Surgical Injury Part II: Ureters and Bowels

Bowel Injuries - Enterotomies and Colotomies

  • Tips for Prevention

    • Surgical technique is crucial in preventing bowel injury.

    • Adhesions can hide the bowel quite well!

      • Entering peritoneum – bowel loop adhered to anterior abdominal wall – very common scenario for injury.

      • Endometriosis – leads to scarring and adhesions, or bowel may be directly impacted and injury may occur with excision.

    • When breaking down adhesions:

      • Gentle, controlled traction and countertraction on bowel loops.

      • Sharp, cold dissection is preferred – typically Metzenbaum scissors or scalpel.

        • Blunt dissection may cause the bowel to tear.

        • Gentle, blunt dissection may be useful for some translucent adhesions – rub your thumb and index finger back and forth over the tissue to loosen it up, then switch back to sharp dissection once the adhesion “window” can be seen.

      • This can be a long process in some surgeries! Patience is key. Don’t be afraid to move to another area if you’re not making progress in one spot.

  • “Running the Bowel”

    • You’ve probably heard of this before… but how do you do it, exactly?

    • Most of the time, we’re talking about small intestine:

      • Start at the Ligament of Treitz. 

        • This band of tissue extends from the diaphragm to the duodenojejunal flexure - so up high (close to T12) and posteriorly (remember the duodenum is largely retroperitoneal).

      • Hand over hand, move down the bowel, inspecting for injury or perforation.

        • You’ll start in the jejunum, and move to the ileum of small intestine.

          • There’s no landmark to distinguish these two, but the ileum feels thinner and the lumen is somewhat smaller.

      • For small intestine, you end your run at the ileocolic junction.

        • This is denoted by the appendix! 

      • Large intestine is distinguished by epiploic appendages, outpouchings of the colonic wall (haustrae), and three large muscular bands (taenia coli). 

        • Should also be inspected for injury if suspected!

  • Site and extent of injury

    • Technique

      • Critically important – repair to bowel injuries are done perpendicular to the long axis of the bowel.

        • I.e., if you are looking at bowel in your hand going right-to-left, your repair is up-and-down.

          • If you repair parallel to the long axis of the bowel, the bowel lumen will narrow and potentially cause obstruction.

Operative obstetrics and gynecology - Correct technique for bowel repair

    • Serosal injuries: 

      • If underlying muscle and mucosa are intact and the serosal injury is small, then this can be left unrepaired – stitching may just increase complications.

      • If muscle is torn as well, then repair should be performed as the muscle provides integrity – the bowel wall may perforate without overlying muscle.

        • Small, tapered needle with 3-0 or 4-0 silk.

        • Avoid placing the stitch through the mucosa and into bowel lumen!

    • Perforating injuries:

      • Ideally they are repaired immediately to limit contamination of the peritoneal cavity!  

      • Antibiotics should be given to cover anaerobic intestinal flora, if they haven’t already:

        • Typically a dose of metronidazole

      • Smaller perforations can typically be closed in a two-layer fashion:

        • Inner layer of absorbable, braided suture (i.e., 3-0 Vicryl or Polysorb) that goes through the full thickness of the bowel.

          • Need to ensure mucosal approximation for a water tight seal!

        • Outer layer is the seromuscular repair as we described before, with 3-0 or 4-0 silk. 

      • Larger perforations may require bowel resection and reanastamsois.

        • Should be considered if perforation:

          • Involves more than 50% of bowel wall circumference

          • There are multiple perforations within a short segment of bowel

          • There is vascular compromise to a segment of bowel

            • If you see the serosa appears dark and dusky and fails to pink up after a few minutes… likely needs resection.

        • This is generally beyond the skillset of a generalist OB/GYN - so call your general surgery or colorectal surgery friends to help with these.

      • Regardless of size, irrigation should be performed copiously to clear out intestinal spillage, particularly if there was a colotomy.

