This chapter should be cited as follows:
Trivedi P, Trivedi S, et al., Glob Libr Women's Med
ISSN: 1756-2228; DOI 10.3843/GLOWM.420753

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 8

Gynecological endoscopy

Volume Editors: Professor Alberto Mattei, Director Maternal and Child Department, USL Toscana Centro, Florence, Italy
Dr Federica Perelli, Obstetrics and Gynecology Unit, Ospedale Santa Maria Annunziata, USL Toscana Centro, Florence, Italy

Chapter

Prevention and Management of Complications in Laparoscopic Surgery

First published: July 2025

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By answering four multiple-choice questions (randomly selected) after studying this chapter, readers can qualify for Continuing Professional Development points plus a Study Completion Certificate from GLOWM.
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INTRODUCTION

Any surgeon who operates on thousands of cases is bound to have experienced some complications in laparoscopic surgery. It is not by accident that many excellent surgeons have fewer complications and also manage most of them laparoscopically. Preventing complications in advanced laparoscopic surgery demands not only thorough understanding, but also exceptional skill and foresight. True mastery lies in the ability to anticipate and navigate potential challenges, transforming limitations that hinder many into opportunities for surgical brilliance. A true expert manages these complexities with seamless precision, ensuring safety and success with effortless ease.¹

Universal application of the minimally invasive approach by average- or less-trained laparoscopists for advanced surgery is the root cause of the considerable increase in complications,^2,3,4 which makes laparoscopy unnecessarily dangerous for a few patients. Prevention of complications starts with the workup of a patient. Understanding the pathology and medical/surgical risks of compromised patients, and availability of advanced infrastructure in the operating theater (Figure 1), in terms of anesthetic machines, multiparameter monitoring and trained staff, are mandatory.⁵ The major component of preoperative evaluation is joint decision-making between the operating surgeon, anesthetist and assistant to opt for or against a laparoscopic approach for surgery. 

Medical risk factors

Patients of advanced age have distinct risks, which can often be effectively managed through the laparoscopic approach. More critical, however, is evaluating whether the patient has a condition such as diabetes, hypertension, respiratory restrictions, allergy, extreme obesity or history of open surgery, such as cesarean section, abdominal myomectomy, prolapse repair or gastrointestinal surgery. These factors increase the likelihood of omental and/or bowel adhesions, thereby elevating the risks associated with Veress needle or port entry. When appropriate, consultation with a physician, cardiologist or pulmonologist is advisable.

Counseling

A key aspect of any surgery is providing the patient with a clear, accurate explanation of the procedure, including any potential complications, based on objective data and the surgeon's own experience, without causing unnecessary fear. It is essential to discuss theoretical complications outlined in the consent form with the patient and accompanying person(s), as the patient will be under anesthesia during the surgery. This approach can help reduce avoidable medicolegal issues.

In the event of a complication, the surgeon should remain calm and composed, avoiding outward expression of frustration that may cause alarm and create the impression that something has gone wrong. For instance, a complication such as bladder injury can be explained by emphasizing the corrective measures taken, such as suturing the defect and using a catheter for 10–14 days, depending on the extent of the injury. Additionally, in settings in which healthcare is not free at the point of use, it is advisable not to charge extra for the extended stay or for corrective procedures, in order to foster trust and transparency between patient and surgeon.⁶

Consistency and temperament of the team

In high-volume gynecological endoscopy centers with decades of experience, the presence of a dedicated surgical team, including at least three competent operating-room nurses and one skilled technician, is essential for ensuring efficiency and safety during the multiple procedures performed each day. A good assistant surgeon is essential, not a novice, but someone who brings experience and adds value to the surgery. The assistant’s age is not as important as their temperament and skill, especially their ability to remain calm when complications occur, which is a critical asset for patient safety.

In our setting, we invite the patient's relative/accompanying person into the operating theater after trocar insertion, once the patient is draped, intubated and under general anesthesia, and after taking appropriate aseptic measures to maintain a sterile environment. This allows the relative to appreciate the value and clarity provided by advanced 3D or 4K imaging systems. Additionally, the surgeon, or other qualified expert, may choose to show the patient an edited video of the surgery after the procedure, creating further transparency. Both options can be tailored to the specific circumstances and the surgeon's comfort level.

