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COMPLICATIONS 461
Flowable Hemostatic Agents
Flowable hemostatic agents such as Surgio (Ethicon, Inc.) and
FloSeal (Baxter Healthcare Corp., Deereld, Ill.) are composed of
either a porcine or bovine gelatin matrix plus thrombin. ese agents
provide both a mechanical and an active hemostat in a single application. Surgio is a porcine gelatin that is used in combination with
bovine or other thrombins. Floseal consists of bovine microgranules
combined with human pooled plasma thrombin and calcium chloride. Both agents allow for more accurate administration compared
with liquid thrombin alone because human plasma thrombin solidies into a pastelike consistency when combined with gelatin. Flowable agents require 2 to 3 minutes of preparation and are applied with
a syringe. e ecacy and safety of Surgio and FloSeal are similar.
Flowable hemostatic agents have been shown to be eective in vascular and cardiac surgeries in which heavy bleeding can occur.
Fibrin Sealants
Fibrin sealants are absorbable dressings that contain brinogen and
thrombin that can be applied to raw surfaces to create a watertight
occlusive eect. Fibrin sealants enhance clot formation by delivering higher concentrations of brinogen and thrombin at the bleeding
site. Fibrin sealants are appropriate for use in patients with coagulopathy who do not have sucient brinogen to form a clot. ey are
eective for control of both local and diuse bleeding.
Tisseel (Baxter Healthcare Corp.) includes human brinogen
and thrombin from pooled donors, as well as aprotinin to prevent
breakdown of clot. Although ecacious, preparation is complex and
involves a two-syringe system that requires stirring and warming for
20 minutes using a device called a Fibrinotherm (Baxter Healthcare
Corp.). is procedure is not ideal for use in emergent settings such
as presacral bleeding.
Evicel (Ethicon) is human pooled brinogen and human pooled
thrombin. Before use it must be thawed, which can take up to 10 minutes. One benet is that it can be delivered with a pressure regulator to form a thin lm over broad bleeding surfaces with no distinct
bleeding site.
Although presacral hemorrhage is an uncommon event, the operating surgeon must be prepared to control hemorrhage when it occurs.
Communication with the operating room team and anesthesia team
is critical. Direct pressure is the initial management; exposure of the
eld allows the bleeding site to be identied and appropriate hemostatic technique to be used. Because even profuse bleeding can almost
always be controlled with pressure, the decision regarding a technique
for hemostasis does not need to be made quickly. It is important to
know all of the options available to control bleeding because some
cases require a series of attempts at control before success is achieved.
With proper preparation and a systematic approach, the situation can
always be salvaged.
S e l e c t e d R e a d i n g
Bague P, Karimdjee B, Iannelli A, etal. Anatomy of the presacral venous plex-
us: implications for rectal surgery. Surg Radiol Anat. 2004;26(5):355–358.
Beck D, Roberts P, Saclarides T, etal., eds. e ASCRS Textbook of Colon and
Rectal Surgery. 2nd ed. Arlington Heights, IL: American Society of Colon
and Rectal Surgeons; 2009.
D’Ambra L, Berti S, Bonfante P, etal. Hemostatic step-by-step procedure to
control sacral bleeding during laparoscopic total mesorectal excision.
World J Surg. 2009;33:812–815.
Harrison JL, Hooks VH, Pearl RK, etal. Muscle fragment welding for control
of massive presacral bleeding during rectal mobilization. Dis Colon Rec-
tum. 2003;46(8):1115–1117.
Jiang J, Li X, Wang Y, etal. Circular suture ligation of presacral venous plexus
to control presacral venous bleeding during rectal mobilization. J Gastro-
intest Surg. 2013;17(2):416–420.
Lou Z, Zhang W, Meng R-G, Fu C-G. Massive presacral bleeding during
rectal surgery: From anatomy to clinical practice. World J Gastroenterol.
2013;19(25):4039–4044.
Metzger P. Modied packing technique for control of presacral pelvic bleed-
ing. Dis Colon Rectum. 1988;31(12):981–982.
Pollard CW, Nivatvongs S, Rojanasakul A, Ilstrup DM. Carcinoma of the rec-
tum. Proles of intraoperative and early postoperative complications. Dis
Colon Rectum. 1994;37:866–874.
Van der Vurst TJ, Bodegom ME, Rakic S. Tamponade of presacral hemor-
rhage with hemostatic sponges xed to the sacrum with endoscopic helical trackers: report of two cases. Dis Colon Rectum. 2004;47:1550–1553.
Wang QY, Shi WJ, Zhao YR, etal. New concepts in severe presacral hemor-
rhage during proctectomy. Arch Surg. 1985;120:1013–1020.
CONCLUSION
Hemorrhage during pelvic surgery can lead to a life-threatening situation. Understanding pelvic anatomy is critical to avoiding this situation because prevention is much preferred to treatment of bleeding.
U I
C S
Bradley C. Gill and Drogo K. Montague
INTRODUCTION
Urologic issues pertaining to colorectal surgery can be broadly categorized according to the organ involved: the ureter, bladder, or urethra and their associated nerves and vessels. Because both colorectal
surgeons and urologists have become more familiar with laparoscopic
techniques, urologic issues encountered in colorectal surgery oen
may be addressed in a minimally invasive fashion without conversion
to an open surgery. In this chapter we will discuss the common situations in which colorectal surgeons and urologists interact.
INFECTION
Perioperative urinary tract infections can be encountered aer urethral catheterization and other instrumentation of the urinary tract.
