Iatrogenic Injury

Intraoperative Injury
• injury during other procedures
• especially during pelvic operations
• The key to managing is early recognition.
– The vast majority
• closed primarily
– If little contamination
– If the patient is otherwise stable.
• gynecologic procedures
– dilatation and curettage of the uterus
– Total abdominal hysterectomy and vaginal hystere
ctomy
– Intrauterine devices have been known to erode int
o the peritoneal cavity and subsequently into the c
olon
• Urologic surgery
– Percutaneous nephrostomy
– Perineal prostatectomy
– suprapubic prostatectomy
– Transurethral resection of the prostate
• Neurosurgical
– Inserting ventriculoperitoneal shunts
• Orthopedic operations
– internal fixation of a hip fracture

• Colorectal stents
– stent insertion attempts.
• Perforation occurred in 22 (4%)
• Delayed recognition
– result in significant peritonitis and life-threatening
sepsis.
• Treatment : fecal diversion
– patient may need repeated exploration for drainag
e of abscesses.
 Injury from Barium Enema
• Cause
– direct penetration of the enema tip
– overinflation of the rectal balloon,
• Spillage of barium (especially above the peritoneal reflec
tion)
– profound peritonitis, sepsis, and a systemic inflammatory resp
onse.
• Manage
– recognized early
• closed primarily
• abdomen irrigated to remove stool and barium
• Manage
– recognized early
• closed primarily
• abdomen irrigated to remove stool and barium

– Patient has developed sepsis

• Fecal diversion (with or without bowel resection)

– small mucosal injury to the extraperitoneal rectum

• bowel rest
• broad-spectrum antibiotics,
• close observation.
 Colonoscopic Perforation
• major complication after either diagnostic or th
erapeutic colonoscopy
– complication is rare and occurs in less than 1% of pr
ocedures
• trauma from the tip of the instrument
• shear forces related to the formation of a “loop” in the co
lonoscope
• Barotrauma from insufflation
• Biopsy or fulguration
• Polypectomy using electrocautery  full-thickness burn
– postpolypectomy syndrome
– abdominal pain, fever, and leukocytosis without evidence of diff
use peritonitis
• Surveillance, Epidemiology, and End Results (SEER) Progr
am registries
• 39,286 colonoscopies (77 perforations)
• 35,298 sigmoidoscopies (31 perforations)

• another study of 26,162 consecutive

• perforations in 11 (0.06%) diagnostic
• 10 (0.11%) therapeutic colonoscopies

• Another consecutive series of 34,620 colonoscopies

• 31 (0.09%) perforations
• Management depends on
– size of the perforation
– duration of time since the injury
– overall condition of the patient
– underlying diagnosis.
• A large perforation recognized during the procedure
– surgical exploration
– most can be repaired primarily
• usually little contamination due to bowel prep

• significant contamination
• delay in diagnosis with resulting peritonitis, or unsta
ble
– proximal diversion with or without resection is the safest
approach
• indication for and findings at the time of colonoscopy.
– If the patient has neoplasm and is stable
– Definitive resection is best

• develop abdominal pain and localized signs of perfora

tion
– “microperforation”
– planes without a free perforation
• resolve with bowel rest, broad-spectrum antibiotics, and close obs
ervation
• Surgical exploration is indicated if any clinical deterioration occurs
• ‘‘silent’’ perforation
– air in the retroperitoneum or free air in the periton
eal cavity
• barotrauma and dissection of air through tissue planes
without a free perforation
– often have no symptoms
• ileus is the most common symptom that occurs
– Manage
• Antibiotics
• observed for evidence of infection or peritonitis
• The potential infecting organisms
– Bacteroides fragilis
– Enterobacteriaceae such as Escherichia coli

• If there is any sign of an ongoing infectious process, anti

biotics should be continued

• abdominal CT is recommended after 5–7 days to exclude

residual signs of peritonitis or abscess formation and to
exclude the possible need for a surgical intervention.
• When the ICP is not immediately detected
• suspected and investigated
– with abdominal pain
– Tenderness
– abdominal distension
– Fever
– and/or rectal bleeding after colonoscopy

• CT scan is the most accurate imaging tool to diagnose

• Explore lap to…
– Colonic closure
– wedge resection
– Ostomy
– Colonic resection
• No RCTs have assessed the superiority of one
method over the others.
• based on …
– Perforation characteristics (e.g., size, time of evolu
tion, and degree of peritoneal contamination)
– patient’s general status (e.g., comorbidities)
– availability of adequate technology and surgical de
vices
• Options:
Simple closure of perforation
• Small perforation
• No fecal contamination
• No concomitant colonic pathology

Bowel resection with primary anastomosis

• Large perforation
• Concomitant colonic pathology
• No significant intra-abdominal contamination

Bowel resection without anastomosis / anastomosis with diverting sto

ma
• Fecal peritonitis or extensive tissue inflammation
• Alternatively, staged repair or, in extreme case
s,
• damage control surgery may be required