It is important to mention live workshop surgeries, as they represent an invaluable educational aspect of surgical practice. In such cases, the primary surgeon should inform the patient and their relatives that the procedure will be performed by an equally competent surgeon. Often, when the surgery is conducted on a different floor as part of a workshop, organizers fail to adequately inform the patient and relatives, which may lead to medicolegal implications, particularly if proper consent is not obtained.

PREVENTION OF COMPLICATIONS DURING SURGERY

Anesthesia

Good anesthesia with proper intubation is essential. Effective airway management is crucial in laparoscopic gynecologic surgery to ensure adequate ventilation and minimize anesthetic complications, particularly in prolonged procedures or when the patient is in steep Trendelenburg position. Seamless coordination between the anesthesiologist and surgeon is essential for optimal intraoperative safety.. Extensive discussion of complications during anesthesia is beyond the scope of this chapter. A multiparameter monitor (Figure 2) is necessary, along with spirometry, to monitor the quantity of gases used and depth of anesthesia, while bipolar invasive signal processing (BISP) monitoring devices are optional.

Posture

In the context of gynecological surgery, the position of the patient is usually a modified lithotomy with legs at a 45° angle downwards (Figure 3), which allows easy movement of lower-port instruments. In addition, having good padded Allen's stirrups (Figure 4), which allow adjustable positioning through the draped leg, is useful. As Trendelenburg or head-low position may be required for an extended period, padded shoulder rests are beneficial. Inappropriate movement of the anesthetized patient, which can lead to neuromuscular strain on the upper arms or legs that may persist for several days, should be avoided. Positioning of the patient's arms at the side of or perpendicular to their body is a collaborative decision made by the surgeon, anesthetist and person responsible for postoperative care.

Rotator cuffs and thromboembolism prophylaxis with low molecular weight heparin are preferred in obese and high-risk patients.

Measures should be taken to reduce postoperative discomfort and pain. At our institution, we administer 10–20 ml of 0.25% bupivacaine (Sensorcaine) to the retroperitoneal presacral area. While transversus abdominis plane (TAP) blocks are an option, we approach them with caution as the blind technique carries risk of petechial hemorrhage in the abdominal wall. Depth of anesthesia and pain control should be monitored meticulously by the anesthetist throughout the procedure. Their experience across multiple surgeons provides valuable expertise in optimizing pain management protocols.

Entry-port safety

In our institution, a disposable Veress needle is preferred for peritoneal access, using the fluid drop aspiration technique with negative pressure to confirm entry into the peritoneal cavity. Unnecessary movement of the Veress needle should be avoided, and a perpendicular entry into the abdomen is recommended for optimal safety and efficacy. When disposable Veress needles are unavailable, reusable Veress needles that meet sterility and sharpness standards may be used as an alternative, provided they undergo strict sterilization protocols between procedures. The electronic CO₂ insufflator is usually set at 15 mmHg to permit venous return. Some laparoscopists, particularly those using laser or robotic techniques, initially maintain an intra-abdominal pressure of 20–25 mmHg, which is then reduced to 15 mmHg after insertion of the ports, typically a 10-mm primary port and 5-mm secondary port on both sides. To minimize the risk of injury to the bowel, blood vessels and, in rare cases, the bladder, during laparoscopy, catheterization of the bladder is often recommended. Emptying the bladder lowers the risk of inadvertent injury during trocar insertion or instrument manipulation within the pelvic region. This simple step enhances visibility and maneuverability for the surgeon, especially in procedures involving the lower abdomen, ensuring a safer and more controlled laparoscopic operation. 

The type of trocar used, either reusable or disposable, or blunt-tip Ternamian trocar, depends on individual preference. Inferior epigastric artery injury by secondary trocar entry on both sides can be prevented by transillumination and also by direct laparoscopic vision.