Both urinalysis (unless strongly positive) and irritative voiding symptoms soon aer urethral catheter removal may be unreliable indicators of infection. However, if symptoms persist or other clinical signs
of infection develop and are unrelated to the recent surgery, a urine
sample should be collected in a sterile fashion and sent for culture.
Empiric antibiotic coverage is started, using twice daily ciprooxacin
or trimethoprim-sulfamethoxazole. Aer the results of the urine culture are available, the antibiotics should be discontinued or changed,
as appropriate.
A urinary tract infection may present outside the postoperative
period. In this situation, a urinalysis may be more reliable. If a urinalysis suggests infection, a urine sample collected in a sterile fashion should be sent for culture. Treatment with the rst-line agents
mentioned previously should be pursued and tailored to the culture
results unless prior microbiology data document resistance to such
an agent. If infections are recurrent and the organism is the same, a
urologic workup is required because the cause may be a foreign body
(e.g., a suture or stone) or an anatomic abnormality (e.g., diverticulum). If recurrent infections with diering enteric organisms develop,
a search for an enteric-urinary stula should be considered.
URETER
e normal anatomic position of the ureter in the retroperitoneum
places it at risk when the ascending and descending colon, the sigmoid colon, and the rectum are mobilized. Furthermore, obstruction,
inammation, neoplasm, radiation, or changes caused by prior procedures may cause the ureter to deviate from its usual course. Preoperative identication of the ureters may avoid inadvertent injury,
especially when a challenging or even routine but extensive retroperitoneal dissection is anticipated. is scenario prompts one of the most
common preoperative, and at times intraoperative, consultations
received by urologists. e placement of temporary ureteral stents is
relatively low risk and not only helps with ureteral identication but
462
also can aid in the recognition of injury and facilitation of its repair. If
a ureter is denuded, crushed, subject to electrocautery at close proximity, or otherwise thought to be at risk of damage or stricture, placement of an indwelling stent (i.e., a JJ stent) that can be le for up to 2
months should be considered.
If the ureter is injured or partially excised, direct reanastomosis
is preferred. e principles underlying choice of direct reanastomosis are similar to those of intestinal anastomosis and include maintenance of a robust ureteral blood supply, creation of a wide-caliber
ureteroureterostomy, and a tension-free anastomosis. Mobilization of
the ureter is required to facilitate this procedure, but avoidance of
skeletonizing the ureter preserves its blood supply and reduces the
risk of anastomotic stenosis. e two ureteral ends are spatulated,
one on its anterior surface and the other on its posterior surface, and
subsequently approximated with transmural resorbing stitches (Fig.
88-1). Permanent suture material should never be used in the urinary
tract because of the risk of calculus formation and development of a
nidus for infection. Prior to placement of the last one or two stitches,
a ureteral JJ stent is inserted to allow anastomotic healing and facilitate urinary drainage. Such a procedure can be performed laparoscopically, if this is the approach used by the colorectal surgeon and
the urologist is skilled in minimally invasive surgery. Generally, stents
are le in place for up to 6 weeks and then removed via cystoscopy
with imaging (the type of imaging study used depends on the urologist’s preference) to conrm ureteral patency.
Injury of the distal ureter may be better managed by reimplantation into the bladder via a ureteroneocystostomy than by ureteral
reanastomosis. As with a ureteroureterostomy, mobilization of the
ureter to facilitate a tension-free anastomosis is required, and avoidance of ureteral skeletonization to maintain blood supply is essential.
When the surgery is performed in an open manner, and if sucient
ureteral length is available, a nonreuxing reimplantation may be
performed. Along with mobilizing the ureter, this procedure involves
opening the bladder anteriorly and passing the ureter through a submucosal tunnel extending from a posterolateral bladder wall stab
incision to the trigone (Fig. 88-2, A and B). e length of the tunnel
should be two or three times the width of the ureter, with the end of
the ureter spatulated and anastomosed to the trigone mucosa (Figure
88-2, C and D). e submucosal tunnel closure and new ureteral ori-
ce are created with one layer of suture while the anterior cystotomy
is closed in two layers, with the mucosa and detrusor approximated
separately. A urethral catheter is then le indwelling for 10 to 14 days
to minimize bladder pressure and facilitate healing.
Loss of a critical length of ureter may make a tension-free ureteroureterostomy and a nonreuxing ureteral reimplantation impossible.
In such situations, simple reimplantation into the bladder dome with
a reuxing ureteroneocystostomy may be performed. is procedure involves dissecting through the bladder wall until the mucosa is
reached, spatulating the ureteral end, and then incising the mucosa
and anastomosing the ureter to the bladder. e ureteroneocystostomy is reinforced by closing the detrusor over the anastomosis site.
FIGURE 88-1 A ureteroureterostomy is performed after spatulating
the ureteral ends on opposing surfaces to create a wide anastomosis.
When simple reimplantation is impossible for the lack of a few centimeters of length, a psoas hitch may be performed. is procedure is
performed by tacking the bladder to the ipsilateral psoas fascia on the
side of ureteral injury, thus raising the bladder wall superiorly. When
this procedure is not sucient, a Boari ap may be fashioned, which
involves tubularizing a full-thickness ap of bladder wall, securing it
to the ipsilateral psoas fascia, and performing an end-ureteral anastomosis to this (Fig. 88-3). Any of these three procedures may be performed during laparoscopic surgery.
