Bowel injury following surgery on the prostate

On 3rd September the BBC1 and national newspapers published the sobering story of Andrew Lane, a 63 year old man who reportedly suffered serious complications from an operation to remove his prostate in 2013. In the post-operative period he had developed necrotising faciitis following an injury to his bowel that went unrecognised for six days. This was then treated appropriately with radical debridement – leaving the patient with a colostomy, a cosmetically abnormal anterior abdominal wall and the loss of most of his penis.

As a result an out of court settlement was made, with Mr Lane compensated with an undisclosed (but reportedly six figure) sum. According to the reports, Mr Lane was left unable to have sexual intercourse, with profound changes to his life as a result of the delay in the diagnosis of the condition after the operation. The prostatectomy procedure was performed laparoscopically.

Bowel injury is a rare but underreported complication of minimally invasive surgery, occurring in 0.13% of laparoscopic cases.2 When it does occur it invariably results in morbidity and occasionally mortality (the mortality rate associated with laparoscopy-induced bowel injury has been reported to be as high as 3.6 per cent).3

Although necrotising fasciitis is a rare complication of minimally invasive surgery, when it does occur it is frequently associated with a loss of integrity of bowel mucosa – whether iatrogenic or due to intrinsic pathology. Treatment is often undertaken with urgent debridement of necrotic tissue and correction of the precipitating factor where possible.4 It is possible that the delay in diagnosis in the case of Mr Lane led to a further delay in correction of the injury; such that the amount of tissue that had to be resected was more extensive and involved the penis and abdominal wall.

If a bowel injury is recognised at the time of surgery it is usually easily repaired with little consequence. However, bowel injury is elusive and may go unrecognised at the time of surgery even under optimal conditions. Any patient with signs of peritonitis, sepsis, or increased abdominal pain after laparoscopic surgery should therefore be investigated promptly. Given the possible subtlety of clinical signs a low threshold for investigation of any deviation from a ‘normal’ recovery should also be set. Unexplained abdominal pain, fever or raised inflammatory markers after surgery should prompt early contrast‐enhanced CT scanning to exclude undetected bowel injury.6 Herniation of the small bowel, including internal herniation (through mesenteric defects or between muscle layers of the anterior abdominal wall), should be a part of the differential.

The consequences of a missed bowel injury are frequently devastating. Khoury et al reviewed 32 patients whose bowel injury was not recognised at the time of surgery and who were diagnosed 1 to 13 days later. Eighteen of the patients required an intensive care unit admission, while 10 went into multisystem organ failure. Seven of the patients died.7

The delayed recognition of an enterotomy and its aftermath has been a frequent ground for allegations of malpractice against surgeons. In 1994, a study by the Physician Insurers Association reported that late diagnosis was behind 75% of the 615 claims for laparoscopic bowel injury over a one-year period.8

The elements of minimally invasive surgery that are particularly associated with bowel injury include the use of cautery and electric coupling, and injury by movement of instruments (especially, but not exclusively, sharps) outside the field of a surgeon’s view, including during port insertion. Electrosurgical devices can cause thermal tissue damage through several mechanisms, including unintended direct application of electrosurgical current to bowel, indirect transmission through another conductive instrument, or electrical discharge through faulty insulation.9

Prevention being better than cure, meticulous technique to reduce the risk of bowel injury is worthwhile. The relevant points of technique include: watching all ports in and out,10 open port insertion rather than using a Veress needle to establish pneumoperitoneum, covering all needle tips with the needle driver as they are passed in/out, careful adhesiolysis to move all bowel from the pathway of instruments, and awareness on the part of assistants that resistance to movement indicates a problem to be looked at and not overcome by increased force. The careful closure of ports >10mm diameter is necessary to prevent port site herniation, which can result in ischemic bowel injury.11 Herniation of bowel between the muscle layers separated on insertion of large bladeless trocars has been reported, and can be prevented by closure of the inner muscle layer/peritoneum as well as the fascia.12

It is unclear from the press release and various reports on the case of Mr Lane whether the patient was discharged and readmitted or stayed in until the diagnosis was made. Small bowel injury tends to present late, and with minimally invasive surgery earlier discharge means that a patient will only become unwell once at home. This is especially the case with diathermy or partial thickness injuries. It is therefore imperative that patients discharged home after major surgery are given appropriate support so that they can make contact with health services to arrange an early review if they become unwell at home. In facilitating this, Clinical Nurse Specialists perform a vital role by being available to field patients calls and arrange early review – as a surgeon’s availability may be limited if they are scrubbed/operating

We would like to hear your views on the prevention and treatment of bowel injuries in minimally invasive surgery. Please use the comment section below to let us know your thoughts. 