        • Surgery may advise placement of a Jackson-Pratt (JP) drain with spillage occurring, to monitor for leaks at site of bowel reanastamosis – this is less and less common as better evidence has emerged that drains don’t alter outcomes.

        • We are definitely not the experts here – defer to surgical colleagues on indications and necessity of drains!

    • Management after Injury/Repair

      • Timing of feeding after bowel injury and repair is also controversial.

        • However, most recent evidence in colorectal surgery suggests that early enteral (PO) feeding is feasible and safe, with early frequently defined as within 24 hours of surgery. 

          • Small injuries that are within the purview of OB/GYNs to repair do not need to have feeding restrictions.

          • Larger injuries where you’re obtaining consultation for sure – defer to your surgical colleagues.

      • Ongoing antibiotic therapy and postoperative imaging studies are generally not warranted.



Ureteral Injuries

  • Prevention

    • Knowing your anatomy is really important, as the ureter runs in some high-risk areas:

      • At the pelvic brim, where it crosses the bifurcation of the common iliac artery – injury can occur with hypogastric artery ligation.

      • In the pelvis, just below the infundibulopelvic ligament – can be injured with oophorectomy.

      • Beneath the uterine artery – often coursing laterally within 1.5 - 2cm – site of injury often in cesarean, if it occurs, and of course at hysterectomy.

      • From there it courses medially and ventrally, around the cardinal ligaments to enter the trigone – also a high risk point of injury at hysterectomy, as well as in urogynecologic surgeries like anterior colporrhaphy and uterosacral ligament suspension.

    • Risk goes up with more complex surgeries – be particularly aware with:

      • Malignancy

      • Large fibroids

      • Adhesive disease and PID

      • Placenta accreta and cesarean hysterectomy generally

      • Vaginal hysterectomy with significant prolapse

      • Congenital anomalies

    • Do preoperative stents help?

      • They may be helpful for identification of ureters and dissecting around them, however, there’s no evidence to say they reduce the risk of injury.

        • They may help you identify it once it happened, though!

      • Consider them on a case-by-case basis with high risk procedures.

  • Detection

    • Intraoperative detection is so much better than delayed injury.

      • Injuries can cause transection which is easily detected, but also be aware that injuries may be delayed particularly with thermal injury, crush injuries, or overly aggressive dissection leading to devascularization.

    • Dye solutions (indigo carmine, methylene blue, fluorescein) provided intraoperatively can allow you to see:

      • Extravasation of dye in the surgical field – an abdominal transection injury

      • Failure to see ureteral efflux on cystoscopy – more likely a crush injury, or a kink from a suture.

    • Cystoscopy is very helpful:

      • You want to see brisk efflux – wisps of dye passage may suggest partial occlusion or kinking.

      • Stents can be passed if you’re qualified, or by urologic consult. 

        • If stents pass easily and dyed urine drips from a stent, it’s likely that ureter of concern is kinked somewhere – review, release suture, and cystoscope again to see if that causes improvement.

        • If stents cannot pass more than a few centimeters, ligation or transection likely occurred.

          • Dye can be passed through a stent retrograde as well to aid in visualization in the abdomen of an injury site.

    • Unfortunately, 50-70% of ureteral injuries are not diagnosed in the acute setting.

      • Delayed recognition of injury manifests as flank / abdominal pain, anuria, urinary ascites, and concern of course for fistula development (copious discharge from wound and/or vagina). 

      • If suspected postop, workup is usually through CT scan (IV pyelogram - preferred) or a retrograde pyelogram.

  • Repair techniques (a brief review, as if an injury occurs this will be done by consultant, typically):

    • Depends largely on the site and mechanism of injury.

    • Stents: may be needed alone for some crush injuries or other ‘minor’ damage.

      • Some small laceration injuries (<50% diameter of the ureter) can be primarily sewn over a stent.

      • If over 50%, requires anastomosis or reimplantation. 