Less commonly, with a shortened ureter a transureteroureterostomy can be performed, which involves tunneling the injured ureter
retroperitoneally and creating an end-to-side anastomosis with the
contralateral ureter. is procedure is limited to open abdominal surgery. It also has fallen out of favor because of the risk inherent to both
kidneys, with disease developing in the solitary distal ureter. In situations of severe ureteral shortening, an ileal interposition or creation of
an ileal ureter may be performed and can be completed laparoscopically. is procedure involves mobilizing a segment of ileum with sufcient length to reach from the renal pelvis to the bladder, passing this
segment retroperitoneally through a window in the colonic mesentery,
and anastomosing its ends to the renal pelvis and bladder (Fig. 88-4).
Using an ileal ureter subjects the patient to metabolic, infectious, and
oncologic risks associated with placing bowel in contact with the urinary tract. Alternatively, renal autotransplantation can be considered if
all other options have been exhausted. In this open procedure, the kidney is repositioned in the iliac fossa with vascular anastomoses to the
iliac vessels and a simple ureteroneocystostomy into the bladder dome.
Unrecognized ureteral injuries generally present as either an
obstruction or a leak. Obstruction will present with hydroureteronephrosis or hydronephrosis, depending on the level of the injury,
COMPLICATIONS 463
which is oen accompanied by ipsilateral ank discomfort and renal
or ureteral colic. Decreased renal function also may be observed.
Diagnosis of such an injury is best achieved by imaging with an
ultrasound or computed tomography scan with use of intravenous
contrast material avoided, if possible, to limit damage to the kidney. Management includes immediate placement of a percutaneous
nephrostomy tube and denitive surgical repair at least 2 months
postoperatively. Leaks may present as either a urethrocutaneous
stula through the surgical wound, a urinoma, or urinary ascites.
e development of ureteroenteric stulas has also been observed,
albeit rarely. If a stula is suspected, laboratory assessment of the
uid will aid diagnosis because a creatinine level higher than that of
the serum concentration confirms a urine leak. A diagnosis of a
urinoma is generally based on imaging, whereas urinary ascites may
present with metabolic derangements and decreased urine output
suspicious for acute kidney injury. Regardless, treatment is generally the same as for obstruction and involves diversion of urinary
ow by placement of an indwelling ureteral stent via cystoscopy or a
percutaneous nephrostomy tube. Cystoscopy also provides the ability to perform retrograde ureteropyelograms and identify the location and extent of the ureteral injury, whereas a urogram requiring
intravenous contrast material may be contraindicated if the serum
creatinine level is elevated.
BLADDER
The bladder may be injured inadvertently or intentionally incised
during colorectal surgery, especially if it is involved with an adherent, invasive neoplasm. If an injury is suspected, the bladder may
be filled with methylene blue solution via a urethral catheter and
the surgical field closely inspected for leakage. Any such leakage
can be localized and the bladder closed in two layers. This procedure may be performed laparoscopically. If the injury presents
late, it generally will appear as a urine leak, similar to that of a
ureteral injury. Specifically, formation of a vesicocutaneous fistula may occur at the surgical wound, and a urinoma or urinary
ascites also may occur. Diagnosis is similar to that of a ureteral
injury. Wound drainage can be sent for creatinine measurement,
and a cystogram can be obtained by contrast instillation through
a urethral catheter.
Small urinary leaks from the bladder will generally resolve by
maintaining a low bladder pressure with an indwelling urethral catheter for 10 to 14 days. Larger leaks may require surgery, in which case
an anterior cystotomy can be created for a transvesical repair, leaving the colorectal surgical site and peritoneal cavity undisturbed. e
defect is closed with transmural sutures and the anterior cystotomy
in two layers, as described previously. A closed suction drain or passive tubing drain is placed in the perivesical space and removed 3 or
4 days later, whereas a urethral catheter is le indwelling for 10 to
14 days. Some urologists obtain a cystogram prior to removal of the
urethral catheter.
Fistula formation between the bladder and bowel may also occur,
either iatrogenically or as a result of diseases such as inammatory
bowel disease, diverticulitis, or neoplasm. Clinical presentation with
fecaluria, pneumaturia, or recurrent urinary tract infection with
enteric organisms should raise suspicion. Diagnosis is generally
performed though use of a cystogram or barium enema, but crosssectional imaging and cystoscopy may detect more severe instances.
Alternative, outpatient strategies to aid in detection include having
patients take activated charcoal or consume an amount of poppy
seeds and then observing the urine for the presence of such. Once
a diagnosis is conrmed, treatment entails resection of the stula
from both the bowel and bladder, primary repair of the cystotomy
and enterotomy, and interposition of a tissue ap, such as omentum. Drainage of the perivesical space and maintenance of a lowpressure bladder with a urethral catheter are required, along with
fecal diversion.
Urologic issUes in colorectal sUrgery464
A
B
C
FIGURE 88-2 A, A ureteroneocystostomy is started by opening the bladder anteriorly and making a stab incision for the ureter. B, A submucosal
tunnel is created to prevent vesicoureteral reflux. C, The ureter is then brought through the tunnel, and the original stab incision is closed. D, The
ureteroneocystostomy is completed by anchoring the end of the ureter to the bladder wall.
URETHRA
Urethral injury during surgery most commonly occurs from traumatic
insertion of a urethral catheter. is injury may involve the placement
of a catheter into a preexisting false passage, or more commonly, creation of a false passage when an impassable urethral stricture is encountered and forceful catheter advancement is attempted. Regardless, both
conditions require urethroscopy and catheter placement by a urologist.
