General principles:
Intraoperative complications arise from unintended injuries to anatomically adjacent structures.
The overall incidence in colon surgeries ranges between 2% and 12%.
Cave: Known risk factors for intraoperative injury to adjacent structures include:
• Obesity
• Previous surgeries
• Adhesive disease (“frozen abdomen”)
• Emergency procedures
• T4 tumors or extensive associated inflammation
Bowel injury:
Incidence: 1%–3%; however, necessary adhesiolysis increases the risk to 4%–13%.
Potential injury patterns:
• Superficial serosal injuries
• Transmural lesions of the bowel wall
• Thermal damage to the bowel wall caused by bipolar scissors or ultrasonic dissectors, particularly near the left colonic flexure
• Mesenteric tears leading to ischemia in the affected bowel segment
• Injuries caused by trocar insertion or the Veress needle
Prevention:
• During reoperations, incisions should ideally be made outside of the previous scar.
• Open insertion of the first trocar after prior surgeries.
• Grasp the bowel, whenever possible, at the taeniae or epiploic appendages, and only with atraumatic grasping forceps under direct vision.
• Avoid blind coagulation; carefully and precisely dissect with ultrasonic scissors or bipolar sealing instruments.
Cave: Ultrasonic scissors and bipolar sealing devices can cause thermal damage for several seconds after active use.
Management upon recognition:
• Robotic suturing for serosal injuries and small defects.
• For larger defects (>1/2 of the circumference) or lesions near the mesentery: robotic-assisted resection and anastomosis.
Splenic Injury
Mechanism of Injury:
During mobilization of the left colonic flexure, traction on the colon or greater omentum typically causes inferior or medial superficial capsular lacerations.
Prevention:
Mobilization of the left colonic flexure must be performed with great care and under optimal exposure of the surgical site. Omental adhesions to the splenic capsule should be released early.
Management upon Recognition:
• Coagulation using bipolar energy (bipolar forceps).
• If necessary, apply a hemostatic agent (e.g., Tachosil, Flowseal) or fibrin glue.
• A spleen-preserving approach should always be pursued, as it is associated with a lower complication rate compared to splenectomy.
Note:
A laparotomy is only required in exceptional cases.
Pancreatic Injury
Mechanism of Injury:
During mobilization of the left colonic flexure and handling of the inferior mesenteric vein, preparation near the pancreatic tail and lower pancreatic border increases the risk of injury.
Management upon Recognition:
• In the case of bleeding, follow a similar approach as for splenic injury: coagulation with bipolar energy (bipolar forceps), application of a hemostatic agent (e.g., Tachosil, Flowseal), or fibrin glue.
• For parenchymal injuries, placement of a drain is recommended to manage pancreatic secretions in the event of a pancreatic fistula and to prevent postoperative complications.
Ureteral Injury
Mechanism of Injury:
During sigmoid mobilization, the ureter may be injured due to its close anatomical relationship to the operative field. Injuries can include sharp partial or complete transections as well as thermal damage.
Prevention:
• Preserve the Gerota fascia.
• Ensure secure identification of the ureter.
• Use indocyanine green (ICG) for enhanced visualization.
Caution in cases of prior surgeries and adhesion formation due to inflammation or tumors with disruption of anatomical layers in the pelvis.
Preoperative stenting of the ureter should be considered to facilitate its identification.
Intraoperative Diagnosis:
• Visual inspection
Treatment:
• Stenting and suturing for short-segment injuries.
• Note: In cases of superficial injuries, laparoscopic suturing can be attempted. Otherwise, a small laparotomy directly over the site of injury is recommended to suture the ureter under direct vision.
• In all cases, placement of a ureteral stent is mandatory.
• Extensive injuries or partial resections require complex urological reconstructions, such as diversion, contralateral implantation, or a psoas hitch procedure.
Intraoperative Bleeding:
Risk Factors:
• Obesity
• Altered anatomy due to previous surgeries, inflammation, or tumors
• Emergency procedures
Symptoms/Clinical Presentation:
Depending on the size of the injured vessel and the associated blood loss, presentations can range from intraoperatively inconspicuous findings to acute shock symptoms.
Diagnosis:
• Intraoperative visual identification of the bleeding source
Prevention:
• Identification of surgery- or patient-related risk factors for bleeding complications
• Use of indocyanine green (ICG) for vascular structure identification
Treatment:
• Temporary bleeding control with compression using laparoscopic/robotic atraumatic instruments
• Inform the surgical and anesthesiology teams
• Ensure optimal material and personnel resources:
• Surgical: vascular surgeon, second experienced operator
• Anesthesiology: attending anesthesiologist, blood products, volume replacement
• Transfusion if transfusion criteria are met
Surgical Tactics:
• Injuries to muscular or epigastric vessels in the abdominal wall during trocar placement:
• Compression, if necessary with a filled urinary catheter
• U-stitches placed above and below the trocar insertion site
• In uncertain cases, extend the incision and place direct sutures, especially in obese abdominal walls
• Bleeding from smaller vessels:
• Usually controlled with bipolar energy or ultrasonic scissors and, if necessary, clipping.
• Injuries to large vessels (e.g., aorta, vena cava):
• Immediate laparotomy is indicated.
• Inform the anesthesiology team and prepare blood products.
• If necessary, involve a vascular surgeon and prepare a vascular instrument tray.
• Ensure clear anatomical exposure and repair the vascular defect.
Cave:
Uncontrolled use of the suction device, particularly in cases of venous injuries, can significantly increase blood loss almost imperceptibly. Therefore, apply compression until readiness for definitive management is achieved, and only then use the suction device in a targeted manner to address the injury.
Intraoperative Leakage of the Anastomosis
Diagnosis:
Perform an intraoperative leak test, either as a hydropneumatic leak test or using diluted methylene blue solution.
Treatment:
• If the leak test is positive and the insufficiency is small and well accessible, an attempt can be made to suture the defect.
• In cases of uncertainty, re-creation of the anastomosis should be performed.
• In general, the creation of a protective ileostomy should be considered in the event of intraoperative leakage.