A case of small bowel serosal injury during the insertion of the first trocar, leading to expanded damage and segmental resection

Abstract

　We present a case of small bowel injury that occurred during laparoscopic surgery in a 45-year-old multiparous woman with a history of prior laparotomy and severe adhesions. She had undergone cesarean section and hysterectomy and developed left ovarian cysts that required the laparoscopic surgery. During the initial laparoscopic access, the serosa of the small bowel, which was adhered to the umbilicus, was inadvertently injured. This serosal injury was not repaired immediately, leading to further damage during manipulation and necessitating small bowel resection with functional end-to-end anastomosis. In cases of laparoscopic surgery with severe adhesions, such as those with prior midline incisions, the risk of bowel injury during the initial approach is notably higher. Preoperative evaluation using ultrasound to detect the sliding viscera sign can help assess adhesions between the abdominal wall and bowel, while alternative entry points such as from above the umbilicus can mitigate injury risks. These approaches are essential for safer surgical outcomes in high-risk patients. This case emphasizes the importance of recognizing and promptly repairing serosal injuries intraoperatively to prevent further complications, particularly in patients with extensive adhesions.