Ination of the catheter balloon in the urethra, most commonly
the intraprostatic region of the male, is another potential means of
injury. ese injuries result in passage of blood through the urethral
meatus and likely hematuria. Management involves maintaining an
indwelling urethral catheter and urologic follow-up for further diagnosis and management.
Disease states such as inflammatory bowel disease and occasionally diverticulitis may involve the urethra. This involvement
D
occurs almost exclusively in men because of the presence of the
vagina in women. The formation of a periurethral abscess is generally treated by incision, drainage, and antibiotics. The scarring
that may follow abscess resolution may lead to subacute urethral
stricture formation, which is best addressed by urologic followup. Along with abscesses, urethroperineal or rectourethral fistulas
can occur and require surgery. Very minor fistulae may resolve
with urinary diversion via placement of a suprapubic tube through
an anterior cystotomy. Otherwise, surgical excision of the fistula
tract and layered closure of the urethra and perineal or rectal tissues with nonoverlapping suture lines is performed. Both abdominal and perineal approaches have been described, with omental
or gracilis muscle flaps used, respectively, to minimize the risk of
fistula recurrence. A urethral catheter facilitates proper urethral
healing, and diversion of both urinary and fecal output may be
required.
COMPLICATIONS 465
AB
CD
FIGURE 88-3 A, Creation of a Boari flap is initiated by outlining an anterior bladder flap. B, The bladder flap is raised. C, Closure of the bladder is
then started. D, Finally, the ureter is anastomosed to the upper end of the Boari flap.
REPRODUCTIVE STRUCTURES
Surgery involving the sigmoid colon and rectum can pose a risk to
male reproductive structures. Because the prostate and seminal vesicles are closely related to the anterior rectum and the vasa deferentia
converge upon this area, any procedures involving dissection here
may risk injury to the structures. Similar to the ureter, the vas deferens is a sensitive structure that may be aected by strictures with
compression, skeletonization, or electrocautery injury. Interruption
of its continuity will prohibit sperm from entering the ejaculate. Likewise, injury or excision of the seminal vesicles will reduce semen volume. Infertility that results from injury to either structure is unlikely
to be repairable but can be addressed with assisted reproductive technology and scrotal procedures used to access the testes.
NERVES
Injury to the pelvic nerves can result in urinary retention, as well
as erectile dysfunction and ejaculatory failure in males. It also may
produce pain or alter sensation in the groin and external genitalia.
Acute urinary retention that develops aer surgery may result from
anesthetic eects, narcotic medications, α-adrenergic agonists, anticholinergic medications, and bed rest. It is treated by placing an
Urologic issUes in colorectal sUrgery466
FIGURE 88-4 For an ileal ureter, a mobilized segment of ileum that is
sufficiently long to reach from the renal pelvis to the bladder is passed
retroperitoneally through a window in the colonic mesentery. The
anastomoses at each end are then completed.
indwelling urethral catheter, eliminating potential etiologic factors,
and performing a voiding trial in a few days. If the voiding trial is
not successful, it is repeated in a few days. However, if the problem is
persistent, chronic urinary retention should be suspected. is condition generally results from injury to the pelvic nerve plexus and
appears on urodynamic testing as detrusor areexia or a weak detrusor contraction.
Chronic urinary retention is best managed by clean intermittent
self-catheterization. Although most patients are opposed to this idea
at rst, many soon welcome the practice because it eliminates the
need for an indwelling urethral catheter and the discomfort caused
by this catheter. Generally, patients are advised to self-catheterize
every 4 to 6 hours to maintain a low-pressure bladder. Bacteriuria
will develop in nearly all patients, regardless of whether catheterization is sterile, but this condition is usually asymptomatic and is not
treated unless other symptoms of a urinary tract infection develop.
Short-term antibiotic therapy tailored to urine cultures is provided if
a urinary tract infection does arise.
Bladder dysfunction resulting from a neurologic injury is oen
transient and thought to develop as a result of inammation and
edema. Recovery of bladder function usually happens by 6 months;
however, if dysfunction persists for a year, it is generally permanent. When voiding function returns, patients should be advised
to record output times and volumes on a chart, as well as check
a postvoid residual volume via self-catheterization and document
this volume. Once residual volumes are consistently below 100 to
50 mL, self-catheterization may be discontinued. In males older
than 40 years, bladder function may not return completely to normal because of pre-existing bladder outlet obstruction from benign
prostatic enlargement. In this situation, medical therapy is rst
pursued using an α-antagonist with or without the addition of a 5-α
reductase inhibitor. Pending the success of this treatment, endoscopic management of the prostate may be required.
Along with diculty voiding, injury to the pelvic autonomic
nerves may result in erectile dysfunction, which is dened as the
inability to obtain or maintain an erection satisfactory for coitus.
Because colorectal surgery that would place the pelvic autonomic
nerves at risk generally involves substantial disease, consideration
of a psychogenic cause (such as anxiety or depression) for erectile
dysfunction should not be dismissed. Obtaining a thorough sexual
history may help delineate a cause, and specialized nocturnal tumescence studies may be indicated in some cases. Specically, pertinent
details include whether erections occur, if they happen spontaneously or nocturnally, and the duration and rigidity of the erection.
e absence of nocturnal erections indicates a physiologic cause
for the condition. A psychogenic basis for erectile dysfunction is
best addressed with sex therapy provided by a certied counseling
professional.