References

  1. BBC News. Payout for man who lost penis to superbug at Southend Hospital. BBC News September 2013 (https://www.bbc.co.uk/news/uk-england-essex-45400694; accessed 08 September 2018). 
  2. Binenbaum SJ, Goldfarb MA. Inadvertent enterotomy in minimally invasive abdominal surgery. JSLS 2006;10(3):336-40.
  3. van der Voort M. Bowel injury as a complication of laparoscopy. Br J Surg 2004;91(10):1253–1258.
  4. Kumar D, Cortés-Penfield NW, El-Haddad H, Musher DM. Bowel Perforation Resulting in Necrotizing Soft-Tissue Infection of the Abdomen, Flank, and Lower Extremities. Surg Infect (Larchmt) 2018;19(5):467-472. doi:10.1089/sur.2018.022.
  5. Cassaro S. Delayed manifestations of laparoscopic bowel injury. Am Surg 2015;81(5):478-82. 
  6. Kirby R, Patil K, Amoroso P, et al. Avoiding and dealing with the complications of robot-assisted laparoscopic radical prostatectomy. BJU Int 2010;106(11):1567-9.  
  7. Khoury W, Abu-Abeid S, Person B, et al. Missed inadvertent gastrointestinal injuries during abdominal operations: characteristics, diagnosis, and treatment. Am Surg 2012;78(1):46-50.
  8. Laparoscopic Procedure Study: May 1994. Washington, D.C.: Physician Insurers Association of America; 1994
  9. Brill AI. Electrosurgery: principles and practice to reduce risk and maximize efficacy. Obstet Gynecol Clin 2011; 38:687–702.
  10. Bhoyrul S. Trocar injuries in laparoscopic surgery. J Am Coll Surg 2001;192(6):677–683.
  11. Lambertz A, Stüben BO, Bock B, et al. Port-site incisional hernia – a case series of 54 patients. Ann Med Surg 2017;14:8-11. doi: 10.1016/j.amsu.2017.01.001.
  12. Elshafie GA, Al-Wahaibi K, Al-Azri A, et al. Port Site Herniation of the Small Bowel following Laparoscopic-Myomectomy: A case report. Sultan Qaboos Univ Med J 2010;10(1):106-13.
Comments (12) Add yours ↓
  1. Christian Brown Urologist

    I read the BBC report and instantly forwarded it to my colleagues who do radical prostatectomy. This is rare but devastating complication and we all need reminding via our own local governance networks and at international congress that complications happen and many can be avoided as Greg Shaw has detailed in this blog. In some circumstances it is the management of complications that attracts litigation rather than the complication itself. We are the advocates for our patients at this difficult time and duty of candor along with prompt, honest realisation that something has gone wrong and involving colleagues from all specialties will not only assist in getting the best outcomes for our patients after complications but also avoiding litigation.

    September 10, 2018 Reply
  2. Roger Kirby Professor of Urology

    This is an important blog and should act as a warning signal to all laparoscopic and robotic surgeons. I have performed more that 2000 robotically assisted radical prostatectomies (RARPs) and have had 3 bowel injuries unrecognised at the time of surgery, one of which resulted in successful litigation because of the delay (72 hrs) in the diagnosis. There were no deaths, but all three patients required intensive care and assistance with their management from a specialist colorectal surgeon. The key to the management is to have a high index of suspicion and to organise an urgent CT scan if a bowel injury is suspected, and to check the images yourself very carefully. Each hour that passes before the diagnosis is made increases the risk of morbidity and mortality resulting from the injury. Large bowel injuries will usually necessitate a temporary colostomy as well as broad spectrum antibiotics to deal with the resultant sepsis. As Greg correctly says: prevention is much better than cure – so do take the greatest care to avoid the problem if you possibly can.

