· Intraoperative complications arise from unintended injury to anatomically adjacent structures.
· The frequency is generally 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
Bowel injury:
- Frequency 1-3%, necessary adhesiolysis increases the risk to 4-13%
- Possible injury patterns:
- Superficial serosal injuries
- Transmural lesions of the bowel wall
- Thermal damage to the bowel wall using bipolar scissors or ultrasonic dissector, especially in the area of the left flexure.
- Mesenteric tears with subsequent ischemia of the dependent bowel segment
- Injury by 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 bowel preferably in the area of the taeniae or appendices epiploicae only with atraumatic grasping forceps under vision.
- No blind coagulations, careful, targeted preparation with ultrasonic scissors/bipolar sealing instruments
Caution: Ultrasonic scissors and bipolar sealing devices can cause thermal damage several seconds after active use.
- Procedure upon recognition:
- Robotic suturing for serosal lesions and smaller defects
- For larger defects >1/2 of the circumference or mesonear lesions: robotically assisted resection and anastomosis
Spleen injury
- Injury mechanism: Pulling on the colon or greater omentum during mobilization of the left flexure typically results in inferior or medially located superficial capsular lesions.
- Prevention: Mobilization of the left flexure with great care and under good exposure of the site. Omental adhesions to the splenic capsule should be addressed and resolved early.
- Procedure upon recognition:
- Coagulation with bipolar current (bipolar forceps), if necessary, apply hemostatic agent (Tachosil, Flowseal, etc.) or fibrin glue.
- A spleen-preserving therapy should always be pursued, as it is associated with a lower complication rate than splenectomy.
Note: A laparotomy is only necessary in exceptional cases.
Pancreas injury
- Injury mechanism: During mobilization of the left flexure and also during management of the inferior mesenteric vein, one works close to the pancreatic tail and lower pancreatic margin, which can lead to injury.
- Procedure upon recognition:
- In case of bleeding, proceed similarly to spleen injuries. Coagulation with bipolar current (bipolar forceps), if necessary, apply hemostatic agent (Tachosil, Flowseal, etc.) or fibrin glue.
- For parenchymal injuries, it is advisable to place a drain to divert secretions in case of a pancreatic fistula and prevent postoperative complications.
Ureter injury
- Injury mechanism: During mobilization of the sigmoid, due to its close anatomical relationship, ureter 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 for better visualization
Caution with previous surgeries and adhesions 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 diagnostics
- Visual examination
- Therapy
- Stenting and suturing for short-segment injuries
Note: For superficial injuries, laparoscopic suturing can be attempted; otherwise, a small laparotomy directly over the injury site is recommended to suture the ureter under direct vision. In any case, placement of a ureteral stent is indicated.
- Extensive injuries 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 associated blood loss, from intraoperatively uneventful 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 by 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 strategy
- Injury to muscular or epigastric vessels in the abdominal wall during trocar placement: compression, if necessary, 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, if necessary, by clipping.
- For injuries to large vessels (e.g., aorta, vena cava), immediate laparotomy is indicated. Inform anesthesia and provide blood products, if necessary, involve a vascular surgeon and prepare a vascular tray, create anatomical overview, repair 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 managing the injury
Intraoperative leakage of the anastomosis
- Diagnostics: Performing an intraoperative leak test as a hydropneumatic leak test or as a test with diluted methylene blue solution.
- Therapy: If the leak test is positive, 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. In principle, in the case of intraoperative leakage, the creation of a protective ileostomy should be considered.