As with bladder dysfunction, erectile dysfunction may be temporary, and the two conditions can coexist aer colorectal surgery. Aer
1 year, if erectile dysfunction persists, it is likely permanent. Firstline treatment involves oral phosphodiesterase inhibitors, a number
of which are available for prescription. If a trial of one inhibitor is
unsuccessful, another may be evaluated. If lack of response to oral
medications persists, intracavernosal injection therapy can be considered if the patient wishes to pursue it. is therapy involves the
injection of a single or mixed solution of vasoactive medications into
the penis. It bypasses the nervous system and creates a usable erection in patients with a healthy intact penile circulation. e medications are titrated to produce an erection that lasts approximately 1
hour, and the injections generally result in little discomfort. However,
injection therapy can result in priapism, hematoma formation, brosis, and penile curvature, as well as infection.
When pharmacologic treatment for erectile dysfunction fails,
physical means of treatment can be pursued. A rst option to consider is a vacuum-assist erection device. ese devices are noninvasive and function by creating a vacuum in a cylindrical chamber
sealed around the base of the penis that draws blood into the erectile
tissue. Once the penis is erect within the chamber, a constrictive ring
is placed at the base of the penis to prevent outow of this blood,
which will oen produce semirigid tumescence that is suitable for
coitus. Alternatively, an implantable penile prosthesis may be considered. ese prostheses range from permanently semirigid hinged
implants and exible malleable implants to an inatable penile prosthesis that mimics the lling and expansion of the penile erectile bodies. All implants are placed into the corpora cavernosa and result in
the permanent loss of the erectile tissue. erefore, penile prosthesis placement should be considered a nal option once the return of
physiologic or pharmacologically induced erections has been ruled
out. Most implants last for 10 years; mechanical device failure, infection, and erosion are the major complications.
At times, ejaculatory failure may develop aer colorectal surgery.
Aside from physical interruption of the seminal vesicles and vasa
deferentia, damage to the lumbar sympathetic chain or hypogastric
plexus can cause this condition. e pathophysiology may vary from
absent bladder neck closure and retrograde ejaculation into the bladder to the absence of seminal emission from lack of deposition into
the prostatic urethra. As a result, infertility may occur, and some
patients may be concerned about the lack of ejaculate. Retrograde
ejaculation can be diagnosed by checking a postorgasm urine sample
for sperm and fructose. Treatment with α-agonist medications an
hour before sexual activity may restore antegrade ejaculation in some
patients. Otherwise, in persons who wish to reproduce, sperm collected from the bladder aer retrograde ejaculation can be used with
assistive reproductive technologies. An alternative option is to use
scrotal procedures to access the testes.
Somatic innervation to the external genitalia and groin are provided by the iliohypogastric, ilioinguinal, lateral femoral cutaneous,
COMPLICATIONS 467
and genitofemoral nerves. e course of these nerves relative to
the retroperitoneal location of the ascending and descending colon
should be known. Although they supply some muscle function to the
cremaster and scrotum, these nerves are largely involved in groin and
genital sensation. Transection, crush, stretch, or electrocautery injury
to these nerves can result not only in absent or distorted sensation but
also in the development of paresthesia or pain.
BLOOD VESSELS
e gonadal veins and gonadal arteries course along the lateral retroperitoneum with the ascending and descending colon and are at risk
of injury during retroperitoneal surgery. Transection or ligation of
these vessels should carry little risk, because the reproductive organs
have a redundant blood supply with various collateral vessels. e
risk of retroperitoneal hematoma should be recognized, however,
because a high-pressure arterial hemorrhage may lead to ureteral
compression and obstruct urine ow. Otherwise, risk of vascular
injury to other urologic structures is low because the blood supply to
the bladder is richly redundant and the urethra, prostate, and external genitalia are also supported by collateral vessels in the pelvis. If
care is taken to preserve the internal pudendal vessels, the vascular
supply to the perineum and external genitalia will remain healthy.
S u g g e S t e d R e a d i n g S
Abboudi H, Ahmed K, Royle J, etal. Ureteric injury: a challenging condition
to diagnose and manage. Nat Rev Urol. 2013;10(2):108–115.
Eswara JR, Raup VT, Potretzke AM, etal. Outcomes of iatrogenic genitou-
rinary injuries during colorectal surgery. Urology. 2015;86(6):1228–1233.
Morey A, Zhao L. Genital and lower urinary tract trauma. In: Wein A, etal.,
eds. Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016:2389–
2392.
Santucci R, Chen M. Upper urinary tract trauma. In: Wein A, etal., eds.
Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016:1148–1169.
P T
C
L
C S
Benjamin Crawshaw, Knut Magne Augestad, and Conor P. Delaney
INTRODUCTION
Laparoscopic colorectal surgery is complex and more technically
demanding than many common laparoscopic procedures performed by general surgeons. Advanced laparoscopic skills are
required to manipulate and mobilize sections of bowel, control
and divide large mesenteric vessels, extract large specimens, and
create an anastomosis. The degree of dissection performed can
be extensive because of the broad attachments of the colon and
rectum. The technical difficulty of these operations raises the likelihood of complications, and the learning curve for laparoscopic
colorectal surgery is well documented.
Complications can occur at any point during a laparoscopic
operation, from the insertion of the rst trocar to its removal and
the closing of all incisions. Although knowing how to identify and
manage complications is important, anticipation and prevention is
prudent. Broadly speaking, complications of laparoscopic colorectal
surgery can be categorized into two groups: those relating to laparoscopy in general, and those specic to intestinal operations. General complications include those related to needle/trocar placement
and removal, pneumoperitoneum, deep venous thrombosis, and
use of electrocautery. Complications specic to colorectal laparoscopy include those related to patient positioning, bleeding, localization of tumors, contamination, anastomosis creation, and urologic
injuries.
