Iatrogenic Non-gynecologic Injuries: A Simplified Management Approach for Gynecologists

1. Iatrogenic Non-gynecologic Injuries:
A Simplified Management Approach
for Gynecologists
Ahmed Samy El-Agwany
Editor: Iatrogenic injury is an unwelcome event at the time of surgery and
they are common in practice. We are going to discuss some issues regarding
iatrogenic injuries in gynecologic surgery that are related to the vascular, uri-
nary, and gastrointestinal tract systems. Intestinal injuries can occur during
gynecologic procedures, from dilatation and curettage to total abdominal hys-
terectomy and laparoscopic or hysteroscopic procedures. Colon injuries can
also occur in patients with adnexal masses, previous abdominal surgeries, and
in women with histories of pelvic inflammatory disease or diverticulitis. The
common places of injury are the large bowel, small bowel, rectum, and rarely
the gastric region.1,2
The urinary tract is at risk of injury during pelvic surgical
operations due to its proximity to the female genital system. Hysterectomy and
cesarean section are responsible for the majority of ureteric injuries.2–4
Vascular
injuries are less common but occur more with retroperitoneum dissections, such
as lymphadenectomies and colposuspensions.
Figures 1–4 are showing a simplified algorithm for management of some of
these common injuries that are encountered intraoperatively and showing how
to approach them. Algorithms can be a guide for gynecologic surgeons to aid
their clinical practice.
References
1. Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury
during hysterectomy: A prospective analysis based on universal cystoscopy.
Am J Obstet Gynecol 2005;192:1599.
2. Rock JA, Jones HW. Intestinal tract in gynecologic surgery. In: TeLinde RW,
Rock JA, Jones HW, eds. TeLinde’s Operative Gynecology, 9th ed. Philadel-
phia: Lippincott Williams & Wilkins; 2003:1239.
3. Ozdemir E, Ozturk U, Celen S, et al. Urinary complications of gynecologic
surgery: Iatrogenic urinary tract system injuries in obstetrics and gynecology
operations. Clin Exp Obstet Gynecol 2011;38:217.
4. Oderich GS, Panneton JM, Hofer J, et al. Iatrogenic operative injuries of abdominal
and pelvic veins: A potentially lethal complication. J Vasc Surg 2004;39:931.
Address correspondence to:
Ahmed Samy El-Agwany, MBBCH, MSC, PhD
Department of Obstetrics and Gynecology
Faculty of Medicine
Alexandria University
Alexandria 21526
Egypt
E-mail: ahmedsamyagwany@gmail.com
ahmed.elagwany@alexmed.edu.eg
Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
JOURNAL OF GYNECOLOGIC SURGERY
Volume 00, Number 0, 2019
ª Mary Ann Liebert, Inc.
DOI: 10.1089/gyn.2019.0055
1
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2. Intraoperative Bowel
injury
Conservative
management
as long as no
distal obstruction
Accidental Transfixing
surgical suture
through the bowel wall
as during uterine artery
ligation
Removal of the
suture from the
colon. If left
in-place, it can
pass smoothly
as long as no
oozing and not
multiple sutures
or traumatized
colonic wall.
Mesentric
injury
It is dangerous in
sigmoid colon on
dissection of
infundibulopelvic
ligament that can lead
to avascular necrosis
or in last 10 cm of
ileum. sigmoid mesentry
or distal ileum injury is
rare, unless there is
frozen pelvis and
distorted anatomy
Colon
surgeon
Bleeding
or tear in
other sites
Warm towel test
For color (red)
and peristalsis
(nerve and blood
supply test)
Positive
3/0 or 4/0
Vicryl or prolene
interrupted
suture
Negative
General
surgeon
Bowel tear
figure 2
Accidental Puncture
with surgical needle
and minimal ooze on
squeeze
FIG. 1. Bowel injury manage-
ment algorithm, (Part 1).
Bowel tear
Exposed Mucosa
seen easily
after dissection
Interrupted 3/0 vicryl
suture for covering
the exposed mucosa
or if large area is
exposed, it is better
to be covered by
omentum.
Complete tear
Single
Two nontoothed intestinal clamps and
elevate up the affected area then clean
the abdomen and inside the injured bowl
between the clamped segments before
suturing as shown below :
1.Transverse suture
2.No mucosa closure
3.2 layer closure
4.3/0 Vicryl suture
4.Rectal tube reaching above the tear
if there is colon injury with daily care
with saline and betadine after suturing
and repeated till clear effluent.(2,3)
5.Postoperative diet
is usual diet than soft one for
solid stool and not soft one
leaking through sutures.
Rectum and
Anal canal
Two layer closure then
covering with levator ani
muscle down to the EAS
over the anal canal (levator
ani is a good identifying
point for good suturing
and identification of the
External anal Sphincter)
then vaginal mucosa
and skin
Multiple or circum-
ferential
General
surgeon
FIG. 2. Bowel injury management algorithm, (Part 2).
2 LETTER TO THE EDITOR
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3. Vascular
injuries
Puncture of
artery or vein
of small or
major vessels
Compress
Tear
Vascular surgeon
for major vessels
Suturing by 5/0/or 6/0
prolene suture
Transected or
avulsed vessel
Artery
Ligate even
if not oozing
Median sacral artery injury
with colposupension or
lymphadenectomy
Ligate
Injuried ovarian
artery retracts in the
retroperitoneum
even without
hematoma or
oozing
Inferior mesentric
artery is Arising from
front of aorta and
injured on
lymphadenectomy
General
surgeon
Vein
Compress or
packing or
suturing
High ligation of ovarian
artery after retracting
the sigmoid mesentry
Although it can pass
smoothly as in case of
rupture uterus with
thrombosed retracted
avulsed infundibulopelvic
ligament
FIG. 3. Vascular injury management algorithm.
Urologic
injuries
Ureter
Crushing
injury
Conservative
management
as long as
no distal
obstruction
Ligate
Immediately
diagnosed
or within
24 hrs
Remove
suture
Oozing after
or after
puncture by
needle
Conservative
management
Symptomatic
after 24 hrs
PCN for 3
month till
edema
resolves
then operate
Tear
Urosurgeon
4/0 vicryl
Interrupted
vertical suture
Stent if large or
multiple or
reimplantation
Bladder
Tear
2 layer
closure.
First is
sutured as
full thickness
with 3/0
vicryl
Urethra
Loss of the last
3 cm of the
urethra over a
metal catheter
in cases with
approached
vulvar cancer
to the urethra
Nothing is
done and
no suture
of edges if
no bleeding
as long as
it is away
from the
sphincter.
Golden tip: It is better to dissect the ureter
before dealing with pelvic masses or use a
preoperative ureteric stent and insertion of
a double J stent in suspected injury
FIG. 4. Urologic injuries management
algorithm.
LETTER TO THE EDITOR 3
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