Surgical Complications: Intraoperative

Written By Sydney Oesch

Episode Notes

  1. Preparation for Complications

    1. Pertains to both mental/emotional regulation as well as technical knowledge

    2. Rehearse mentally as if you were in charge

    3. Consider checklists and adding length of surgery and expected blood loss to your surgical time out

    4. Pre-op setup

      1. Open: assistance, lighting, retraction, low-lithotomy, IV access

      2. Laparoscopic: assistant port (>=8 mm to pass raytecs/suture), suction irrigator, available clip applier

  2. Vascular Injuries

    1. Types: minor, major, diffuse

    2. Initial steps no matter type

      1. First: control w/ pressure (finger, sponge stick, pack)

      2. Optimize lighting, retraction, exposure, suction (consider setting up 2nd)

      3. Gather supplies and/or call for help

      4. Ask anesthesia if they need to “catch up”

    3. Arterial

      1. Relatively rare

      2. Intimal: occur in pts w/ underlying atherosclerosis

        1. Monitor distal perfusion to rule out embolic events

      3. Puncture/tear

        1. Obtain control proximally/distally - aortic compression or vascular clamps

        2. Small: fine monofilament (i.e. 4-0 Prolene)

        3. Large: vascular surgery consultation for grafting

      4. Inferior epigastric artery

        1. Classic site of injury during laparoscopic entry

        2. Manage w/ foley balloon through trocar w/ applied upward traction or balloon trocar for occlusion

        3. Identify proximal/distal portions and tie off laparoscopically or w/ Carter-Thomason

    4. Venous

      1. More common

      2. Small

        1. Roll of vein wile suctioning

        2. Identify defect w/ pickup

        3. Apply clip below (don’t pull)

      3. Large (i.e. external iliac, hypogastric)

        1. Use Judd-Allis clamps to show yourself injury

        2. Clip if vascular stump remaining or suture defect prn

      4. Largest (i.e. vena cava)

        1. Same principles

        2. May require intervening pledget (non-absorbable material such as felt or PTFE) to reinforce sutures

        3. If very large, call vascular - may need to patch w/ autologous vein, bovine pericardium, or synthetic materials

      5. Consider preemptive Potts ties/ligatures

        1. Placed proximally and distally tot he area of dissection by passing a vessel loop circumferentially around the vessel → apply traction to collapse the vessel/restrict blood flow

      6. Presacral veins

        1. May retract into the sacral foramen with injury, precluding ability to grasp or see the defect

        2. Options: packing or tacking, topical haemostatic agents, direct/indirect electrocoagulation and suture

        3. Unique management

          1. Sterile thumbtack into sacral foramen

          2. Bone cement or wax

          3. High wattage diathermy (100 watts) to “weld” a fragment of omentum or rectus to achieve hemostasis

    5. Coagulopathy

      1. Balanced resuscitation

        1. 1:1:1::PRBCs, FFP, Plt

      2. Consider POC testing w/ thromboelastrography (TEG) or rotational thromboelastrometry (ROTEM)

      3. Maintain normothermia; prevent hypocalcemia, hyperkalemia; Correct acidosis

      4. Interventions

        1. Hypogastric artery ligation

          1. Ligate 2-3 cm distal to the bifurcation of the common iliac to avoid ligation of the posterior division of the internal iliac

        2. Hemostatic agents

      5. If HDS: unilateral or bilateral uterine artery embolization with IR

      6. If all fails: pack abdomen and perform take back in 48 hours

  3. Gastrointestinal Injuries

    1. Management dependent on several factors: location, extent of injury, patient stability, degree of contamination, time since injury

    2. Always close defect perpendicular to the long axis of the bowel to minimize stricture risk

    3. Small Bowel

      1. <50% of circumference w/ minimal devitalization

        1. Mgmt: primary repair in 2 layers

          1. Inner layer w/ absorbable suture (i.e 2-0 or 3-0 Vicryl) w/ full-thickness, continuous or interrupted throws

          2. Outer layer w/ Lembert or interrupted throws thru seromuscular layers w/ absorbable or non-absorbable suture (i.e. 2-0 or 3-0 Vicryl or silk)

      2. >50% of circumference or devitalized

        1. Mgmt: segmental resection w/ primary anastomosis (end-to-end or side-to-side)

          1. Mobilize and isolate injured segment

          2. Divide mesentery to preserve blood flow

          3. Fire linear stapler proximally and distally to injury

          4. Align healthy bowel side by side at antimesenteric borders and make enterotomies

          5. Insert linear stapler into each bowel loop to create a common lumen

          6. Use GIA or TA stapler across common enterotomy to close the lumen

    4. Large Bowel

      1. Mgmt dependent on context

        1. Small, healthy, non-contaminated: primary repair

        2. Large, minimally-contaminated: segmental resection w/ primary anastomosis

        3. Large, unstable, gross contamination, delayed: colonic resection and diversion w/ either end colostomy or loop colostomy