GENERAL COMPLICATIONS
Contraindications
Although historically laparoscopy has been restricted to certain
patients, currently the only absolute contraindication for its use is
the inability of the patient to tolerate general anesthesia or a laparotomy. Relative contraindications, such as previous abdominal surgery,
pregnancy, morbid obesity, and pulmonary disease, can be limited
through careful planning, surgical skill, and experience. Some surgeons believe that the hand-assist laparoscopic technique is helpful.
should be fully decompressed to reduce the risk of organ perforation
during trocar placement.
Although we avoid its use under any circumstances, Veress
needle use should at least be limited to patients without previous
abdominal surgery, periumbilical inflammation, or hernias. Gripping and elevating the abdominal wall and dissection to identify
the fascia during insertion may reduce the risk of injury to underlying structures. Aspiration through the needle should always be
performed after placement and prior to insufflation. The presence
of blood or enteric content should immediately raise concern for
injury and mandates immediate exploration for the site of injury.
Initially this exploration may be performed using laparoscopy in
a stable patient, but laparotomy is often warranted in the event
that the extent of the injury cannot be evaluated or large vessels
are involved.
e safest way to obtain initial peritoneal access is through an
open technique using a Hassan trocar, which permits direct visualization and identication of underlying structures, although similar
complications are still possible. Regardless of technique, aer initial
trocar placement and insertion of the laparoscope, care should be
taken to inspect the surrounding anatomy for injury prior to continuing with the procedure.
Placement of secondary trocars should always be under direct
visualization into an area clear of visceral structures. Transilluminating the abdominal wall during secondary trocar placement, as well as
positioning ports lateral to the rectus, can reduce injury to the inferior epigastric vessels. Suprapubic trocar placement carries the risk of
bladder laceration, especially if the bladder is not fully decompressed,
and theoretically can be identied by gaseous lling of the urine collection bag or bloody urine.
Minor complications of trocar placement include an air leak
around the port, which may cause diculty in obtaining or maintaining pneumoperitoneum, and minor skin level bleeding at the insertion site. Tightening the skin around the port with sutures or towel
clips can close air leaks, and skin-level bleeding is oen self-limiting
or easily controlled with electrocautery. Incisional hernias at extraction sites for colorectal surgeries are equivalent to those of any open
procedure. Port site hernias are rare as long as the fascia at the site of
trocars 10 mm or larger is closed.
Peritoneal Access Complications
Obtaining access to the peritoneal cavity can be complicated in several
ways. Injuries may occur during initial trocar placement or during
placement of secondary trocars. Initial trocar placement is associated
with injury to large intra-abdominal vascular structures and bowel
perforation, whereas secondary trocar placement is associated with
injury to intra-abdominal vessels—as well as those in the abdominal
wall—and bowel and bladder perforation. e bladder and stomach
468
Pneumoperitoneum Complications
Improper Veress needle or trocar placement can cause subcutaneous
or preperitoneal emphysema upon insuation. More rarely, pneumothorax, pneumomediastinum, or pneumopericardium may occur
as well. Insuation should be immediately released with the occurrence of any of these conditions. Subcutaneous emphysema is usually
self-limited and resolves within hours postoperatively with minimal
intervention. Patients with large amounts of subcutaneous carbon
COMPLICATIONS 469
dioxide may experience hypercarbia and acidosis, which should be
treated with prolonged mechanical hyperventilation until the excess
carbon dioxide can be cleared. Preperitoneal insuation also is not
of great clinical signicance but may make proper access to the peritoneal cavity dicult and may require moving trocars to a new site or
conversion to laparotomy.
Gas embolism, although rare, is the most feared complication of
pneumoperitoneum. is potentially fatal event occurs when a large
amount of carbon dioxide is introduced to the venous circulation.
e gas collects in the right heart and creates a vapor lock, causing
a right outow obstruction that leads to sudden cardiovascular collapse. High suspicion for this complication should occur with any
sudden drop in patient end-tidal carbon dioxide. Treatment includes
immediate release of pneumoperitoneum, administration of 100%
oxygen, and placement of the patient in Trendelenburg position with
the le side down to allow blood to ow under the air bubble. e gas
is then aspirated from the heart via a central venous catheter.
Other complications of pneumoperitoneum include arrhythmias/
vasovagal events and postoperative shoulder pain. Peritoneal distension causes a reex vagal response, which may lead to signicant
arrhythmias or bradycardia. Treatment includes release of pneumoperitoneum and administration of an anticholinergic agent. When
the arrhythmia has resolved, pneumoperitoneum may be slowly
reintroduced. Recurrence of the arrhythmia may require conversion.
Postoperative shoulder pain is caused by diaphragmatic irritation
from retained carbon dioxide. Although it is very common, no treatment is required beyond attempting to prevent the occurrence by
thoroughly evacuating all gas at the end of the procedure.
Thromboembolic Complications
Postoperative deep venous thrombosis and pulmonary embolism are
relatively uncommon aer laparoscopy because of earlier postoperative mobilization. Prolonged reverse Trendelenburg positioning,
as well as impaired venous return with intra-abdominal pressures
greater than 15 mm Hg, may lead to venous stasis and risk of thromboembolism. Intermittent use of pneumatic compression stockings
and pre- and postoperative subcutaneous heparin should be used as
prophylaxis in any patient undergoing major laparoscopic surgery
unless otherwise contraindicated.
