately because the cannula may not stay within the bowel or may pass through the lumen. Such injuries usually occur when a single loop of bowel is adherent to the anterior abdominal wall. The injury may not be recognized until peritonitis, abscess, enterocutaneous fistula, or death occurs (123,124). Therefore, at the end of the procedure, the removal of the primary cannula must be viewed either through the cannula or an ancillary port, a process facilitated by routine direct visualization of closure of the incision of the primary port.
Trocar-related injuries to the stomach and bowel require repair as soon as they are recognized. If the injury is small, a trained operator can repair the defect under laparoscopic direction using a double layer of running 2-0 or 3-0 absorbable sutures. Extensive lesions may require resection and reanastomosis, which in most instances requires at least a small laparotomy. The preoperative use of mechanical bowel preparation in selected high-risk cases minimizes the need for laparotomy or colostomy, but recent evidence suggests that bowel surgery, if necessary, may be safely performed in unprepared bowel (125).
When mechanical bowel trauma is recognized during the dissection, treatment is the same as that described for trocar injury. Should the injury involve radiofrequency electrical energy, it is important to recognize that the zone of desiccation and coagulation may exceed the area of visual damage. This is especially true if the exact mechanism of the thermal injury is unknown or if injury results from contact with a relatively large surface area electrode that would be more likely to create a large coagulation injury. Conversely, bowel injury created under direct vision with a radiofrequency needle or blade electrode is associated with little collateral coagulation effect and can be managed similar to a mechanically induced lesion.
Consequently, surgical repair should be implemented considering these factors, and should include, if necessary, resection of ample margins around the injury. Thermal injury may be handled expectantly if the lesion seems superficial and confined, such as when fulguration (noncontact arcing of modulated high-voltage current) involves bowel. In such instances, the depth of injury is generally less than half a millimeter. In a study of 33 women with such injuries who were managed expectantly in the hospital, only 2 required laparotomy for repair of perforation (126).
Urologic Injury Damage to the bladder or ureter may occur secondary to mechanical or thermal trauma incurred during laparoscopic procedures. Ideally, such injury should be prevented; otherwise, as is the case for most complications, it is preferable to identify the trauma intraoperatively.