Management of large bowel injury during laparoscopic surgery.

in substantially less morbidity, with lower rates of total complications (OR 0.54), intra-abdominal infections (OR 0.67), total infections (OR 0.44), and wound compli- cations (OR 0.73) relative to colostomy. Similarly, Max- well and Fabian compiled data from 20 retrospective studies and found an overall complication rate of 14 % for primary repair versus 31 % for colostomy, with equivalent mortality [4]. According to Reich et al. [ 5], if the large bowel is involved, the treatment options include primary repair, colostomy, or segmental resection. Resection is mandatory in thermal injuries. Intraoperative lacerations may be repaired laparoscopically according to the size of the lesion, surgeon experience, and preoperative bowel prep- aration. Proctosigmoidoscopy can be performed at the end of the surgery to evaluate intraluminal abnormality or rectosig- moid injury. The pelvis is then filled with isotonic fluid and observed laparoscopically for air leakage. The use of drains almost brooks no debate and indeed may be considered mandatory. However, its routine use may be contentious. When used, it is commonly removed after 5 days. However, several prospective randomized trials have demonstrated that there is no significant difference in postoperative morbidity and mortality between patients who do and those who do not undergo closed-suction drainage [6–8]. There are no significant differences in anastomotic leaks (clinical or radiologic) or infectious morbidities. I do suspect, however, it would take a surgeon with nerves of steel to not place a drain under these circumstances. Postoperatively, it is prudent to start fluids early rather than late. This flies in the face of the ‘‘conventional’’ practice of keeping patients starving arbitrarily for 5 days. The secretion of intestinal fluids is unabated and the patient is never really ‘‘nil by mouth.’’ With the advancement of gastrointestinal laparoscopy, surgeons have moved away from the traditional practice of postoperative nasogastric decompression and oral feeding only after passage of flatus has signaled the resumption of bowel function. Several prospective randomized trials have demonstrated that early feeding or patient-controlled feeding is safe in patients undergoing both laparoscopic and open bowel resections and anastomosis [ 9–13]. Furthermore, nasogastric decom- pression was discontinued immediately after the surgery in the majority of these studies. Postoperative nasogastric tube decompression does not provide any significant ben- efit in gynecology patients, including those undergoing bowel resection [ 14]. Although the surgeon should make decisions based on each specific case, it is reasonable to begin clear liquids as early as the first postoperative day. When bowel function resumes or an adequate volume of the clear liquid diet is consumed, a regular or low-residue solid diet may be instituted. Standard postoperative intra- venous fluids should be maintained until the patient dem- onstrates an adequate oral intake. Early recognition of a failed repair or anastomosis is vital to patient outcome. Leaks present as peritonitis, an intra-abdominal abscess, fistula, and sepsis. A majority of leaks occur within 5–7 days of the original surgery. In a recent study of 655 consecutive patients undergoing colo- nic and rectal anastomoses, the authors report a 6 % rate of clinical leaks [15]. If there is radiologic evidence of a leak or a strong clinical suspicion, immediate re-exploration is warranted with repair of the failure/leak site and proximal diversion by colostomy. Prevention of large bowel injury at laparoscopy includes techniques like gentle bowel manipulation, the use of sharp tissue dissection, dissection of tissue from non-adherent areas to the adherent sites, bowel sparing tissue dissection, a meticulous use of electrosurgery, etc. However, at the end of surgery, a search to detect any undetected bowel injury if any is mandatory. Laparoscopic management of cases of severe endome- triosis or cases where dense pelvic adhesions are suspected includes apprising the patient of the possibility of bowel injury during such surgery and providing her the confi- dence about such an event being dealt with competently if the need arose. The drill that the surgeon needs to follow is exacting which entails a detailed preoperative clinical and radiologic assessment, meticulous bowel preparation, a mental visualization of the surgical process, and an involve- ment of a surgeon experienced in management of large bowel injury. Procrastination can mean that a generally forgiving organ that responds well to insult and injury if treated well and in time may later turn its back with fatal consequences.

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