A skilled laparoscopic assistant is an invaluable asset to the surgeon, especially for precise camera control and maintaining optimal visualization. Similarly, a proficient operating room nurse is crucial in ensuring a seamless flow of instruments, minimizing delays and enhancing surgical efficiency. To prevent unnecessary disruptions, the operating surgeon should confirm that all necessary instruments and devices are properly arranged on the trolley before the procedure begins. When positioning foot switches, it is important to place them near the active leg — typically the left leg for a right-handed surgeon standing on the left side of the patient. This setup provides ergonomic access and reduces the risk of unintentional movement. Additionally, any cordless or hand-operated energy devices should be clearly communicated to the surgeon before use, ensuring awareness and avoiding accidental activation, which could potentially cause thermal injury to critical intraperitoneal structures.⁷

Energy sources

In laparoscopic gynecological surgery, energy sources such as monopolar electrosurgery, bipolar devices and ultrasonic instruments are essential tools but carry specific risks. Thermal injuries to adjacent structures, such as the ureters, bowel or bladder, can result from direct contact, lateral heat spread or delayed tissue necrosis. Insulation failure of instruments, capacitive coupling and direct coupling may lead to unintended tissue damage, particularly when metal instruments are used in close proximity. Skin burns at the return electrode site may occur with improper grounding pad placement, and surgical smoke poses visibility and health hazards. Though rare, operating room fires can occur, especially with alcohol-based skin preparations in oxygen-rich environments. These risks can be significantly mitigated by using the lowest effective power settings, minimizing activation time, routinely inspecting instrument insulation, and employing advanced energy devices with safety features. Proper placement of grounding pads, avoiding contact between active and conductive instruments, allowing skin preps to dry fully, and using smoke evacuation systems further enhance safety. Regular staff training in the safe use of energy sources is also crucial to prevent complications and ensure optimal surgical outcomes.

LAPAROSCOPIC HYSTERECTOMY

Laparoscopic hysterectomy and myomectomy are among the most commonly performed procedures by general gynecologic surgeons, in contrast to other more specialized gynecologic surgeries. The indication for laparoscopic hysterectomy remains paramount, followed by surgical eligibility criteria and the surgeon’s level of laparoscopic expertise, which can vary considerably. For the sake of clinical clarity and patient safety, laparoscopic hysterectomy should generally be avoided if vaginal hysterectomy is feasible. Specific technical and clinical considerations relevant to laparoscopic hysterectomy are outlined below.

Size of the uterus 

Although our team has successfully removed a uterus weighing 3.4 kg, approximately equivalent to a pregnant uterine size of 28–30 weeks' gestation, space limitations for trocar placement and the technical challenges of morcellating large specimens generally set the practical upper limit for laparoscopic removal at a uterine size of 24 weeks (Figure 5).^{8 9,10} One of the key advantages of laparoscopic surgery is the ability to maintain anatomic orientation even in the presence of uterine enlargement. With the use of a 30° laparoscope or 3D imaging, key landmarks such as the infundibulopelvic ligament and round ligament remain consistently positioned near the pelvic brim. Once pneumoperitoneum is established, the enlarged uterus typically does not obscure the view, allowing for safe and efficient dissection.

Hemostasis

Hemostasis is best achieved by careful dissection and release of pedicles of the uterine artery, cornual structures and infundibulopelvic ligament. Unnecessary manipulation of veins should be avoided. To minimize intraoperative bleeding, prophylactic clipping of the uterine artery is considered a safe and effective measure. The optimal site for this is near the infundibulopelvic ligament, either lateral or medial to the ureter, where the anatomy is consistently well-defined (Figure 6). Once mastered, this technique enables the surgeon to manage larger uteri laparoscopically when indicated. In cases involving very large uteri, the placement of two additional 5-mm ports, one on each side, can greatly enhance visualization. This setup allows the uterus to be retracted to the opposite side using a myoma screw or spiral, thereby exposing the vascular pedicle more effectively. To further reduce bleeding, especially at myoma screw puncture sites, diluted vasopressin (20 units in 200 ml of saline) may be infiltrated into the myometrium. Special caution is warranted in patients with a duplicated ureter. It is important to note that not all patients require uterine artery clipping at the origin; its use should be tailored to individual surgical needs.

