PERIOPERATIVE GRAND ROUNDS
Bowel Injury After Laparoscopic Surgery THE CASE A 30-year-old man presented for ambulatory laparoscopic inguinal hernia repair with mesh placement. He had no significant past medical history and did not take any medications at home. The surgery was uneventful, but postoperatively, the patient had high levels of pain at the surgical site and was admitted to the hospital. A resident physician was called multiple times overnight by the charge nurse regarding the patient’s pain, and the resident ordered additional IV pain medication. When the primary surgical team arrived in the morning, they further increased the patient’s pain medication. The patient remained in sustained pain, and the team was called multiple times during the next two days. His physical examination was documented as unremarkable, and he was started on a patient-controlled-analgesia pump with hydromorphone. After he was weaned off the patient-controlled analgesia, he continued to have abdominal pain and became increasingly tachycardic with slight abdominal distention and a low-grade fever. A computed tomography scan of the abdomen was ordered, and it showed a bowel perforation. To fix the perforation, he was sent back into the OR and then had a long stay in the intensive care unit because of septicemia. He eventually recovered and was discharged home.
DISCUSSION Bowel injuries occur in approximately 0.13% of laparoscopic procedures,1 but that figure is probably an underestimate because of the retrospective nature of most studies.2 Risk factors for bowel injuries include surgeon-related factors, such as inexperience or a steep learning curve, and patientrelated factors, such as previous abdominal surgery, adhesions, or obesity. The injury could be a result of direct injury during laparoscopic port insertion (access injury) or during handling the bowel with instruments. Bowel injuries can be prevented by adhering to basic principles of laparoscopic surgery. Using the open technique to access the peritoneal cavity is considered safer than using a Veress needle
to achieve pneumoperitoneum. Laparoscopic trocars must always be inserted under direct vision, and laparoscopic instrument changes should also be made under direct vision. Laparoscopy should be performed at the end of long, complex laparoscopic procedures, which are more likely to be associated with bowel injuries. Bowel handled during procedures associated with lysis of adhesions should always be examined systematically before the laparoscopic ports are removed. These steps to prevent bowel injuries should be undertaken in addition to surgeons undergoing laparoscopic surgery training and credentialing, which involves completion of a fellowship training program with a requirement to perform a certain number of procedures. Early recognition is essential in preventing adverse outcomes from bowel injuries. Delayed diagnosis is associated with a higher risk of septicemia (as seen in this case), the need for a laparotomy, high risk of multiple operations, stoma formation, prolonged hospital stay, and, most importantly, mortality. The estimated mortality rate for all laparoscopic bowel procedures is 3.6%.1 If an injury is recognized during surgery, it can be repaired with minimum consequences. A surgeon who encounters this complication but lacks proper experience in laparoscopic suturing should convert to an open laparotomy to repair the injury. In most circumstances, this approach would be safer than a poorly performed laparoscopic repair. continued on page 318 This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Krishna Moorthy, MD, MS, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, Boerne, TX. (Citation: Moorthy K. Bowel injury after laparoscopic surgery. AHRQ WebM&M [serial online]. http://webmm .ahrq.gov/case.aspx?caseID¼339. Published January 2015. Accessed September 27, 2015.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. http://dx.doi.org/10.1016/j.aorn.2015.12.005 ª AORN, Inc, 2016
358 j AORN Journal
www.aornjournal.org
Perioperative Grand Rounds
March 2016, Vol. 103, No. 3
continued from page 358
PERIOPERATIVE POINTS
The policy of performing relaparoscopy in patients who are not improving is believed to be one reason for recent advances in early detection and management of anastomotic leaks in patients who undergo gastrointestinal surgery.3
Vigilance and early recognition are essential to rescuing patients from bowel injuries. Teamwork, communication, and leadership are essential in ensuring that patients are rescued effectively with minimal morbidity and mortality. Postoperative care should be protocol-based, and there should be triggers to escalate care. Patients whose progress deviates from the norm are likely to have complications.