      2. Thermal

        1. Causes: direct contact, conducted heat, capacitive coupling, insulation failure

        2. Intraop clues: discoloration or charring on serosa, edematous or blistered tissue, sluggish or nonviable bowel

        3. Can lead to delayed perforation or peritonitis

        4. Mgmt

          1. Small, superficial burn: local excision and primary repair

          2. Full thickness or questionable: resect segment 1-2 cm on either side and use principles above

    5. Surgical Staplers Crash Course

      1. Two numerical descriptors: length of staple line, depth of staples themselves

      2. Staple depths (most common)

        1. 2.0 mm for vascular

        2. 2.5 mm for small bowel/stomach

        3. 4.8 mm for large bowel

        4. 3.5 or 3.8 mm for thicker bowel or early edema

      3. Types of staplers

        1. GIA (gastrointestinal anastomosis), EndoGIA (laparoscopic gastrointestinal anastomosis)

          1. Two double rows or staples w/ a central knife dividing the tissue

          2. Uses

            1. Side-to-side anastomoses

        2. TA (thoracoabdominal)

          1. One or two rows of staples w/o a knife

          2. Uses

            1. Close enterotomies/gastrotomies or to reinforce staple lines

            2. Divide the rectum from the sigmoid colon in deep pelvis

        3. EEA (end-to-end anastomosis)

          1. Circular stapler that creates resection of two “donuts” of tissue and a circular staple line

          2. Anvil placed in one bowel end, stapler inserted into other bowel end

          3. Confirm anastomotic integrity w/ a “bubble test”

  4. Urologic Injuries

    1. Most common: bladder, ureters; less common: urethra

    2. Increased risk: large fibroids, endometriosis, advanced malignancy, prior radiation, prior pelvic surgery

    3. Prevention

      1. Know your landmarks!

      2. Preop stenting doesn’t reduce risk; however, some suggest can help identify injury w/ difficult dissections

    4. Ureteral: intraop recognition key

      1. If crush, kink, suture injury: stenting

      2. Repair dependent on location

        1. Distal ⅓ or w/i 6 cm of bladder: reimplantation w/ ureteroneocytotomy

          1. Consider psoas hitch for tension-free

        2. Middle ⅓: Boari flap

        3. Clean transection, short segment, or >7 cm from bladder: uretero-ureterostomy

      3. Generally, place stent during healing process to prevent stricture

        1. Selected based on pt height

        2. 165-175 cm: 26 cm stent

        3. Obtain CT urogram to confirm injury resolution after several weeks

    5. Bladder

      1. Most at dome

      2. Stop and confirm w/ retrograde instillation of fluid

      3. Mgmt steps

        1. Identify full length of defect

          1. If unsure if trigone or ureteral orifices involved, open defect further and look

        2. >1 cm → 2 layer closure

          1. Reapproximate mucosa/muscularis w/ absorbable suture (i.e. 3-0 Vicryl)

          2. Second imbricating layer for water-tight closure

          3. Leave foley for 5-7 days

            1. Bladder w/ normal strength after 21 days

        3. If trigone involved…

          1. Identify both ureteral orifices, repair with steps above, and sew away from UO in order to not distort

          2. If any concern for tension or kinking at UOs, place ureteral stents

            1. Keep in for 4-6 weeks

          3. Keep foley for 5-7 days

    6. Urethral

      1. Usually present post-op w/ urinary retention or incontinence

      2. Most common cause: radical vulvar resection

      3. Distal ⅓ can be resected w/o losing continence

      4. If more proximal, close primarily off tension and keep foley 5-7 days

  5. Pancreatic Injuries

    1. Rare, but serious

    2. Pancreatic tail is nestled in splenorenal ligament, directly caudal to the splenic artery and vein

    3. Key: early recognition, controlled repair

      1. Stop and assess

      2. Small: simple direct closure w/ fine absorbable suture (i.e 4-0 or 5-0 Vicryl)

      3. Larger: especially if involves splenic vessels → splenectomy, pancreatic tail resection, pancreatic duct stenting

    4. Approaches

      1. Anterior: more traditional; lateral: alternative technique that provides more direct angle to the spleen

      2. Risk of pancreatic tail injury may be lower w/ lateral approach

Reference List

1.    Celentano V, Ausobsky JR, Vowden P. Surgical management of presacral bleeding. Ann R Coll Surg Engl. 2014;96(4):261. doi:10.1308/003588414X13814021679951

2.    Chacon E, Chiva L. The art of bowel surgery in gynecologic cancer. International Journal of Gynecological Cancer. 2024;34(3):421-425. doi:10.1136/IJGC-2023-004595/ASSET/0D92D048-141E-4105-9B2C-E58BAD93558C/MAIN.ASSETS/IJGC-2023-004595-F4.JPG

3. Gynecologic Oncology Education. Surgical Complications by Dr. Steve Rose. Vimeo. Published May 24, 2020. https://vimeo.com/422188022. Accessed May 15, 2025.

Sydney Oesch
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Hereditary Syndromes Part 2