2016 Update on minimally invasive gynecologic surgery

What this EVIDENCE means for practice
Compared with the use of bipolar electrosurgery to attain hemostasis, the use of a topical biosurgical agent or suturing could be significantly better for protection of the ovarian follicles during laparoscopic ovarian cystectomy for endometrioma. These alternative methods especially could benefit those women desiring future pregnancy who are demonstrated preoperatively to have a low ovarian reserve. As needed, electrosurgery should be sparingly employed for ovarian hemostasis.

Large Study identifies incidence of bowel injury during gynecologic laproscopy

Llarena NC, Shah AB, Milad MP. Bowel injury in gynecologic laparoscopy: a systematic review. Am J Obstet Gynecol. 2015;125(6):1407−1417.

In no aspect of laparoscopic surgery are preventive strategies more cautiously employed than during peritoneal access. Regardless of the applied technique, there is an irreducible risk of injury to the underlying viscera by either adhesions between the underlying bowel and abdominal wall or during the course of pilot error. Moreover, in the best of hands, bowel injury can occur whenever normal anatomic relationships need to be restored using intra-abdominal adhesiolysis. Given the ubiquity, these risks are never out of the surgeon's mind. Gynecologists are obliged to discuss these risks during the informed consent process.

Until recently, the rate of bowel injury has not been well established. Llarena and colleagues recently have conducted the largest systematic review of the medical literature to date for incidence, presentation, mortality, cause, and location of bowel injury associated with laparoscopic surgery while not necessarily distinguishing for the type of bowel injury. Sixty retrospective and 27 prospective studies met inclusion criteria.

The risk of bowel injury overall and defined
Among 474,063 laparoscopic surgeries conducted between 1972 and 2014, 604 bowel injuries were found, for an incidence of 1 in 769, or 0.13% (95% CI, 0.12−0.14%).

The rate of bowel injury varied by procedure, year, study type, and definition of bowel injury. The incidence of injury according to:

• definition, was 1 in 416 (0.24%) for studies that clearly included serosal injuries and enterotomies versus 1 in 833 (0.12%) for studies not clearly defining the type of bowel injury (relative risk [RR], 0.47; 95% CI, 0.38−0.59; P<.001)
• study type, was 1 in 666 (0.15%) for prospective studies versus 1 in 909 (0.11%) for retrospective studies (RR, 0.78; 95% CI, 0.63−0.96; P = .02)
• procedure, was 1 in 3,333 (0.03%; 95% CI, 0.01−0.03%) for sterilization and 1 in 256 (0.39%; 95% CI, 0.35−0.45%) for hysterectomy
• year, for laparoscopic hysterectomy only, was 1 in 222 (0.45%) before the year 2000 and 1 in 294 (0.34%) after 2000 (RR, 0.75; 95% CI, 0.57−0.98; P = .03).

How were injuries caused, found, and managed?
Thirty studies described the laparoscopic instrument used during 366 reported bowel injuries. The majority of injuries (55%) occurred during initial peritoneal access, with the Veress needle or trocar causing the damage. This was followed by electrosurgery (29%), dissection (11%), and forceps or scissors (4.1%).

According to 40 studies describing 307 injuries, bowel injuries most often were managed by converting to laparotomy (80%); only 8% of injuries were managed with laparoscopy and 2% expectantly.

Surgery to repair the bowel injury was delayed in 154 (41%) of 375 cases. The median time to injury discovery was 3 days (range, 1−13 days).

In only 19 cases were the presenting signs and symptoms of bowel injury recorded. Those reported from most to least often were: peritonitis, abdominal pain, fever, abdominal distention, leukocytosis, leukopenia, and septic shock.

Mortality
Mortality as an outcome was only reported in 29 of the total 90 studies; therefore, mortality may be underreported. Overall, however, death occurred in 1 (0.8%) of 125 bowel injuries.

The overall mortality rate from bowel injury--calculated from the only 42 studies that explicitly mentioned mortality as an outcome--was 1 in 125, or 0.8% (95% CI, 0.36%-1.9%). All 5 reported deaths occurred as a result of delayed recognition of bowel injury, which made the mortality rate for unrecognized bowel injury 1 in 31, or 3.2% (95% CI, 1%-7%). No deaths occurred when the bowel injury was noted intraoperatively.

What this EVIDENCE means for practice
In this review of 474,063 laparoscopic procedures, bowel injury occurred in 1 in 769, or 0.13% of procedures. Bowel injury is more apt to occur during more complicated laparoscopic procedures (compared with laparoscopic sterilization procedures, the risk during hysterectomy was greater than 10-fold).

Most of the injuries were managed by laparotomic surgery despite the potential to repair bowel injury by laparoscopy. Validating that peritoneal access is a high risk part of laparoscopic surgery, the majority of the injuries occurred during insufflation with a Veress needle or during abdominal access by trocar insertion. Nearly one-third of the injuries were from the use of electrosurgery, which are typically associated with a delay in presentation.

In this study, 41% of the injuries were unrecognized at the time of surgery. All 5 of the reported deaths were associated with a delay in diagnosis, with an overall mortality rate of 1 of 125, or 0.8%. Since all of these deaths were associated with a delay in diagnosis, the rate of mortality in unrecognized bowel injury was 5 of 154, or 3.2%. Among women who experienced delayed diagnosis, only 19 of 154 experienced signs or symptoms diagnostic for an underlying bowel injury, particularly when the small bowel was injured.