Bowel & Bladder injury

Tagged Complications, bowel injury, bladder injury, ureteric injury; Comments 4 ; Posted 12 years ago

A couple of months ago, I attended an AGES conference on surgical disasters. I am interested in surgical complications professionally and academically. The majority of participants were general gynaecologists.  What caught my interest was the general motion of the audience that the scare of “being in trouble” and not knowing how to get out of trouble causes notable stress in our profession.

General gynaecologists operate in the pelvis, a shared space between uterus/tubes/ovaries, the bladder at the front, the sigmoid colon and rectum at the back, and major blood vessels and nerves laterally.

A couple of cases of presumed surgical complications were presented and discussed during that session.

The panel presented a case of a patient with free fluid in the abdomen postoperatively; the urologist was called to take over, even if a diagnosis of a bladder leak or a ureteric fistula was not made yet (postoperative inflammation in the pelvis can also cause fluid accumulation and is normally treated with antibiotics and/or NSAIDS).

An accidental touch of the bowel with the diathermy causing blanching of the colonic serosa triggered calling the general surgeon who than was asked to take over and could pretty much do whatever s/he wanted to do. Bowel resection and stoma included.

Whenever gynaecologists attempted to tend to their patients themselves, one of the senior colleagues got up and noted that if a bowel complication happens and you don’t call a bowel surgeon – you are in deep trouble. If a bladder or ureteric injury happens and you don’t call a urologist – you are in deep trouble. The threat of litigation was the elephant in the room, and automatically strangulated all rational thinking about the actual case right from the beginning.

Should there be more interest from general gynaecologists in their own surgical complications? If we delegate problematic issues straight away, our brain learns that we have nothing to do with it; learn nothing, don’t advance our skills. How would a patient feel (when there is a problem) if the only way of managing it is to straight hand over care (to a “real surgeon”)? While we do need to involve urologists and general surgeons - would it not be nice to boost the own training in this area and at least know to confirm or exclude the presence of a problem and maybe even learn - extend out knowledge and expertise what needs to be done?

My colleagues and I are certainly happy to receive a “call from a friend” (and I actually do receive those calls and appreciate them): “What do I do next with this patient?”

From time to time I teach at the Anatomy of Complications workshop and one of those workshops was targeted to urologists. One of the tasks was to reimplant a ureter into the pig bladder. I demonstrated the task and then handed over to one of the senior urology trainees. He did a great job, handling the Pott’s scissors, the suture and the stent well. During his suturing I asked him how many times he would have reimplanted a ureter in his career so far. He never had done it before! As a matter of fact, he never dissected a ureter previously. However, when it comes to repairing a ureteric injury during gynaecological surgery we ask for the urologist on call and assume that they do it all the time. Why can’t gynaecologists at least get trained in diagnosing ureteric injuries and learn (at least theoretically) what needs to be done in that case. I realise that urologists might be more comfortable and may have better support than general gynaecologists and (to clarify it for once and ever) I recommend that general gynaecologists hand over urological complications in the interest of our patients. However, we might wish to diagnose and define the problem first and then work in collaboration and have input into its repair. In real life, a lot of my general gynaecology colleagues do that actually.

When I trained as a gynaecological oncology fellow I assisted with a case of a TLH when my boss incidentally caused an injury to the sigmoid colon. It was a thermal injury accidentally caused when the monopolar scissors touched the sigmoid colon when he attempted to open a window into the peritoneum to mobilise an ovary. The bowel serosa was blanched but no spill of bowel contents was noted. He was obviously not happy, converted the laparoscopic operation to an open operation and proceeded with a sigmoid colon resection.

What we should have done that day is that: Recently, a paper was published in Minimally Invasive Gynecology on laparoscopic repair of bowel injuries at colonoscopies. Over a 17-month period the authors were asked to assist with a total of five acute iatrogenic perforations during colonoscopy. The perforations were secondary to trauma (n=3) or thermal injury (n=2) and located at the sigmoid colon (n=4) or the caecum (n=1). Patients’ mean age was 71 years. All perforations were attended to within 24 hours and managed successfully with a colorrhaphy (oversewing of bowel injury). No patient required a bowel resection, a stoma or a conversion to laparotomy. After surgery, there were no complications noted and no patient had to be taken back to the operating theatre or be readmitted to hospital.

This paper is teaching us that we don’t need to convert to an open operation; we don’t need to divert the patient’s bowels and give her a stoma and a bag; we simply need to suture the defect and we can do that laparoscopically in the majority of patients if not always.

Do we need to be more interested in managing our own surgical complications?

You can say you heard this from Andreas’ Blog.