In one line
Most serious endoscopic injuries happen in the first 60 seconds (laparoscopic entry) or are made by a fluid and an electrolyte you chose before you started (hysteroscopic distension media); the consultant skill is anticipating the at-risk patient, recognising the injury the moment the physiology shifts, and converting or correcting without losing time.
This is the complications chapter for minimally invasive gynaecological surgery. It assumes you already know how to perform a laparoscopy and a hysteroscopy, and how to pick the route and the energy source for an operation — that groundwork sits in the companion surgical-procedures chapters on perioperative care and safe surgery, on surgical approach, route and energy, and on the intraoperative complications common to all gynaecological surgery (haemorrhage, ureteric and bladder injury). What follows is one level up: the failure modes that are specific to getting into the abdomen blind, to insufflating it with gas, and to distending the uterus with fluid.
Mechanism & pathophysiology
Two mechanisms underlie almost every complication of endoscopic surgery.
The first is that laparoscopy starts blind. Whatever the technique, the first instrument crosses the abdominal wall before you can see the structures on the other side of it. The anterior abdominal wall is thin — in a slim woman the aorta and the common iliac vessels lie only a few centimetres below the umbilicus, and the bowel is mobile and adherent in anyone who has had previous surgery or pelvic infection. So the catastrophic entry injuries are anatomically predictable: a Veress needle or trocar driven in the wrong axis spears the aorta, common iliac vessels or inferior vena cava (immediately life-threatening), or the anterior abdominal wall vessels — the inferior epigastric artery, lateral to the obliterated umbilical ligament — when a secondary port is placed without transilluminating, or it perforates bowel or bladder. The umbilicus is chosen because it is the one place the wall layers are fused and thinnest, but it is also fixed to the abdominal contents, so adhesions tether bowel directly under it in the previously operated patient. Every entry-safety manoeuvre — angle of the Veress needle, intra-abdominal pressure before the trocar, an alternative entry point — is an attempt to manage a blind step.
The second is that you are putting something into a body cavity that does not belong there. In laparoscopy that something is carbon dioxide under pressure; in operative hysteroscopy it is a column of fluid pushed into the uterus above venous pressure. CO2 is chosen because it is cheap, non-combustible (it does not support the diathermy spark the way oxygen would) and highly soluble, so small intravascular boluses dissolve and are exhaled — which is precisely why a gas embolism is usually survivable if recognised. But a pneumoperitoneum is not physiologically free: raised intra-abdominal pressure splints the diaphragm and compresses the IVC, and the Trendelenburg position needed for pelvic access loads the heart and the cerebral venous system. Hysteroscopic fluid does something subtler and more dangerous — it is absorbed through the open venous sinuses of the cut myometrium directly into the circulation, and what it does there depends entirely on what is dissolved in it. The tonicity and electrolyte content of the distension medium govern the whole hysteroscopy section: a hypotonic, electrolyte-free fluid absorbed in volume causes dilutional hyponatraemia; an isotonic, electrolyte-containing fluid absorbed in the same volume causes circulatory overload without the sodium catastrophe.
Assessment
The "assessment" in this topic is mostly risk assessment before the case and pattern-recognition during it — by the time you are taking a focused history the complication has usually declared itself.
- Stratify entry risk pre-operatively. Who is high-risk? The previously operated abdomen (especially midline laparotomy, previous caesarean with a low scar, previous peritonitis or extensive endometriosis), the very thin woman (in whom the great vessels are alarmingly close to the umbilicus and the wall offers no buffer), and the very obese woman (in whom the umbilicus migrates caudally relative to the aortic bifurcation and the wall is deep and hard to gauge). A known large pelvic-abdominal mass, gross ascites, or a gravid uterus changes the geography. This stratification is the assessment, because it dictates the entry technique — it is the difference between a routine sub-umbilical Veress and a planned Palmer's-point or open entry.
- Recognise entry injury intra-operatively. A drop of free blood welling up the Veress needle, or blood/bowel content aspirated through it, is a perforation until proven otherwise. After insufflation, the laparoscope's first job is to inspect the entry site and the bowel beneath it before any other manoeuvre — the under-umbilical loop of bowel, the great vessels, the omentum. Sudden cardiovascular collapse at insufflation is gas embolism until disproved.
- Recognise pneumoperitoneum physiology. Rising airway pressures and falling tidal volumes, hypercarbia on the capnograph (the absorbed CO2 the anaesthetist must blow off), subcutaneous surgical emphysema crackling up the chest wall and neck (extraperitoneal gas tracking — benign in itself but a marker that gas is going where it should not, and a warning of possible capnothorax/capnomediastinum), and the haemodynamic effects of a tense abdomen plus head-down tilt.
- Recognise fluid overload at hysteroscopy. This is monitored, not diagnosed late: the running fluid deficit (inflow minus outflow, measured continuously) is the single number that protects the patient. Clinically, overload declares as a rising filling pressure, bradycardia and hypertension then hypotension, falling oxygen saturation (pulmonary oedema), confusion and — with the hypotonic-media syndrome — nausea, visual disturbance and seizures from acute hyponatraemia and cerebral oedema. Send urgent serum sodium the moment the deficit climbs.
- Recognise uterine perforation. A sudden loss of distension and of the view, the hysteroscope advancing further than the measured uterine length, or seeing bowel/omentum/peritoneal fat through the scope. The critical first question is not that you perforated but with what and whether the energy was on.
Management
Organise the response immediate → ongoing → long-term — but recognise that each of the four headline complications has its own internal algorithm. Take them in turn, hardest first.
Laparoscopic entry injury
Vascular injury to a great vessel is the surgical emergency of this chapter. If the Veress needle or trocar is sitting in the aorta or a major vein, the instinct to pull it straight out is wrong as the first move: it is tamponading the hole. Call for help, convert immediately to laparotomy (do not waste minutes on a laparoscopic repair of a major retroperitoneal vessel), get large-bore access and activate massive transfusion, and have the assistant maintain pressure while you open. Vascular surgery help is summoned early. An anterior-abdominal-wall vessel (inferior epigastric) bleed is less dramatic but easily missed; it is controlled by direct pressure, a port-site suture passed full-thickness around the vessel (a Foley balloon can tamponade temporarily), or under-running.
Visceral (bowel) injury at entry is the one that kills slowly through missed recognition. The classic scenario is the Veress needle, or the primary trocar, passing through a loop of small bowel. The principles:
- A recognised, clean, small Veress-needle puncture of bowel — confirmed by aspirating bowel content — can sometimes be managed conservatively (leave it, observe, antibiotics) precisely because a needle hole is small; but you must be certain it is only a needle injury, and you inspect for a second injury (the needle passes through two walls of a loop).
- A trocar through bowel is a different problem — the defect is large. The key manoeuvre: do not remove the offending trocar. Leave it in the bowel to mark the injury and to splint the defect (it stops faeculent soiling and tells you exactly where the hole is), place a fresh entry elsewhere under vision, inspect, and then repair — primary closure for a clean small-bowel injury, with intra-operative general-surgical or colorectal help for large-bowel or complex injury, and a low threshold for converting to laparotomy. Wash out, cover with broad-spectrum antibiotics.
- The delayed presentation is the lethal one. A thermal bowel injury or an unrecognised perforation presents on day 3–5 with pain out of proportion, low-grade fever, ileus, tachycardia and rising inflammatory markers — not with an acute abdomen at first. A patient deteriorating after laparoscopy is assumed to have a bowel injury until imaging or relaparotomy excludes it; sending her home reassured is how this becomes a mortality and a medicolegal case.