Ureter and bladder

Ureteric injury is one of the most important complications associated with total laparoscopic hysterectomy, largely due to the ureter’s close proximity to the uterine vessels, approximately 5–7 mm from the uterine artery anteriorly and the uterine vein posteriorly at the level of the uterine isthmus. Continuous awareness of the site of the ureter is mandatory during and immediately after laparoscopic hysterectomy. The medial or posterior approach to the infundibulopelvic ligament is generally easier for gynecologists, while the lateral approach is more familiar to oncologists. In case of doubt, cystoscopic ureteric catheterization is useful and simple to perform.

Risk of bladder injury is particularly increased in patients with a history of cesarean section. This risk can be minimized using the lateral window technique (Figure 7) in which, after dissecting the round ligament and uterovesical peritoneal fold, the laparoscopist stays above the uterine artery and adequately displaces the bladder to safely secure the artery and avoid injury.

In the correct plane, the bladder can be pushed below the cervix without needing extensive separation from the vagina, thereby reducing the risk of bleeding. In the event of a bladder injury, a two-layer closure (Figure 8) is recommended, after which the primary surgery can be continued.

In hysterectomy patients with endometriosis, care must be taken to identify and protect the ureter, as it may be pulled medially by the disease; hence, careful skeletonization of the ureter is advised. Furthermore, in cases with posterior adhesions due to uterosacral-ligament or rectovaginal endometriosis, precise dissection in the correct plane (along Denonvilliers’ fascia) is required.

Laparoscopic radical hysterectomy and pelvic lymphadenectomy

Laparoscopic radical hysterectomy and pelvic lymphadenectomy can be performed for early-stage cervical and uterine cancers. The use of indocyanine green (ICG) dye injected into the cervix helps identify the sentinel lymph node, and if this node is negative for metastasis, further pelvic lymphadenectomy may be avoided, thereby reducing the risk of pedal edema. The gynecological laparoscopist should have comprehensive knowledge of the relevant anatomical spaces, nerves and vessels; otherwise, an oncological laparoscopist should be consulted to ensure the procedure is completed appropriately.

LAPAROSCOPIC MYOMECTOMY

Large-tissue extraction

Large-tissue-specimen extraction remains a technical challenge in minimally invasive gynecologic surgery. One effective approach is the lateral coring technique, in which a 4-cm strip of cervical and adjacent uterine tissue is incised and gradually extracted. The remaining portion is maneuvered in an L-shaped fashion and removed vaginally, minimizing the need for abdominal extension. At our institution, we have developed expertise in contained, visually guided in-bag morcellation for large uterine fibroid specimens, with large number of procedures performed since 2015, including cases involving uteri weighing up to 2.5 kg.¹¹ While laparoscopic morcellation is subject to regulatory restrictions in many countries, our data suggest that this contained approach offers a safe and practical alternative, eliminating the need to enlarge the port site to 3–4 cm, which effectively constitutes a mini-laparotomy.

Hemostasis

Blood loss during myomectomy has historically been a significant concern, and strategies to minimize it are important.¹²

Methods that can be employed include:

1) Injection of diluted vasopressin. Our approach is to inject 20 units of vasopressin diluted in 200 ml of saline, following standard safety protocols. Caution should be exercised to avoid intravascular injection of vasopressin, informing the anesthesiologist in advance, and ensuring continuous monitoring of blood pressure, oxygen saturation (SpO₂) and heart rate. In borderline cases, it may be prudent to defer the use of vasopressin until necessary. We have used vasopressin for over two decades and have not encountered major complications.

In cases involving multiple fibroids (e.g 12–18), it is advisable to inject vasopressin into four or five fibroids initially. These should then be enucleated and the myometrial defects sutured. This staged approach helps clear the operative field of blood and allows for additional vasopressin injections after a 20–30-min interval, thereby enhancing safety.

