Inadvertent enterotomy in minimally invasive abdominal surgery.

BACKGROUND: Inadvertent enterotomy (IE) in laparoscopic abdominal surgery is underreported. Patients with a prior history of laparotomy are at significantly increased risk of enterotomy if another operation is needed. The incidence of enterotomy in laparoscopic surgery may even be greater than that during an open procedure and may go unrecognized due to the limited field of vision. The purpose of this study was to report the incidence of inadvertent enterotomy in a variety of laparoscopic abdominal procedures at our institution and discuss ways to minimize the risk of this complication.

METHODS: Using the data from morbidity and mortality conferences, we retrospectively reviewed all complications from 3,613 consecutive patients who had laparoscopic abdominal surgery from November 1998 through November 2004. Patients with inadvertent enterotomy were divided into 4 groups according to the type of laparoscopic procedure. Inadvertent enterotomy was defined as any transmural penetration of any part of the intestine. All inadvertent enterotomies that occurred during laparoscopic abdominal surgery were analyzed for mechanism of injury and method of repair, whether diagnosis was made intraoperatively or postoperatively, clinical presentation, conversion rate, and whether a second procedure was necessary.

RESULTS: Laparoscopic operations were performed in 3,613 persons. Patients diagnosed with IE were divided into 4 groups: Group #1: cholecystectomy; Group #2: all patients requiring intestinal resection with or without primary anastomosis; Group #3: patients with any type of hernia repair; Group #4: all patients that had adhesiolysis as a primary indication for the operation. The incidence of IE according to each group was 0.39% (8/2,016), 0.8% (3/375), 1.9% (6/312), 100% (4/4), respectively. Twenty patients had 21 inadvertent enterotomies (4 men, 16 women; mean age, 60.9 years). One patient had 2 operations and had an enterotomy both times. Four patients (4/21, 19%) with unrecognized IE were diagnosed postoperatively. The overall incidence of IE was 0.58%. No deaths occurred.

CONCLUSION: Inadvertent enterotomy in laparoscopic abdominal surgery is especially dangerous if unrecognized during the primary operation. The incidence of IE can be significantly reduced with careful individualized risk assessment. Only surgeons who are trained in advanced laparoscopy should attempt complicated cases and must always be wary of possible bowel injury. Any patient with signs of peritonitis, sepsis, or increased abdominal pain after laparoscopic surgery must promptly be investigated. The department culture of intraoperative cooperation helped improve outcomes.