It is likely that with the growing use of laparoscopic surgery in complex operations and complex patients (eg, those with high body mass index), bowel injuries may occur with increasing frequency.1 In these circumstances, surgical teams should be vigilant for complications and develop rescue systems that can be applied rapidly. In this case, the unexpectedly prolonged severe pain should have prompted responses throughout the postoperative period. Research has shown that the difference between lowmortality and high-mortality surgical units is likely their ability to rescue patients from surgical complications.4 For years, the surgical community believed that postoperative outcomes were predicted by surgical technical skills alone. Recently, the importance of leadership, communication, and teamwork has been recognized,5 and these skills are fundamental to rescuing patients.6 Their application often predicts postoperative outcomes.7,8 An organizational culture that emphasizes safety will flatten hierarchies, so junior residents and nurses will be empowered to call on senior residents or attending physicians without fear of ridicule or insult whenever they are concerned about a patient’s postoperative progress. Teamwork leads to better communication, resulting in earlier recognition of complications and more-aggressive diagnostic and therapeutic interventions. Creating this kind of culture requires formal training in effective behaviors.9 Teamwork training courses highlight the importance of teamwork, coordination, and communication, in addition to emphasizing the roles of briefings and checklists.10 Protocols and checklists are essential in postoperative care and often include triggers that prompt case review. In this case, triggers would have included persistent pain and tachycardia. Other triggers that are relevant to postoperative patients in gastrointestinal surgery may also include high volume of nasogastric aspirates and high drain outputs. Protocol-based care is associated with shorter hospital stays and lower incidence of postoperative complications and death.11,12 Effective protocols help teams develop a shared mental model of care, address some of the issues that arise with shift work, and trigger responses to protocol deviationsdthese mechanisms may lower complications and mortality.
318 j AORN Journal
References 1. van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury as a complication of laparoscopy. Br J Surg. 2004;91(10):1253-1258. 2. Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy: a prospective multicentre observational study. Br J Obstet Gynaecol. 1997;104(5): 595-600. 3. Kirshtein B, Roy-Shapira A, Domchik S, Mizrahi S, Lantsberg L. Early relaparoscopy for management of suspected postoperative complications. J Gastrointest Surg. 2008;12(7):1257-1262. 4. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009; 361(14):1368-1375. 5. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg. 2004;239(4):475-482. 6. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg. 2009;250(6):1029-1034. 7. Moorman DW. Communication, teams, and medical mistakes. Ann Surg. 2007;245(2):173-175. 8. Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159-169. 9. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700. 10. McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style nontechnical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care. 2009;18(2):109-115. 11. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010; 29(4):434-440. 12. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
www.aornjournal.org
Bowel Injury After Laparoscopic Surgery THE CASE A 30-year-old man presented for ambulatory laparoscopic inguinal hernia repair with mesh placement. He had no significant past medical history and did not take any medications at home. The surgery was uneventful, but postoperatively, the patient had high levels of pain at the surgical site and was admitted to the hospital. A resident physician was called multiple times overnight by the charge nurse regarding the patient’s pain, and the resident ordered additional IV pain medication. When the primary surgical team arrived in the morning, they further increased the patient’s pain medication. The patient remained in sustained pain, and the team was called multiple times during the next two days. His physical examination was documented as unremarkable, and he was started on a patient-controlled-analgesia pump with hydromorphone. After he was weaned off the patient-controlled analgesia, he continued to have abdominal pain and became increasingly tachycardic with slight abdominal distention and a low-grade fever. A computed tomography scan of the abdomen was ordered, and it showed a bowel perforation. To fix the perforation, he was sent back into the OR and then had a long stay in the intensive care unit because of septicemia. He eventually recovered and was discharged home.