2) Clipping the uterine artery. This should be undertaken early during surgery, either at the origin of the uterine artery (Figure 9) or near its uterine insertion, while carefully safeguarding the ureter. The use of a temporary vascular loop or 'shoelace' technique, which is removed at the end of the procedure, can further assist in minimizing blood loss.¹³

During tissue extraction, care should be taken to avoid spillage of myoma tissue, which can lead to peritoneal leiomyomatosis or port-site fibroid formation. This is best achieved through contained bag morcellation (Figure 10). Although the risk of inadvertently morcellating a leiomyosarcoma instead of a benign fibroid is extremely low, it remains a concern. In our experience, leiomyomas do not genetically transform into leiomyosarcomas, which are de-novo malignancies that can arise from any smooth muscle tissue.

Laparoscopic suturing of the defect after myoma enucleation is a critical skill that needs to be mastered. The introduction of self-retaining, knotless barbed sutures has simplified the process, allowing for efficient two-layer closure. The outer layer can be closed using baseball suturing (Figure 11).

LAPAROSCOPIC SURGERY FOR ADENOMYOSIS

Laparoscopic surgery for adenomyosis differs significantly from laparoscopic myomectomy or focal adenomyoma excision. The procedure involves leaving a 0.75-cm layer of myometrial tissue intact around the surgical site to avoid entering the endometrial cavity. Suturing can be performed using interrupted box sutures or interrupted full-thickness polyglactin sutures. The goal is to achieve adequate but optimal removal of adenomyotic tissue. Following surgery, it is recommended that patients wait at least 6 months before attempting conception, allowing sufficient time for healing. A follow-up examination with color Doppler ultrasound is advised to assess the vascularity and integrity of the sutured site, confirming full repair.

LAPAROSCOPIC REMOVAL OF TUBAL AND OVARIAN PATHOLOGY

The removal of tubal and ovarian pathology is generally straightforward; however, in cases of ruptured ectopic pregnancy, achieving hemostasis is important. For ovarian cysts of varying types and size, careful enucleation should be performed to preserve healthy ovarian tissue, which may occasionally require suturing. When managing a twisted ovarian cyst, detorsion is generally performed irrespective of the ovary’s initial appearance, as its color often returns to normal once perfusion is restored. As a result, salpingo-oophorectomy is rarely required.

LAPAROSCOPIC SURGERY FOR PROLAPSE AND STRESS URINARY INCONTINENCE

Laparoscopic Burch colposuspension for genuine stress urinary incontinence involves entering the space of Retzius, dissecting the paracolpium, and placing helical sutures over the surgeon’s finger to remove fat and ensure proper placement. Sutures are typically placed 2 cm lateral and 2 cm below the bladder neck, then anchored to the ipsilateral Cooper’s ligament to create a tension-free 'hammock' (Figure 12).

To minimize complications, it is important to enter in the correct anatomical plane, as this reduces the risk of excessive bleeding and facilitates precise suture placement. In cases of severe stress urinary incontinence or sphincter deficiency, a suburethral or transobturator Trivedi’s tape (Figure 13) is the preferred approach. When performed by experienced surgeons, success rates are over 70% for Burch colposuspension and 90% for midurethral tape procedures, highlighting their effectiveness in managing these conditions.

LAPAROSCOPIC SURGERY FOR UTEROCERVICAL PROLAPSE AND VAULT PROLAPSE

In laparoscopic surgery for uterocervical and vault prolapse, it is recognized that structures separated from the vaginal apex (roof) cannot be effectively corrected through a purely vaginal approach.

Uterocervical prolapse

For young women with uterocervical prolapse, proper anatomical correction using Y-mesh sacral colpopexy or fixation to the pectineal ligament with appropriately placed tape is important. Care should be taken to select a soft mesh and anchor it securely to the sacral promontory without tension. The cervix should be suspended above the level of the ischial spines to ensure adequate support. Additionally, covering the mesh with peritoneum is important to reduce the risk of adhesions and other complications.