    • Ureteroneocystotomy: the ureter is reimplanted into a deliberate cystotomy site. 

      • Typically for distal injuries.

      • Modifications if additional mobilization is needed include:

        • Elongation of the bladder

        • Psoas hitch: a technique where the bladder is hitched up onto the psoas muscle to bring it closer to the ureter.

    • Ureteroureterostomy: can be:

      • Ipsilateral – the two cut ends are brought back together. Most common.

      • Transureteroureterostomy (contralateral) - essentially connecting the ureter to the other side, creating a “Y-shaped” drainage. For more complex repairs that are more proximal. Not common.

    • Boari flap: similar in principle to a psoas hitch, but a lot more extensive – the bladder is essentially turned into a tube to allow for greater reach for more proximal injuries.

  • Postoperative management:

    • Guided by urology – stent needs to be left in place for healing for a while, usually 2-6 weeks.

      • If cystotomy as well, a Foley catheter would also be left.

    • Retrograde pyelogram can be performed at time of stent removal to demonstrate healed tissue without leaking or stenosis, and patients should be followed by urology postoperatively.  

Surgery: Postpartum Sterilization Techniques

What is a postpartum tubal? 

  • Procedure done after birth of a baby to permanently prevent future pregnancy 

  • Reason for performing it postpartum:

    • Usually done within 1-2 days after vaginal delivery 

    • Highly effective: risk of pregnancy is <1% (though if you want to look at the actual rates depending on type of surgery, please check out the CREST study!

    • Increased access: patients are already in the healthcare setting after delivery of their baby; don’t have to come back to the hospital/healthcare setting for a different procedure

    • Mostly minimally invasive: not laparoscopy, but can be done through a single, mini-lap incision below the belly button as the fundus of the uterus is still high 

Today we will focus on the surgical steps 

  • For pictures, we still like Atlas of Pelvic Surgery:

  • Pre-operative 

    • Surgical consent 

      • Review the way the procedure is done and discuss the different methods that you can provide.

      • Discuss the risks, benefits, and alternatives

        • Benefits: stated above, quick recovery usually 

        • Risks: as with all surgeries, there are risks of bleeding, infection, injury to organs around the uterus and fallopian tubes 

          • Another big risk I tell people: we can’t perform the surgery that they want after delivery 

          • A few major reasons: significant anemia after delivery, infection (ie. chorio/endometritis), inability to palpate the fundus after delivery 

            • Can also be an issue for patients with increased central adiposity 

          • Lastly, it is possible that we enter the abdomen but cannot perform the surgery because we can’t find the tubes, usually due to adhesions 

        • Alternatives: no sterilization procedure or use a different form of birth control until 6 weeks postpartum for a laparoscopic procedure 

        • MA-31 - 30 day consent! For those with state insurance

    • Preoperative work up 

      • History: 

        • Ask specifically about history of abdominal surgeries and pelvic infections (ie. Chlamydia/Gonorrhea) 

        • This can help determine if there will be significant intrabdominal adhesions that may prevent surgery 

        • Not a strict contraindication for surgery, but should go into counseling of patients 

      • Physical 

        • Palpation day of surgery of the fundus 

        • Can decide to proceed or not if fundus is easily palpable 

      • No additional work up usually beyond prenatal care and delivery 

      • Sometimes, if there is significant blood loss with delivery, providers may want to get a CBC 

      • Usually, will have a type and screen on file already as patients are admitted for delivery (but should have this definitely)

    • Anesthesia 

      • Most procedures are done with neuraxial anesthesia 

      • Sometimes, patients can keep their epidural from labor/birth 

      • However, some patients may not want another epidural/spinal 

    • Expectations 

      • Patient will not need to necessarily stay longer than for delivery 

      • May need a small amount of narcotic medication for incisional pain, but usually, I do not prescribe more than 5 tabs of 5 mg oxycodone, and only if needed 