    September 10, 2018 Reply
  3. Ben Eddy Consultant Urologist

    Congratulation to Greg for this article and keeping this complication in the forefront of our minds. Awareness and training are key. There are certain parts of a robotic prostatectomy where bowel is more at risk and all too often tends to happen in the more complex or difficult patient i.e. obesity or previous abdominal surgery. Port placement injuries can now be avoided with blunt trocars, adhesionolysis should be performed with care with additional time given on an operating list to allow safe dissection. This should also be discussed at team brief to prepare theatre staff so no one is under time pressure. There is also no shame in admitting a failed access. All patients with complex abdomens should also be councelled for longer op times and increase risk of bowel complications. caecum and sigmoid should be mobilised if in the line of instruments, assistant damage off camera can easily happen to the unaware. Profuse sigmoid diverticular disease can also increase the risk if stuck to the pelvic sidewall, better to not perform a lymphadenectomy in this occasional situation. Rectal injuries again are rare but non nerve spare, gross T3 disease wider resection can increase the risk, a low threshold for rectal pressure test can be helpful. Port closure as described I would support especially the now commonly used surgiquest port. Experience of course helps and if early in your learning curve knowing when to say no to a complex case is also key. Greg thanks again.

    September 14, 2018 Reply
  4. Jim Adshead Urologist

    Excellent summary from Greg Shaw of this devastating complication that Mr Lane has suffered.
    Robotic companies also should listen up here
    It is long overdue for the robotic companies to come up with a reverse view camera so that the console surgeon can watch behind in a TilePro view everything that is coming in and out out of their view
    This is technically possible and would prevent or at least spot rare but currently unrecognised injuries.
    Bowel injury (other than rectal) is not in my opinion an acceptable complication of a RARP unless it is documented that the bowel had to be dissected.
    For example, in the case of ahesions or extended node dissections the bowel has to be dissected and therefore a risk of bowel injury is possible and therefore not always negligent.
    Early pick up is the key for patients to do well as Greg points out and I would add to prof Kirby’s point that have a low threshold for CT with the addition of gastrograffin contrast per rectum to look for small holes early.
    This certainly has helped me in the first day post op to spot things when the patient is “just not quite right”

    September 18, 2018 Reply
  5. Pete Cooke Consultant Urologist

    There, but for the grace of God, go many of us. The case described is a harrowing reminder of what can occur, and why treatment decisions, case selection, MRI-guided surgical planning, and consent are so important. While I do mention rectal injury as a potential complication, perhaps in a post-Montgomery era, I should give more detail rather than mentioning it to dismiss it. There are a few precautions I take – specifically, very judicious use of cautery or energy device near the NVBs during robotic cystectomy or prostatectomy, a posterior approach to locally invasive tumours to optimise the view and lateral NVB mobilisation, a tonsillar swab in my left hand Marylands to push the rectum off bluntly, and a mental checklist to formally inspect the rectum on completion of specimen dissection. Routine video recording allows a review to be undertaken if a patient represents with sepsis and doubt (paranoia) exists. I have previously repaired 3 laparoscopic rectal injuries successfully, with a delayed TWOC after a cystogram and an on-table underwater air rectal leak test. The only significant bowel complication I have encountered robotically is an incarcerated inguinal hernia which strangulated after prostatectomy – steer clear of these, even if the prostatectomy is doable. On one occasion after a posterior reconstruction the patient reported pneumaturia in his catheter, which settled on prolonged catheterisation. I routinely do a 3 layer reconstruction to help continence, but use a semicircular needle rotated backhand to pick up the tissue with the needle tip parallel to the rectum, rather than forehand perpendicular to it, as some available videos show.
    There is no doubting the importance of early recognition, which can be less easy in tertiary referral patients repatriated elsewhere, so thorough post op guidance and written discharge advice can save the day

    September 18, 2018 Reply
  6. Joseph A. Smith, Jr., M.D. Professor, Department of Urology, Vanderbilt University

    This is a nice summary of an unusual complication but it is one which even expert surgeons have encoutered at some point. I had a couple of these early in my experience with robotic assisted radical prostatectomy and then performed over 5000 in a row without any bowel injuries. I was not cavalier by any means but I thought I was not going to have another one. Yet, earlier this year I caused a rectal injury in a patient who really had no factors which would have placed him at increased risk. Fortunately, we recognized it and repaired it successfully. As mentioned, prevention is best but recognition is next in line. For delayed diagnosis, a high level of suspicion and prompt treatment are necessary.

