- Intraoperative complications arise from unintended injury to anatomically adjacent structures.
- The frequency generally ranges between 2 and 12% for colon procedures.
Caution: Known risk factors for intraoperative injury to adjacent structures include:
- Obesity
- Previous surgeries
- Adhesive abdomen
- Emergency procedure
- T4 tumor or extensive accompanying inflammation
Small bowel injury:
- Frequency 1-3%, necessary adhesiolysis increases the risk to 4-13%
- Possible injury patterns:
- Superficial serosal injuries
- Transmural lesions of the intestinal wall
- Thermal damage to the intestinal wall using bipolar scissors or ultrasonic dissector, especially in the area of the left flexure.
- Mesenteric tears with subsequent ischemia of the dependent intestinal segment
- Injury from trocar placement, Veress needle
- Prevention:
- In recurrent procedures, incision as far as possible outside the scar
- Open insertion of the first trocar after previous surgeries
- Grasping the intestine as much as possible in the area of the taeniae or appendices epiploicae only with atraumatic forceps under vision.
- No blind coagulations, careful, targeted preparation under vision
- Caution: Even ultrasonic scissors and bipolar sealing devices can cause thermal damage several seconds after active use.
- Approach upon recognition:
- Robotic suturing for serosal lesions and smaller defects
- For larger defects >1/2 of the circumference or near-mesenteric lesions: robotically assisted resection and anastomosis
Pancreatic injury
- Injury mechanism: During central preparation of the vessels near the pancreatic head, injury can occur in the process.
- Approach upon recognition:
- For bleeding, coagulation with bipolar current (bipolar forceps), possibly using a hemostatic agent (Tachosil, Flowseal, etc.) or fibrin glue.
- For parenchymal injuries, drainage is recommended to divert secretions in case of a pancreatic fistula and prevent postoperative complications.
Ureteral injury
- Injury mechanism: During mobilization of the right hemicolon from the retroperitoneum, due to its close anatomical relationship, ureteral injury can occur. This includes sharp partial or complete transections as well as electrical injuries.
- Prevention:
- Preservation of Gerota's fascia
- Secure identification of the ureter
- Use of ICG (Indocyanine Green) for better visualization
Caution with previous surgeries and inflammation- or tumor-related adhesions (large tumors with organ-overlapping growth) with disruption of anatomical layers: preoperative stenting of the ureter may be considered to facilitate its identification.
- Intraoperative diagnostics
- Visual examination
- Therapy
- Stenting and suturing/possibly anastomosis for short-segment injuries
Note: For superficial injuries, robotic suturing or possibly anastomosis can be performed; alternatively, a small laparotomy directly over the injury site can be performed to suture the ureter openly. In any case, the placement of a ureteral stent is indicated.
- Extensive injuries with substance loss or partial resections require complex urological reconstructions (diversion, contralateral implantation, psoas hitch procedure).
Intraoperative bleeding
- Risk factors:
- Obesity
- Altered anatomy due to previous surgeries, inflammation, and tumors
- Emergency procedures
- Symptoms/Clinical presentation: Depending on the size of the injured vessel and the associated blood loss, ranging from intraoperatively inconspicuous courses to acute shock symptoms (hemorrhagic shock) are possible.
- Diagnostics: Intraoperative visual identification of the bleeding source
- Prevention:
- Identification of surgery- or patient-related risk factors for bleeding complications
- Use of ICG for identification of vascular structures
- Therapy
- Temporary bleeding control through compression with laparoscopic/robotic atraumatic instruments
- Informing the surgical team and anesthesia
- Creating the best possible material and personnel situation surgically (vascular surgeon, second experienced surgeon) as well as anesthesiologically (senior physician, blood units, volume, etc.) Transfusion if transfusion criteria are met
- Surgical tactics
- Injury to muscular or epigastric vessels in the abdominal wall during trocar placement: compression, possibly over a filled bladder catheter. U-sutures above and below the trocar insertion site. In case of doubt, enlargement of the incision site and direct suturing, especially in obese abdominal walls.
- Bleeding from smaller vessels can usually be controlled using bipolar current or ultrasonic scissors and possibly clipping.
- For injuries to large vessels (e.g., aorta, vena cava), immediate laparotomy is indicated. Informing anesthesia and providing blood units, possibly involving a vascular surgeon and preparing a vascular tray, creating anatomical overview, repairing the vessel defect.
Caution: Uncontrolled use of the suction device, especially in venous injuries, can significantly but almost imperceptibly increase blood loss. Therefore, compression until readiness for intervention is established and only then targeted use of the suction device for injury management.
Intraoperative anastomotic leakage
- Diagnostics: Visual inspection of the anastomosis
- Therapy: If the leak test is conspicuous, an attempt can be made to suture a small and easily accessible insufficiency. In case of doubt, re-establishment of the anastomosis should be performed.