  • During the surgery 

    • Adequate anesthesia and prepped and draped 

    • Positioning: 

      • Dorsal supine 

      • Though during surgery, we can ask the anesthesiologist to airplane the patient to the left or right in order for the uterus to fall to one way or the other and bring the fimbria of the tube into view 

    • Surgical steps 

      • After prepping the abdomen, mark approximately 3-4 cm on the inferior edge of the umbilicus 

      • Some people will inject 1% lidocaine at this time, but I find that it distorts the anatomy 

      • Incise along edge and continue downward dissection until the fascia is reached. Can use Army-Navy or other retractors to hold back the skin 

      • Pick up the fascia with either Kelly, Kocher, or Allis and make a small incision with the Metzenbaum scissors after ensuring no bowel is adhered to the fascia 

      • Incise the fascia after protecting with a finger, and place a Kocher on either end. Some people will also throw a stitch on either end with an 0-vicryl and hold these with hemostats to be able to find your fascia later 

      • Retract the fascia (again, can use army-navies or some people like the small Alexis-O retractor) and pop into peritoneum, then use a finger to feel for the cornua and tube 

      • Can airplane the patient right or left for either tube 

      • Once the tube is found, use a Babcock to hold it up and follow it out to the fimbria. Make sure it is a tube and not a round ligament! 

      • Salpingectomy

        • Use a Ligasure to clamp, seal, and cut the tube along the mesosalpinx 

        • Make sure to hug the tube 

        • Clamp, seal, and cut where the tube meets the cornua to remove the tube 

        • Inspect area of sealing and cutting to ensure no bleeding 

        • Allow the tube to fall back into the abdomen, and proceed with the next tube 

        • If you don’t have a Ligasure, can use a kelly clamp to clamp along the mesosalpinx below the tube. Cut above the Kelly clamp until the end of the clamp is reached 

        • Use a 3-0 synthetic absorbable suture and take a bite with the needle just beneath the level of the clamp and tie this portion down 

        • Do this several more times until the cornua is reached 

        • Use the Kelly clamp to clamp off the end of the tube, cut off the tube, and again, use the 3-0 synthetic absorbable suture to ligate the end of the tube 

        • Send tube to pathology for confirmation of cross section

      • Pomeroy Technique

        • Place the babcock in the middle of the tube so that a small, 1-2 cm portion of tube is elevated 

        • Tie a 3-0 synthetic absorbable around the base of this elevated section. Can tie two for a modified pomeroy 

        • Hold the suture with a hemostat and then excise the knuckle of tube for pathologic confirmation 

        • Use the hemostat to keep the tube out of the abdomen to inspect the area that you have incised for any bleeding. Use a bovie to coagulate any areas of bleeding

        • Once the area is dry, can take off the hemostat and let the tube drop back into the abdomen 

  • Parkland technique

    • Place the babcock in the middle of the tube so that a small, 1-2 cm portion of tube is elevated 

    • Using the Metzenbaum scissors, incise a small, avascular portion of the mesosalpinx beneath the babcock 

    • Pass two ligatures of 3-0 synthetic absorbable suture through the area that was incised and tie down on either end of the tube

  • Hold one end with a hemostat 

  • Use the scissors to incise the knuckle of tube above the ligatures and send to pathology 

  • Inspect the incised portions and ensure no bleeding

  • Allow the tube to fall back into the abdomen 

  • Once you have completed both sides and achieved hemostasis, close the fascia with 0-Vicryl or similar suture 

  • Then close the skin with 4-0 Biosyn/Monocryl 

  • Can inject lidocaine at this time if desired 

  • Bandage the area with small pressure dressing 

  • Post operative 

    • Spinal/epidural should wear off before going to postpartum unit 

      • Can breastfeed immediately if desired 

    • Routine postpartum in the hospital, with small amount of narcotics if needed

    • Remove dressing in 24 hours  

    • Follow up for routine postpartum care