    September 18, 2018 Reply
  7. ben challacombe Urologist

    very sensible advice and thoughts from my esteemed colleagues
    This can and eventually will happen to all of us eventually as Jay indicates!
    Peter, Jim and Ben have suggested intra -op techniques to minimise injury all of which are key points. I would suggest post op intuition helps as well. Mosts RARPs are fine for home day 1. If they aren’t have a low index of suspicion for a CT. Specific tenderness around a port site is a potential sign of bowel injury. Post op bloods with CRP can help and a NEWS or similar alert score. regular review if concerns. Also in this world of big centres and tertiary referrals make sure the patient has an easy and reliable way of re contacting the team. Standardise follow up phone call on days after discharge may also help.

    September 19, 2018 Reply
  8. Raj Persad Consultant Urological Surgeon and Andrologist

    All Robotic surgeons should read this blog, as even the most experienced, high volume surgeons can not afford to be complacent in this area. All precautions outlined by esteemed colleagues above should be noted whilst awareness and early detection are key. On a practical point and with increasing service pressures; for day case RARP, for early discharge, and even for nurse led discharge, everyone in the team should be aware of warning signs if things are just ‘not quite right’for patient discharge. It is then mandatory for further team review and further imaging as indicated, as this could be life-saving.
    The invention of a ‘rear view mirror’ as mentioned by Jim Adshead and even deployment of real-time VOC sampling may help reassure that there is no Intra -operative mischief going on!

    September 19, 2018 Reply
  9. Greg Shaw Consultant Urologist

    These comments are exactly the pearls of wisdom I was hoping would be posted. I have picked up a few points of technique from this which I intend to incorporate into my operative routine and I hope others doing this kind of work will have too. Thank you all for your sage contributions.

    September 19, 2018 Reply
  10. Krishna Patil Consultant Urologist

    What an eye opener for for all Laparoscopic and Robotic Surgeons.
    I would call this as “The Blog of the year”
    It is for all practioners from beginners to experienced alike.
    Prof KIRBY and Prof Smith the Doyens in the field have clearly stated nobody is immune.
    Greg and all the contributors have really made every point crystal clear.
    Minimally invasive surgery has allowed us to discharge patients earlier than open surgery. But there is a very fine line
    Between early and safe discharge.
    The manifestations of bowel injury are very suttle and as repeatedly mentioned high index of suspicion and early imaging is the key in diagnosis and prompt treatment before
    It is too late. Seeking opinion of your colleague or bowel surgeons at early time always make you think outside the box.

    Thanks to Creg and contributors
    I am going to pass this on to all my colleagues.

    October 15, 2018 Reply
  11. Matthew Perry Consultant Urological Surgeon

    Knowledge of ones data is paramount here and where a patient should be at a particular time point on his/her recovery. These cases do not present in a text book manner. I’ve had men with bowel injuries who showed no abdominal signs yet just “weren’t right”. Lack of progression of recovery from surgery is a valid reason to scan and early imaging is extremely valuable here. Good relationships with colleagues and general surgeons to get a second opinion will overcome ones internal bias.
    Always be suspicious!

    October 15, 2018 Reply
  12. Krishna Patil Consultant Urologist

    What an Eye-Opener for all beginners and experienced!
    It should be a constant reminder for patient safety as well as
    For surgeon’s peace of mind
    As the signs and symptoms do not follow Text book description, early imaging along with septic parameters and opinion of colleague or bowel Surgeon is worth
    Considering at the earliest.
    Updating the patient and relatives is also of utmost importance.
    Thanks to Prof KIRBY, Prof Smith, Creg and all contributors.
    I have already passed it on to all my colleagues.

    October 15, 2018 Reply

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