Question 24

A 34 yo G0 is undergoing laparoscopic myomectomy for an 8cm fundal leiomyoma. During your dissection, you notice that your monopolar scissors were in direct contact with the colon during coagulation. You identify a 1.5 cm area of white blanching on the bowel in the area of contact without bowel spillage. The remainder of the case is uncomplicated with EBL 300 mL. What is the best next step in management of the bowel injury?

Answer Choices:

Bowel resection with temporary diverting colostomy

Expectant management with IP drain

Oversew the blanched area in 2 layers

Purse string suture around the blanched area in a single layer

Segmental bowel resection with reanastomosis

Correct Answer:

Segmental bowel resection with reanastomosis

Explanation:

  • Bowel injury can occur in 1 in 769 laparoscopic surgeries

  • Outcomes are greatly improved with intraoperative recognition and repair

  • Electrosurgical modalities are responsible for about 29% of bowel injuries- leading cause of delayed recognition because they can be difficult to identify

  • Electrothermal injuries can be identified by area of blanching, but the area of spread is usually much greater than the initial area visualized due to coagulative necrosis (this can lead to bowel perforation if not treated appropriately)

  • Damage to superficial serosa can be repaired with purse string suture beyond the margins of the impact, but the depth of injury can be difficult to determine

  • Segmental resection should be standard for thermal injuries with generous margins of 4-5 cm around the area of blanching

  • Segmental resection with colostomy should be performed if 2 or more bowel injuries, require 4 or more units of blood or have significant contamination from bowel leakage.

  • Trocar-induced penetrating injuries can often be over-sewed. Suture line should be placed perpendicular to the long axis of the bowel to decrease the risk of stricture