DISCUSSION Bowel injuries occur in approximately 0.13% of laparoscopic procedures,1 but that figure is probably an underestimate because of the retrospective nature of most studies.2 Risk factors for bowel injuries include surgeon-related factors, such as inexperience or a steep learning curve, and patientrelated factors, such as previous abdominal surgery, adhesions, or obesity. The injury could be a result of direct injury during laparoscopic port insertion (access injury) or during handling the bowel with instruments. Bowel injuries can be prevented by adhering to basic principles of laparoscopic surgery. Using the open technique to access the peritoneal cavity is considered safer than using a Veress needle
to achieve pneumoperitoneum. Laparoscopic trocars must always be inserted under direct vision, and laparoscopic instrument changes should also be made under direct vision. Laparoscopy should be performed at the end of long, complex laparoscopic procedures, which are more likely to be associated with bowel injuries. Bowel handled during procedures associated with lysis of adhesions should always be examined systematically before the laparoscopic ports are removed. These steps to prevent bowel injuries should be undertaken in addition to surgeons undergoing laparoscopic surgery training and credentialing, which involves completion of a fellowship training program with a requirement to perform a certain number of procedures. Early recognition is essential in preventing adverse outcomes from bowel injuries. Delayed diagnosis is associated with a higher risk of septicemia (as seen in this case), the need for a laparotomy, high risk of multiple operations, stoma formation, prolonged hospital stay, and, most importantly, mortality. The estimated mortality rate for all laparoscopic bowel procedures is 3.6%.1 If an injury is recognized during surgery, it can be repaired with minimum consequences. A surgeon who encounters this complication but lacks proper experience in laparoscopic suturing should convert to an open laparotomy to repair the injury. In most circumstances, this approach would be safer than a poorly performed laparoscopic repair. continued on page 318 This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Krishna Moorthy, MD, MS, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, Boerne, TX. (Citation: Moorthy K. Bowel injury after laparoscopic surgery. AHRQ WebM&M [serial online]. http://webmm .ahrq.gov/case.aspx?caseID¼339. Published January 2015. Accessed September 27, 2015.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. http://dx.doi.org/10.1016/j.aorn.2015.12.005 ª AORN, Inc, 2016
358 j AORN Journal
www.aornjournal.org
Perioperative Grand Rounds
March 2016, Vol. 103, No. 3
continued from page 358
PERIOPERATIVE POINTS
The policy of performing relaparoscopy in patients who are not improving is believed to be one reason for recent advances in early detection and management of anastomotic leaks in patients who undergo gastrointestinal surgery.3
Vigilance and early recognition are essential to rescuing patients from bowel injuries. Teamwork, communication, and leadership are essential in ensuring that patients are rescued effectively with minimal morbidity and mortality. Postoperative care should be protocol-based, and there should be triggers to escalate care. Patients whose progress deviates from the norm are likely to have complications.
It is likely that with the growing use of laparoscopic surgery in complex operations and complex patients (eg, those with high body mass index), bowel injuries may occur with increasing frequency.1 In these circumstances, surgical teams should be vigilant for complications and develop rescue systems that can be applied rapidly. In this case, the unexpectedly prolonged severe pain should have prompted responses throughout the postoperative period. Research has shown that the difference between lowmortality and high-mortality surgical units is likely their ability to rescue patients from surgical complications.4 For years, the surgical community believed that postoperative outcomes were predicted by surgical technical skills alone. Recently, the importance of leadership, communication, and teamwork has been recognized,5 and these skills are fundamental to rescuing patients.6 Their application often predicts postoperative outcomes.7,8 An organizational culture that emphasizes safety will flatten hierarchies, so junior residents and nurses will be empowered to call on senior residents or attending physicians without fear of ridicule or insult whenever they are concerned about a patient’s postoperative progress. Teamwork leads to better communication, resulting in earlier recognition of complications and more-aggressive diagnostic and therapeutic interventions. Creating this kind of culture requires formal training in effective behaviors.9 Teamwork training courses highlight the importance of teamwork, coordination, and communication, in addition to emphasizing the roles of briefings and checklists.10 Protocols and checklists are essential in postoperative care and often include triggers that prompt case review. In this case, triggers would have included persistent pain and tachycardia. Other triggers that are relevant to postoperative patients in gastrointestinal surgery may also include high volume of nasogastric aspirates and high drain outputs. Protocol-based care is associated with shorter hospital stays and lower incidence of postoperative complications and death.11,12 Effective protocols help teams develop a shared mental model of care, address some of the issues that arise with shift work, and trigger responses to protocol deviationsdthese mechanisms may lower complications and mortality.
318 j AORN Journal
References 1. van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury as a complication of laparoscopy. Br J Surg. 2004;91(10):1253-1258. 2. Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy: a prospective multicentre observational study. Br J Obstet Gynaecol. 1997;104(5): 595-600. 3. Kirshtein B, Roy-Shapira A, Domchik S, Mizrahi S, Lantsberg L. Early relaparoscopy for management of suspected postoperative complications. J Gastrointest Surg. 2008;12(7):1257-1262. 4. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009; 361(14):1368-1375. 5. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg. 2004;239(4):475-482. 6. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg. 2009;250(6):1029-1034. 7. Moorman DW. Communication, teams, and medical mistakes. Ann Surg. 2007;245(2):173-175. 8. Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159-169. 9. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700. 10. McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style nontechnical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care. 2009;18(2):109-115. 11. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010; 29(4):434-440. 12. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
www.aornjournal.org
