Total Laparoscopic Hysterectomy (TLH): management of a bowel complication

We present the case of a 65-year-old patient, diagnosed with uterine fibroids that have increased in volume over the last months. The patient had previously undergone a rectosigmoid resection and an appendectomy due to an adenocarcinoma. This surgery was streamed live worldwide, and it provides a unique opportunity to learn how to assess, diagnose, and treat intraoperative unexpected complications.

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Total   Laparoscopic   Hysterectomy   (TLH):   management   of   a   bowel   complication

Authors
Abstract
We present the case of a 65-year-old patient, diagnosed with uterine fibroids that have increased in volume over the last months. The patient had previously undergone a rectosigmoid resection and an appendectomy due to an adenocarcinoma. This surgery was streamed live worldwide, and it provides a unique opportunity to learn how to assess, diagnose, and treat intraoperative unexpected complications.
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live recorded, winners
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55'42''
Publication
2013-02
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E-publication
WeBSurg.com, Feb 2013;13(02).
URL: http://www.websurg.com/doi-vd01en3915.htm

Total   Laparoscopic   Hysterectomy   (TLH):   management   of   a   bowel   complication

3. Diagnosis and management of intraoperative bowel injury 03'15''
During adhesiolysis, fecal material is visualized, indicating a bowel injury. The surgeon carries on with the adhesiolysis at a higher level in order to find an adequate plane and avoid the lesion, and a suture is prepared to repair the complication. A gentle and careful dissection is performed, with an additional difficulty of the distorted anatomy and the presence of very fibrotic tissue, which makes it difficult to work in the appropriate plane. Due to the previous bowel resection, the normal tissue is hardly recognized. Therefore, the surgeon visualizes the right ureter and promontory, and dissects its peritoneum in order to progress caudally and locate the normal edge of the bowel. It is of major importance to restore a normal anatomy, to achieve an easier mobilization of the remaining rectum in order to isolate the lesion and repair it. The assistant grabs the right adnexa and keeps a constant traction, in order to help the surgeon advance laterally to the lesion. Progress is made caudally until the rectovaginal space is reached. Once the anatomy has been restored and the proper plane has been identified, the bowel lesion can be repaired. A monocryl 3/0 stitch is made to repair the bowel perforation. It is preferred to close the defect before pushing the rectal probe so as not to displace feces into the abdominal cavity. Once the injury has been repaired, the surgeon makes sure that there is not a second injury on the bowel, as there previously seemed to be.