1. Bringing cutting edge to daily practice in
gynecological cancer surgery
January 2013
Murad Aljiffry MD, MSc, FRCSC
HPB and Transplant Surgery
General Surgery
Bowel Injury and Bowel Anastomosis

2. Objectives
¨ Introduction
¨ Preoperative preparation
¨ Operative management
¤ Small bowel
¤ Colorectal
¨ Current techniques of bowel anastomosis

3. Background
¨ The incidence of intestinal injury in gynecologic
surgery is 0.1–0.7%
¨ The commonest site of injury is small bowel
(60-70%)
¨ Most injuries are minor with uncomplicated clinical
outcome
¨ Immediate VS delayed presentation (15-40%
delayed)
Vilos GA, J Obstet Gynaecol Can
Erratum, Am J Obstet Gynecol

4. Background
¨ Risks:
¤ Previous surgery
¤ Prior infection
¤ Radiation
¤ Endometriosis
¤ Obesity
¨ Commonly during entrance into the peritoneal
cavity (45%), adhesiolysis (35%) and pelvic
dissection (10%)
RVan der Voort, Br J Surg
Alan Lam, Best Practice & Research Clinical Obstetrics and Gynaecology

5. Background
¨ Mechanisms:
¤ Sharp
¤ Rough handling of tissue (tear)
¤ Thermal (25%) à usually late
Michael J, Rev Obstet Gynecol.
Diamantis T, Surg Today.

6. Background
¨ An open entry technique has not been shown to
reduce the incidence of entry related bowel injury
¨ BUT allow immediate recognition of the bowel
injuries
Ahmad G, Cochrane Database Syst Rev.
Penfield AJ, J Reprod Med
Hashizume M , Surg Endosc

7. Recognition
¨ Return of bowel contents
¨ Foul-smelling gas
¨ Serosal tears
¨ Hematomas wall or mesentery
¨ Laparoscopy à high insufflation pressures,
asymmetric distension
¨ Good exercise to run the bowel after extensive
dissection

8. Delayed diagnosis
¨ The later the diagnosis, the higher the morbidity
and mortality associated with bowel injury
¨ Time of recognition is variable depends on type:
¤ Small bowel 4 days
¤ Colon 5.5 days
¨ Presentation range from septic shock to localized
abscess
Brosens I, J Am Assoc Gynecol Laparosc.
BishoffJT, J Urol

9. Background
¨ Early diagnosis is critical
¨ If suspecting bowel injury:
¤ Admit pt for close monitoring
¤ Use blood test and CT when indicated
¤ Low threshold for exploration
¤ Ask for help if not clear

10. Don t let the abdominal wall stand between you and
the diagnosis

11. Preparation
¨ Multidisciplinary approach for complex cases
¨ Proper pt education and communication
¨ Prophylactic antibiotics (within 30 min)

12. Mechanical bowel prep (MBP)
¨ Bottom line no need
¨ Paucity of literature specific to gynecologic surgery,
it is reasonable to extrapolate from the colorectal
data against MBP
Sarah L. Cohen, Rev Obstet Gynecol. 2011

13. No Statistically Significant Difference
Between MBP and No-MBP
2003
No Difference
2005
Statistically Significant
Increase in Anastomotic
Leak with MBP
2009
No Difference
14 RCTs with > 4500 Pts
Primary outcome anastomotic leakage
Secondary outcome measures surgical site infection
Guenega KKFG, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery.
Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD01544. Pub1-3.

14. Mechanical bowel prep (MBP)
¨ There is sufficient evidence to
abandon MBP
¨ MBP Has Been Shown to be
harmful in few studies
¨ No-MBP is (or becoming) the
standard for colorectal
surgery
¨ Side Does Not Matter (Right
v. Left, Colon v. Rectum)
Sarah L. Cohen, Rev Obstet Gynecol. 2011

15. Mechanical bowel prep (MBP)
At Least From the Patients Perspective MBP Should
Be Abandoned
¨ Quality of life and patient preference
¨ Dehydration and electrolyte disturbance
¨ Bacterial translocation
¨ Spillage with Bowel Prep (17%) v. NO Bowel Prep
(12%)
Mahajna A, Bowel preparation is associated with spillage of bowel contents in colorectal surgery. Dis Colon Rectum 2005
Slim K, Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before
colorectal surgery. Ann Surg Feb 2009

16. Mechanical bowel prep (MBP)
So, Who Should we Prep?
¨ Inadequate localization or possibility of intra-op
Colonoscopy
¨ Defunctionalized anastomoses?
¨ Low-level rectal resections?