Electrosurgical Complications
e use of electrocautery in laparoscopy raises the concern for inadvertent thermal injury. Such injuries may occur outside of the eld of
vision of the operator and can be dicult to identify.
e four major causes of electrosurgical injuries are inadvertent
tissue contact, insulation failure, direct coupling, and capacitive coupling. Bipolar, monopolar, and ultrasonic tools generate signicant
heat, which may cause thermal injury if the active tips make inadvertent contact with a structure. is type of injury occurs when
active instruments are not kept in view, as well as when introducing or removing a potentially hot instrument tip. Insulation failure
occurs when a break in insulation provides an alternate path for
energy, leading to thermal injury to tissue adjacent to the instrument.
Injury by direct coupling occurs when an active electrode makes
contact with another conductive instrument. In capacitive coupling,
the accumulation of electromagnetic current in conductors near the
surgical eld, such as retractors or clamps, occasionally can generate
enough energy to cause injury.
Electrosurgical complications are best prevented through careful and mindful control of instruments. e active tip of thermal
devices should always be kept in the eld of view, and care should
be taken when removing or repositioning these tools to avoid electrosurgical and mechanical injury. All instruments, especially reusable tools, should be routinely inspected for insulation integrity.
Surgeons must be aware of warning signs of inadvertent current discharge, including a reduction in anticipated electrosurgical eect,
electrostatic interference on the monitor, or involuntary abdominal
muscle contraction.
ermal injury to the bowel is particularly worrisome because
burns may progress to full-thickness injury and perforation if they
are unrecognized. Small burns recognized at the time of the operation are best treated with suture imbrication, whereas larger burns
may require a segmental resection. Missed full-thickness injuries
may present with peritonitis within hours or as intra-abdominal sepsis days aer perforation occurs.
SPECIFIC LAPAROSCOPIC
COLORECTAL SURGERY
COMPLICATIONS
Positioning Complications
Laparoscopic colorectal surgery oen employs extremes of patient
positioning to allow visualization of the operative eld, as well as
simultaneous abdominal and rectal access. Additionally, frequent
adjustments to patient position are required during dierent steps of
many procedures. It is thus imperative that the patient be safely and
suciently secured to the operating table to prevent injury and slippage. Care must be taken to pad and protect all exposed bony prominences, and a beanbag mattress or other protective measures should
be used to immobilize the patient.
Nearly all laparoscopic colorectal procedures are performed with
the patient in a modied lithotomy position. e prolonged time
that a patient’s legs are placed in stirrups to allow for this positioning raises the concern of nerve injury and “well-leg” compartment
syndrome. Correct positioning of the patient, especially during prolonged surgeries, is vital to the prevention of these injuries. Compression of the common peroneal nerve is most common and occurs with
inadequate padding along the lateral head of the bula. Postoperative
neurologic symptoms relating to nerve compression oen resolve
within 5 days but may be permanent. Compartment syndrome may
occur when the patient is in the lithotomy position for more than
4 hours. Decreased venous return from pneumoperitoneum, along
with direct pressure to the calf from improper positioning, may result
in ischemic injury to the leg muscles, leading to edema and compartment syndrome in an otherwise healthy leg. Prompt recognition in
the postoperative period is vital, because early treatment with a fourcompartment fasciotomy is oen required. Adequate hydration and
close monitoring for rhabdomyolysis is also necessary. is complication has been noted more frequently with the prolonged operative
times associated with robotic surgery.
Bleeding Complications
One of the most common complications in laparoscopic intestinal
surgery is bleeding. As previously discussed, the most common
vascular injuries encountered during trocar placement are to large
abdominal vessels (i.e., the aorta, inferior vena cava, and iliac vessels) and the inferior epigastric vessels. Injury to a large vessel may
be catastrophic. Direct pressure and/or packing at the site, a prompt
laparotomy, and involvement of a vascular surgeon are advised. In
the event of instrument puncture of a large vessel, it is best to leave
the instrument in place rather than remove it, because the instrument may provide some degree of tamponade, and removal could
cause rapid hemorrhage. Bleeding from the inferior epigastric vessels may be controlled through cautery, tamponade with the trocar
or a Foley catheter, or transabdominal gure-of-eight suture ligation.
Care must be taken to control the vessel both proximal and distal to
the injury.
Prevention and treatment of ComPliCations of laParosCoPiC ColoreCtal surgery470
Intraoperatively, the most important source of hemorrhage comes
from the mesenteric vessels. Great care must be taken during the
identication and control of these vessels to prevent accidental damage and ensure adequate control. Once they are carefully isolated and
skeletonized, several methods are used to divide the vessels, including clips, vascular staplers, bipolar cautery, and the harmonic scalpel.
Occasionally, a pre-tied surgical ligature is placed around the mesenteric stump for added security. Should bleeding occur from a cut
vessel end, attempts should be made to isolate and clamp the stump,
followed by application of a clip or pre-tied ligature. Blind clipping
is not advised because it may injure surrounding structures. If the
operative eld is obscured with blood, direct pressure to the area and
thorough irrigation with a 1-cm aspirator tip may facilitate laparoscopic eorts. If the vessel cannot be identied or controlled, conversion to a hand-assist or open approach is warranted.
Some portions of certain procedures are more prone to bleeding
complications than are others. e loss of tactile feedback in laparoscopy may lead to excessive traction on the spleen and its connections during splenic exure manipulation and mobilization, leading
to lacerations to the splenic capsule or the vessels in the ileocolic
ligament. Use of the reverse Trendelenburg position during splenic
exure mobilization, as well as minimizing the tension placed on the
spleen, can prevent these injuries. Capsule tears oen can be controlled with spray thrombin or similar topical hemostatic agents. A
massive hemorrhage may require a laparotomy and/or splenectomy.
