"The key word is AWARENESS!" There are many wonderful take home points in this article which is a retrospective review of bowel injury among 1,073 of the authors' cases and of a meta-analysis of 21 other studies with 14,447 patients, all undergoing laparoscopic surgery of the retroperitoneum:

a.) We are getting worse! The incidence of bowel injuries has increased slightly up to 0.65% in the meta-analysis and 0.75% in the currently reported series. However, this is very likely due to the increased complexity of retroperitoneal cases being attempted (e.g. partial nephrectomy, RPLND, etc.) and the extension of retroperitoneal laparoscopy to high-risk individuals (e.g. history of extensive abdominal surgery, morbid obesity, etc.). Indeed, this hypothesis is supported by the fact that the major cause of bowel injury is no longer Veress needle or trocar entry, but tissue dissection (60%).

b.) We are getting better! Between 1993 and 2001, 70% of all bowel injuries were diagnosed postoperatively! For these patients, the incidence of exploratory laparotomy (83%), need for a subsequent procedure after the laparotomy (90%), and death (12%) were high. Indeed, death secondary to bowel injury occurred only in patients in whom the diagnosis was made postoperatively. Fortunately, between 2002 and 2009, the meta-analysis showed only 37% of injuries were diagnosed postoperatively; over 60% were diagnosed during the procedure itself; indeed, in the authors' series, 75% of injuries were also diagnosed intraoperatively and treated largely uneventfully.

c.) While a retroperitoneal approach is associated with a two-fold decrease in bowel injuries (0.38% vs. 0.8%) compared to a transperitoneal approach, the overall incidence of complications in general is similar for the two approaches.

d.) The median time to presentation of a "missed" bowel injury is 4 days postoperatively, but the range is 3-120 days!

e.) The most common signs of a "missed" bowel injury are abdominal discomfort (60%) or tenderness over a port site (47%); leucocytosis was rare (7%). Regarding the latter, these authors and others have shown that a left shift on the white count is a more reliable harbinger of a missed bowel injury than the absolute white cell count.

Bottom line: Look carefully before you leave the site of your laparoscopic surgery. Irrigate at the end of the procedure and as you aspirate the irrigant look again for any possible fecal contaminant. The time to find and repair a bowel injury is at the time of the initial laparoscopic procedure; if you "miss it", they may die.

Schwartz MJ, Faiena I, Cinman N, Kucharczyk J, Meriggi JS, Waingankar N, Richstone L, Kavoussi LR
J Urol. 2010 Aug;184(2):589-94
doi: 10.1016/j.juro.2010.03.133

UroToday Medical Editor Ralph V. Clayman, MD

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