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Bowel damage during gynaecological surgery
Current Obstetrics & Gynaecology
© 1997Pearson ProfessionalLtd
(1997}7, 115-118
Operative techniques
Bowel damage during gynaecological surgery
R . J. C. Steele
Little has been written a b o u t bowel damage during gynaecological surgery, as it represents a rare complication. However, the female genital tract is adjacent to the rectum, sigmoid colon and pelvic small bowel, and in the presence o f adhesions, endometriosis, inflammation or malignancy, bowel damage may be difficult to avoid.
spillage. A major injury can be defined as breaching of the mucosa in multiple adjacent sites or in association with significant loss of tissue. The importance of this classification lies in the treatment of the injury; superficial damage needs little or no intervention and minor injuries can be dealt with by primary closure. Major injuries, on the other hand, require intestinal resection with anastomosis or even, in the case of the large bowel, stoma formation.
In this chapter, the problem o f bowel injury will be considered under the following headings: • Recognition and classification • Injury during access Laparotomy Laparoscopy • Injury during procedure Division of adhesions Hysterectomy and oophorectomy Vaginal and intrauterine procedures Laparoscopic procedures • Repair Superficial and minor injuries Major injuries.
INJURY DURING ACCESS Laparotomy One of the most common causes of bowel injury is laceration during entrance into the peritoneal cavity; it is almost always the small bowel that is affected, and adhesions from previous surgery are usually present) The small bowel often becomes adherent to the undersurface of a laparotomy wound, probably as a result of ischaemia produced by tight closure of the peritoneum, 2 and the presence of a previous laparotomy wound should alert the surgeon to this possibility. If a different incision is to be used (e.g. a Pfannenstiel in the presence of a midline scar) the problem may be averted. If, however, the same wound is to be used, it is advisable to extend the incision beyond the boundaries of the scar so that access to the peritoneal cavity can be gained at some distance from the likely site of adhesions. In addition, when the deep fascia has been divided, great care must be
RECOGNITION AND CLASSIFICATION Injury to the bowel can be classified as superficial, minor and major.' Superficial injury implies damage to the serosa or muscular layer that spares the mucosal layer. In a minor injury there is an isolated breach of the mucosa that can be recognized by the presence of a small hole in the lumen surrounded by a pouting mucosal surface. In the small bowel, frothy bile stained fluid may issue from the defect, whereas in the large bowel there is the risk of frank faecal
R. J. C. Steele, Readerin Surgery,Dcpt of Surgery,University Hospital, QueensMedicalCentre, Nottingham, UK.
115
116
Current Obstetrics & Gynaecology
taken to distinguish between the peritoneum and the serosal surface of bowel. When the bowel is adherent to the wound, it is helpful to hold up the fascial edges with tissue forceps and to dissect the bowel free before extending the wound further. This is best achieved by applying gentle traction on the bowel to demonstrate the ideal site of division for the adhesions, but if the bowel is firmly stuck it is better to dissect off some of the fascia and leave it attached to the serosa than to risk bowel perforation. Laparoseopy The bowel can be injured at laparoscopy either by insertion of the Veress needle or by insertion of the trocar after the pneumoperitoneum has been established. Veress needle injuries are rare, and are usually self-limiting, requiring no specific intervention? Trocar injuries, however, are serious and tend to affect the small bowel when it is adherent to the underlying abdominal wall, or the transverse colon when it is dilated. ~ The small bowel is likely to be adherent when there has been previous surgery, and even previous laparoscopy can result in a loop of bowel sticking to the undersurface of the periumbilical wound. Such bowel may be injured by the insertion of the trocar, but this is likely to go unnoticed during the procedure as it will be hidden from view by the trocar sheath. All patients undergoing laparoscopy should, therefore, be carefully examined for signs of peritonitis before being discharged home. Equally, it is important that special care is taken during laparoscopy in patients who have had previous intraabdominal surgery, and for such patients an open technique for inserting the laparoscope has much to commend it. A simple method for achieving open laparoscopy is to make a subumbilical incision, deepening it along the inferior surface of the umbilicus to the deep fascia. The fascia is then grasped firmly with Kocher's forceps and drawn up to the surface, where it is incised with heavy scissors. Strong sutures (preferably on small but heavy 5/8 circular needles) are placed at each of the lateral ends of this incision, and the underlying peritoneum picked up by fine artery forceps and incised. It should then be possible to insert a little finger into the peritoneal cavity and ensure that there is no underlying bowel that could be damaged. A 'Hasson' type cannula' with a blunt trocar is then inserted, and an air-tight seal is ensured by a conical sleeve that can move up and down the shaft of the cannula (Fig.). The sutures in the wound are then tied to the wings on the sleeve to ensure a good seal and to prevent slippage of the cannula. This technique does not entirely rule out the possibility of bowel injury,5 but comparative studies indi-
Figure A disposableversion of the Hasson-typecannula used for open laparoscopy.
