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 (3) 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

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