Similarly, bleeding from the presacral and pelvic vessels can complicate pelvic dissection. Careful dissection in the appropriate anatomic plane, although not always feasible, is the best prevention for
this type of bleeding. If bleeding occurs in this area, manual pressure
and packing may provide hemostasis. If bleeding continues, a muscle
patch may be utilized.
Close inspection for hemostasis is vital at the completion of laparoscopic surgery. Massive postoperative hemorrhage is most oen
the result of an inadequately secured mesenteric vessel and requires
exploration and repair. Smaller scale bleeding is oen venous. e
pressure of pneumoperitoneum may be enough to tamponade small
veins during surgery, and thus vessels that appeared hemostatic on
inspection may bleed when the intra-abdominal pressure is released.
Close observation of these patients is reasonable, as long as they are
hemodynamically stable, because much of this type of bleeding is
controlled by the patient’s normal hemostatic mechanisms. Use of
nonsteroidal antiinammatory drugs and other antiplatelet or anticoagulation agents in the immediate postoperative period may interfere in this process and prolong bleeding. In the stable patient with
ongoing concern for bleeding, initial exploration may be performed
with a laparoscope; however, a denitive source may not be found,
and a laparotomy may be required.
Tumor Identification Difficulties
e identication and localization of an intraluminal or hepatic mass
may be dicult because of the lack of tactile feedback and the inability
to manually palpate the specimen prior to resection. is phenomenon may be minimized with careful preoperative planning, including use of contrast enemas and computed tomography (CT) scans
to thoroughly document the tumor location. Injection of India ink
at the time of colonoscopy can clearly identify the location but may
not prove useful if it is unable to be visualized during laparoscopy.
Sometimes the needle penetrates the bowel wall and ink is dispersed
throughout the peritoneal cavity. If an intraluminal mass cannot be
accurately identied, intraoperative colonoscopy may be performed.
Alternatively, conversion to a hand-assist approach permits manual
palpation of the bowel. Once removed, the specimen should always
be opened and examined away from the operative eld to conrm the
presence of the tumor and the resection margins. Hepatic metastases
also may be missed with routine laparoscopy for similar reasons. Preoperative CT scans are useful for liver evaluation, and laparoscopic
ultrasound is now routinely used for staging of hepatic lesions at the
time of primary colon resection.
Contamination
Peritoneal and wound contamination can occur with enteric bacteria and tumor cells, leading to surgical site infections and tumor
implantation. Infectious contamination can be prevented in several
ways. Preoperative mechanical and antibiotic bowel preparation
should be used if no bowel obstruction is present. Rectal irrigation
with a Betadine solution should be performed aer the induction of
anesthesia if a rectal anastomosis is planned. Bowel manipulation
should be minimized as much as possible and atraumatic graspers
should be used to minimize the potential for accidental perforation.
When it is necessary to retract a piece of bowel, a closed grasping clamp should be used, and whenever possible, the manipulated
bowel should be within the planned resection. During specimen
extraction, the incision should be protected with plastic drapes or
a commercial wound protector. Instruments and gloves used in the
creation of the anastomosis or that have otherwise come into contact with enteric contents should be removed from the operative
eld and replaced with clean versions. Extracorporeal resection and
anastomosis may have a lower risk of contamination than a totally
intracorporeal technique; however, the latter may be safely performed by an experienced surgeon.
Implantation of malignant cells in a surgical incision at the time
of resection is rare. Despite initial concerns and reports of increased
implantation of malignant cells at trocar sites, several studies have
shown no increase in tumor recurrence in laparoscopic versus open
cases. Manipulation of the tumor during the operation should be
minimized to prevent violation of the specimen and dissemination
of tumor cells through the peritoneum. Plastic drapes or commercial
wound protectors should be used to protect extraction incisions, and
laparoscopic extraction bags should be used if intracorporeal resection and anastomosis is performed.
Anastomosis Complications
When creating a colorectal anastomosis, care must be taken to prevent torsion of the bowel limbs. is endeavor may be more difcult in a laparoscopic resection with extracorporeal anastomosis
because the bowel is removed from its normal anatomic position
and may be twisted accidentally as it is extracted from the abdomen. Careful attention to the orientation of the limb will prevent
accidental torsion, leading to early bowel obstruction. Care must
be taken not to let the ends of the bowel inadvertently rotate aer
specimen extraction and division, and in procedures such as an
extended right colectomy, particular care needs to be taken to avoid
making a 360-degree twist in the mesentery. Laparoscopic low rectal transection may be dicult because of the technical challenges
of stapling, especially in obese patients and those with a very narrow pelvis. Rectal division usually requires two rings of the stapler.
Positioning the stapler low enough on the rectum in the correct orientation may be challenging because of the 45-degree angulation
limit of laparoscopic staplers. Drawing the rectum to the le opens
the angle on the right and facilitates stapler positioning. External
pressure on the perineum may help li the pelvic oor enough to
allow the stapler to be placed low enough. Alternatively, placement
of a suprapubic port may permit improved stapler placement. If
these attempts fail to allow for appropriate placement, a conversion
may be necessary with creation of a short Pfannenstiel incision,
thus allowing use of a 30-mm linear stapler, or for lower tumors
a transanal intersphincteric dissection with hand-sewn coloanal
anastomosis can be used. Other anastomotic complications are not
specic to laparoscopic technique but may occur, including a stapler misre, staple line bleeding, and an anastomotic leak.