Vault prolapse

Laparoscopic correction of vault prolapse begins with anterior dissection using a vaginal probe or malleable retractor to elevate the bladder up to the bladder neck. Posteriorly, the rectovaginal space is entered, and the levator ani muscles are identified bilaterally. A Y-shaped mesh is positioned with its central portion anchored to the vaginal vault using 4–5 sutures anteriorly and posteriorly, while the lateral arms are secured to the levator ani muscles. The mesh is then covered with peritoneum to prevent mesh exposure, bowel adhesions and obstruction. At the sacral promontory, tackers are placed just below the curvature to avoid the median sacral vessels and minimize the risk of injury to intervertebral discs at higher levels. Intraoperative ureteral injury, although rare, may necessitate immediate reconstruction. When adequate ureteral length is available, a uretero-ureteral anastomosis can be performed using four interrupted 4–0 or 5–0 non-absorbable or delayed-absorbable sutures over a double-J (DJ) stent. For distal ureteral injuries, ureteroneocystostomy is the preferred approach (Figure 14). The ureter is fish-mouthed to enlarge its opening and anastomosed to a freshly created cystotomy, typically at the 5 or 7 o’clock position on the bladder dome. A DJ stent is inserted to ensure patency. When tension is anticipated at the anastomosis site, ureterovesical implantation with psoas hitch is indicated. This involves mobilizing the bladder through dissection of the space of Retzius and anchoring it to the psoas muscle to reduce tension. The ureter, ligated above the injury site, is brought into the bladder through a small cystotomy. It is stabilized with anchoring sutures to the bladder wall, and mucosa-to-mucosa anastomosis is performed at the 6, 3, 9 and 12 o’clock positions. A DJ stent is placed, and the bladder is closed in two layers. To date, we have successfully performed six ureterovesical reimplantations. Nevertheless, meticulous surgical technique to prevent ureteral injury remains paramount, as prevention is always preferable to repair. 

MANAGEMENT OF COMPLICATIONS IN LAPAROSCOPIC SURGERY

Complications present opportunities to develop and refine the skills necessary to manage challenging situations safely and, in the context of this chapter, to advance the quality of women's healthcare.

Complications related to anesthesia

This section briefly covers practical important aspects of the management of anesthesia complications, supplementing information in the 'Prevention' section above. 

With the patient in the supine position, a Veress needle and trocars are inserted perpendicularly under guidance. On initiation of pneumoperitoneum, a transient vasovagal response may occur and should be managed by temporarily deflating the abdomen, administering atropine and ensuring adequate ventilation. Once stabilized, pneumoperitoneum can be restarted gradually, using a lower CO₂ flow rate and pressure. In the authors’ practice, intra-abdominal pressure is maintained at 15 mmHg.

A critical sign in hysteroscopic surgery is a sudden drop in end-tidal CO₂ (ETCO₂), which may indicate gas embolism, especially when the patient's head is in a low position. The hysteroscopic system should be withdrawn and management undertaken by the anesthetist. Once stabilized, the procedure can resume. A cardiologist may be needed in the operating theater for high-risk complicated patients.

In a crisis situation, the anesthetist and senior operating-theater assistant play crucial roles. One of the anesthetist's primary responsibilities is to maintain an adequate depth of anesthesia and ensure the patient remains pain-free. The worst-case scenario is the patient being conscious while intubated, potentially resulting in a traumatic memory that may last a lifetime.

Another concern in hysteroscopic surgery is fluid overload. The anesthetist plays a vital role in identifying early signs, initiating appropriate management with diuretics and ensuring adequate oxygenation. If necessary, the anesthetist may request a temporary pause or complete cessation of the procedure to ensure patient safety.

The use of 5% dextrose, normal saline or Ringer’s lactate in bipolar resectoscopic procedures is often considered safer than monopolar techniques. However, in our experience (we have performed over 15,000 such surgeries since 1992), this safety profile may be overstated. These so-called 'safer' fluids carry their own risks, including pulmonary edema and hypokalemia. Additionally, isotonic solutions like normal saline mix readily with blood, leading to compromised visualization, unlike 1.5% glycine, which offers a clearer operative field. That said, 1.5% glycine also has its own set of complications and must be used with caution. This is not intended as a definitive recommendation, but it reflects the perspective of experienced hysteroresectoscopic surgeons, including many urologists, who have successfully used this technique for over three decades.

In terms of intraoperative blood loss, the anesthetist has the final authority on its assessment.

