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<huc>Q.</huc>What is the only surgical procedure that is completely safe?
<huc>A.</huc>The surgical procedure that is not performed.
The unfortunate truth is that complications can occur during any operative procedure, despite our best efforts—and laparoscopy is no exception. Being vigilant for iatrogenic injuries, both during and after surgery, and ensuring that repairs are both thorough and timely, are two of our best weapons against major complications, along with meticulous technique and adequate experience.
This article features five cases that illustrate some of the most serious complications of laparoscopy—and how to prevent and manage them.
CASE 1: Surgical patient returns with signs of ureteral injury
A 42-year-old woman with a history of endometriosis undergoes laparoscopic hysterectomy and bilateral salpingo-oophorectomy. She is discharged 2 days later. Two days after that, she returns to the hospital complaining of fluid leaking from the vagina. She has no fever or any other significant complaint or physical findings other than abdominal tenderness, which is to be expected after surgery. A computed tomography (CT) scan with intravenous (IV) contrast reveals left ureteral obstruction near the bladder, with extravasation of contrast media into the abdominal cavity. Further investigation reveals a left ureteral transection.
Could this injury have been avoided? How should it be managed?
Postoperative diagnosis of ureteral injury can be challenging, in part because up to 50% of unilateral cases are asymptomatic. Be on the lookout for this complication in women who have undergone pelvic sidewall dissection or laparoscopic hysterectomy, such as the patient in the case just described. As the number of laparoscopic hysterectomies and retroperitoneal procedures has risen in recent years, so has the rate of ureteral injury, with an incidence of 0.3% to 2%.1,2
Ureteral injury can be caused by ligation, ischemia, resection, transection, crushing, or angulation. Three sites are particularly troublesome: the infundibulopelvic ligament, ovarian fossa, and ureteral tunnel.3,4 In Case 1, injury to the ureter was proximal to the bladder and probably occurred during transection of the uterosacral cardinal ligament complex.
What’s the best preventive strategy?
Meticulous technique is imperative to protect the ureters. This includes adequate visualization, intraperitoneal or retroperitoneal dissection, and early identification of the ureter. In a high-risk patient likely to have distorted anatomy due to severe endometriosis and fibrosis, retroperitoneal dissection of any adhesions or tumor and identification of the ureter are the best ways to avoid injury.
Intraperitoneal identification and dissection of the ureters can be enhanced by hydrodissection and resection of the affected peritoneum.3,4 To create a safe operating plane, make a small opening in the peritoneum below the ureter and inject 50 to 100 mL of lactated Ringer’s solution along the course of the ureter, which will displace it laterally.5
Although neither IV indigo carmine nor ureteral catheterization has been shown to reduce the risk of ureteral injury or identify ligation or thermal injury,3,6 both can help the surgeon identify intraoperative perforation of the ureter. Liberal use of cystoscopy with indigo carmine administration for identification of ureteral flow and ureteral catheterization can be used in potentially high-risk patients. If there is suspicion for devascularization or thermal injury, use prophylactic ureteral stents postoperatively for 2 to 4 weeks.
Don’t hesitate to consult a urologist
In Case 1, the surgeon sought immediate urologic consultation and the patient underwent laparotomy with ureteroneocystotomy without sequelae.
In general, management of ureteral injury depends on its severity and location, as well as the comfort level of the surgeon. Minor injuries are sometimes managed with cystoscopic stent placement, but more severe cases may require operative ureteral repair.
In cases like this one, where ureteral injury occurred in close proximity to the bladder, a ureteroneocystotomy is possible. However, in more cephalad injuries, there may be insufficient residual ureter to allow such a repair. In these cases, a Boari flap may be attempted to use bladder tissue to bridge the gap to the ureteral edge. Rarely, in high ureteral injuries, trans-ureteroureterostomy may be appropriate. This procedure carries the greatest risk, given that both kidneys are reliant on one ureter.