Transverse Colon Injury During Initial Umbilical Access for Robot-Assisted Laparoscopic Hysterectomy: Presumed Bowel Tethering by Omental Adhesions to the Abdominal Wall

Initial laparoscopic access can cause visceral injury even in patients without previous abdominal surgery. Here, we report the case of a 49-year-old woman with adenomyosis and no history of abdominal surgery underwent robot-assisted laparoscopic hysterectomy with bilateral salpingectomy. During initial umbilical access, a camera port fitted with a reusable 8-mm blunt obturator was advanced through the peritoneum. Immediately after camera insertion, bowel mucosa was visualized before pneumoperitoneum had been established. Mini-laparotomy revealed omental adhesion to the anterior abdominal wall, whereas the transverse colon itself was not directly adherent. Two closely adjacent perforations of the transverse colon were consistent with tangential penetration of the colonic wall after the instrument had passed through the adherent omentum. The injury was repaired in two layers, and the planned robotic procedure was completed by converting the mini-laparotomy incision into a sealed camera-port site. Recovery was uneventful. The adherent omentum was considered to have tethered the transverse colon close to the abdominal wall. This case illustrates that the absence of previous abdominal surgery does not guarantee safe umbilical access. Controlling the force and depth of peritoneal entry, using preoperative ultrasonographic assessment as an adjunct rather than a guarantee of safety, and immediately recognizing and systematically evaluating any access-related bowel injury may help reduce the risk of injury and limit its consequences.