Extubation following reversal should be smooth, with careful attention to prevent regurgitation or vomiting. Postoperative pain control is best managed by the anesthetist. Finally, the transfer of the patient from the operating theater to the hospital bed is a critical period and should be closely supervised.¹⁴

Entry-point complications

The Veress needle is often blamed for entry-related complications, though many such issues arise from improper use rather than the instrument itself. If incorrect placement is suspected, as identified by the electronic insufflator or other verification method, the needle should not be moved blindly, as this can cause injury to unexpected structures. Unless the needle is confirmed to be within a blood vessel, it can be gently withdrawn and reinserted, or, in experienced hands, direct trocar insertion may be considered.

Vessel injuries

Injury to the inferior epigastric artery can occur by ancillary side trocars (Figure 15a). If bleeding is acute, a Foley catheter can be passed through the trocar, the bulb distended to provide tamponade, and the trocar then removed (Figure 15b). Under visualization, bipolar cauterization from another port can be used for coagulation, while applying external pressure with a finger on the abdominal wall adjacent to the trocar site (Figure 15c). A through-and-through suture placed on either side of the port site, with a gauze pad on the skin surface, can help control bleeding. The trocar should then be reinserted at a different site to continue the procedure.

The most serious complication can occur during primary 10-mm trocar entry, particularly if introduced obliquely, potentially injuring the iliac vessels. Injuries to the aorta or inferior vena cava typically require significant force. If such an injury occurs, the trocar should not be removed. The anesthetist should focus on stabilizing the patient's hemodynamics, including controlling blood pressure and maintaining adequate oxygen saturation (SpO₂). Proximal pressure should be applied to the injured vessel, and a general or vascular surgeon should be called immediately. The patient's relatives must also be informed without delay.

For venous injury, continuous pressure and use of absorbable hemostatic agents can be highly effective in avoiding opening of the abdomen.

Vessel injury during dissection, especially with monopolar cautery/scissors (Figure 16A), can be managed if venous, by applying pressure with a gauze, and, if small, by holding it with an atraumatic dissector and the use of bipolar in bursts (Figure 16B).

In the event of uterine artery bleeding during dissection, once identified, the laparoscopist should remain calm. CO₂ insufflation and suction at pressures below 300 mmHg help maintain pneumoperitoneum. The bleeding vessel should be carefully grasped with bipolar cautery forceps or another appropriate instrument (Figure 17) after adequate dissection. Occasionally, the presence of a gauze piece can help localize the bleeding source. It is important to avoid forcefully grasping the bleeding area, as the uterine artery lies above the ureter, which in turn is above the uterine vein. If the bleeding originates from the vein, bipolar cautery may inadvertently damage the ureter. Once hemostasis is achieved, hemostatic agents such as Surgicel may be applied, although they are often unnecessary.

During sacral colpopexy, the left common iliac vein (Figure 18) may be inadvertently punctured by a needle. In such cases, it is best to apply pressure using two gauze pads placed perpendicularly for 5–10 minutes. Once the bleeding stops, a small retroperitoneal collection is usually self-limiting.

An important precaution during pelvic lymphadenectomy inferomedial to the external iliac vein while removing obturator lymph nodes, is to avoid the corona mortis (the vascular connection between the obturator vessels and external iliac or inferior epigastric vessels), which can cause significant bleeding if damaged.

Bowel injury

If the primary trocar enters the bowel, identified on creation of pneumoperitoneum, the trocar should not be removed immediately. Instead, gas inflow should be stopped and the abdomen accessed through an alternate port, such as Palmer’s point. Using a 30° laparoscope, the trocar in the bowel can be visualized. It should be ascertained whether the injury involves the small or large bowel or, less likely, is a through-and-through injury. After access via additional ports, the primary trocar should be removed from the bowel. The defect is usually amenable to primary closure in two layers (Figure 19). The intended surgical procedure can then be completed and postoperatively the patient kept nil by mouth. A drain may be placed to allow early detection of any leakage. When there is no evidence of peritonitis or leakage and peristalsis has resumed, oral liquids can be gradually reintroduced. The involvement of an experienced surgeon, administration of potent broad-spectrum antibiotics and adequate intravenous fluid management are critical for optimal outcomes.