18. Measures may reduce bowel injuries
¨ When entering the abdomen in high-risk patients:
¤ Watch for adhesions to abdominal wall
¤ Extending the previous scar
¨ Routine inspection of the bowel below the entry
¨ Minimize bowel handling

19. Measures may reduce bowel injuries
¨ Use atraumatic instruments for bowel handling
¨ Careful tissue dissection under vision
¨ Limit adhesiolysis to clinically indicated cases only
¨ Limit the use of thermal energy when working close
to or on bowel wall

21. Management
¨ The management of bowel injuries depends on the
following:
¤ The timing of the diagnosis
¤ The patient s clinical status
¤ Type and site of injury
¤ The available experties

22. Small bowel injuries
¨ Control contamination and assess
¨ Close enterotomies and serosal tears (transversely)
¨ Resection and anastomosis:
¤ >½ diameter
¤ Multiple injuries in a small segment
¤ Devascularized
¨ Avoid multiple resections

24. Colon injuries
¨ Control contamination and assess
¨ Depends on type of injury
¤ (destructive VS non-destructive)
¨ Generally two options:
¤ Primary repair (The Standard)
¤ Resection with anastomosis or diversion
¨ Exteriorization is abandoned à failure and
complications

25. Colon injuries
Trauma literature
¨ Numerous large retrospective and several
prospective studies have demonstrated that primary
repair is safe and effective in the majority of
patients with penetrating injuries
¨ 1% failure rate for all primary repairs
The eastren association for the surgery of trauma, J Trauma
George SM Jr, Ann Surg
Gonzalez RP, J Trauma

26. Colon injuries
Trauma literature
¨ 5-8% failure rate for resection anastomosis
¨ Most failures with resection in:
¤ Significant associated injuries
¤ Hemodynamic unstability
¤ Delayed presentation (peritonitis)
¤ Significant underlying disease
The eastren association for the surgery of trauma, J Trauma
George SM Jr, Ann Surg
Gonzalez RP, J Trauma

27. Colon injuries
¨ Primary repair of all repairable injuries:
¤ The decreased morbidity associated with avoidance of
colostomy, the disability associated with the interval
from creation to closure of the colostomy all support
primary repair of non-destructive colon injuries
The eastren association for the surgery of trauma, J Trauma
George SM Jr, Ann Surg
Gonzalez RP, J Trauma

29. Colon injuries
¨ Resect all non-repairable injuries
¨ Anastomosis if favorable general condition
¨ Resection + proximal diversion:
¤ Shock (massive transfusion > 6 units)
¤ Significant underlying disease
¤ Significant associated injuries (> 2)
¤ Delay of operation (>12hrs)
The eastren association for the surgery of trauma, J Trauma
George SM Jr, Ann Surg
Gonzalez RP, J Trauma

31. Rectal injury
¨ Intraperitoneal
¤ Similar to colonic injuries
¨ Extraperitoneal
¤ Repair if feasible, avoid unnecessary dissection
¤ Diversion
¤ Drainage
¤ Distal Washout

33. Bowel anastomosis
¨ Pillars of of technically successful anastomosis:
¤ Healthy edges
¤ Adequate blood supply
¤ No tension
¨ Overall suturing or stapling are equally safe in
bowel surgery (as long as done properly)
¨ Currently most are done stapled
Cochrane Database Syst Rev. 2011
Cochrane Database Syst Rev. 2012

34. Anatomical Side-To-Side / Functional End-To-End
Anastomosis

35. Circular Anastomosis

36. Summary
¨ Be familiar with general principles of bowel surgery
¨ Call for help when needed
¨ High index of suspicion in complex cases
¨ No need for routine MBP
¨ Primary repair or resection/anastomosis is the Role
¨ Diversion is the Exception

37. Questions