Bladder injury

During dissection or energy-source injury, the size and location of the bladder injury (Figure 8A), as well as its proximity to the ureteric orifices, should be identified. The bladder should be mobilized to allow repair with healthy tissue margins, followed by a two-layer closure; the choice of suture may vary (Figure 8B). In some cases, placement of a ureteric DJ stent may be necessary. The planned surgical procedure should then be continued. The Foley catheter should typically be left in place for 7–14 days, depending primarily on the nature and extent of the energy-source injury.

Ureteric injury

In cases of ureteric injury during surgery involving an energy source, where there is a partial or small beveled incision on healthy tissue, including ureteral or DJ stent sites, repair can be performed using fine sutures. Following the completion of the primary surgery, the ureteric stent should typically be left in place and removed after 3–6 weeks to ensure proper healing and function.

Late bladder or ureteric injury ~ fistula

Bladder injuries are often detected only a few days to a week postoperatively. A three-swab test using diluted methylene blue instilled into the bladder via a catheter can help confirm the presence of an injury. Alternatively, cystoscopy can be used to assess the site, size and proximity of the injury to the ureteric orifices.

Depending on the surgeon’s expertise, the injury may be repaired via a vaginal or laparoscopic approach. Vesicovaginal fistula (VVF) repair requires clear exposure of the fistulous tract, which is typically achieved using a vaginal approach with adequate lighting and retraction, or laparoscopically in select cases. Stay sutures should be placed beyond the lateral margins of the fistula to provide traction. Saline with a few drops of adrenaline is injected into the plane between the vagina and the bladder mucosa. Dissection is then carried out in this plane to ensure adequate mobilization of healthy bladder tissue. The bladder is closed in two layers: an inner layer using continuous, non-locking absorbable sutures (e.g. V-Loc 2–0 or Vicryl 2–0), and an outer layer of interrupted sutures incorporating the muscularis and mucosa. The vaginal wall is subsequently closed with similar absorbable sutures. When the ureter is involved or at risk, a ureteric catheter or DJ stent should be placed prophylactically and is typically removed after 3–4 weeks to support healing and prevent obstruction.

Laparoscopic repair can be performed similarly, following adequate dissection of healthy bladder tissue around the fistula. The closure technique mirrors that of the vaginal approach. The laparoscopic route is preferred, and either approach can be effectively performed by experienced gynecologists.

A unique laparoscopic technique for VVF repair involves passing a ureteric catheter through the vaginal opening of the fistula and retrieving it cystoscopically through the urethra. The two ends of the catheter are tied together, eliminating the need for a catheter within the bladder during dissection. Laparoscopic dissection is then performed, carefully separating the tissue planes laterally until the fistula is visualized, guided by the ureteric catheter. Adequate dissection distal to the fistula opening is essential to mobilize enough healthy bladder tissue for closure. Once this is achieved, the ureteric catheter is cut and removed. The vaginal side of the fistula is closed using interrupted 1–0 Vicryl sutures. The bladder defect is then closed in two layers: a continuous suture with V-Loc, followed by a second layer of interrupted 1–0 or 2–0 Vicryl sutures (Figure 20). If necessary, the bladder can be filled with 200–250 ml of diluted methylene blue to test for leakage.

Finally, a Foley catheter is placed per urethra for 3 weeks before removal.

Ureteric injuries can vary in both location and extent, occurring near the bladder, at the pelvic brim, or involving significant segmental loss. For injuries close to the bladder, laparoscopic ureterovesical implantation is typically performed over a ureteric or DJ stent. This involves fish-mouthing and freshening the distal end of the ureter to ensure an optimal connection with the bladder. In cases of significant ureteric segment loss, the bladder is mobilized, and the ureter dissected to allow a psoas hitch, which relieves tension on the ureter. Ureterovesical implantation with a DJ stent, typically left in place for 6 weeks, is recommended in such cases (Figure 14). For minor injuries located at the pelvic brim, a uretero-ureteric anastomosis over a stent is a viable and effective option.

Currently, all these procedures are routinely performed laparoscopically, offering faster recovery and fewer postoperative complications.

PRACTICE RECOMMENDATIONS

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