cate that the open method is less likely to cause such damage when compared with the closed Veress needle method? In addition, if bowel damage does occur with open laparoscopy, it will almost certainly be recognized at the time of operation, which is not necessarily the case with blind trocar insertion. Open laparoscopy is not without its problems however, and leakage of C027 makes a high-flow insufllator mandatory. In addition, there is an impression that wound infection and haematoma may be more common than with the closed technique? In general, therefore, the open technique should be considered when there has been previous abdominal surgery, but use of the Veress needle remains the standard approach and is acceptably safe in the unoperated patient.
INJURY DURING PROCEDURE Division of adhesions
As with all abdominal surgery, division of adhesions to the bowel carries the risk of damage, and in pelvic procedures difficult access makes this risk more acute. Again, gentle traction on the bowel to be freed, and counter traction by the assistant on the adherent structures, is the key to displaying the correct line of division. The adhesions can be separated using scissors, a knife or a hand-held diathermy, but if the latter is used great care must be taken to avoid thermal injury to the intestinal wall. When the adhesions are dense or vascular, and particularly if endometriosis is present, the process is much more hazardous. Under these circumstances an obvious line of division may not present itself, and it is safer to divide the adhesions well away from the bowel wall and accept adherent tissue left on the bowel. In extreme circumstances bowel damage may be inevitable, and if this is recognized a formal resection is preferable to uncontrolled leakage.
Bowel damage during surgery
Hysterectomy and oophorectomy In the absence of adhesions, a straightforward hysterectomy for menorrhagia should not be complicated by bowel injury, although if the uterus is very bulky the rectum may be at risk. Occasionally, however, the uterus may be attached to the small or the large bowel as part of a malignant process or endometriosis, and an intestinal resection may be required as part of the procedure. This is more common during an oophorectomy for ovarian carcinoma. In diverticular disease, paracolic abscess formation may occur at the point where a colonic loop is adjacent to the uterus or ovary. Attempts at separation of the organs by sharp or blunt dissection are likely to lead to faecal leakage, and should be done with extreme care. Under most circumstances it is better to opt for en-bloc resection of the affected segment of the bowel.
Vaginal and intrauterine procedures Bowel injury occurring during vaginal operations is most common in association with opening of the posterior fornix as part of a vaginal hysterectomy, but should occur in less than 0.5% of cases? When it does occur, it is usually the rectum that is damaged, and if this is suspected, the vaginal incision should be extended to provide adequate exposure of the injury. It should then be possible to close the rectal defect with a single layer of interrupted sutures and then to close the vaginal incision with a single layer continuous suture. On no account should the rectal and vaginal defects be closed together, as this will almost inevitably lead to a recto-vaginal fistula. The most common type of intrauterine procedure is still a dilatation and curettage, and perforation leading to bowel injury occurs in around 0.1% of procedures. A similar rate is seen with pregnancy terminations? Recently, however, myometrial ablation using laser or diathermy resectoscopes has rapidly gained favour, and there have been reports of laserinduced perforation and thermal bowel injury? Likewise, more ambitious intrauterine procedures, such as hysteroscopic resection of fibroids, can result in intestinal damage.9
Laparoscopie procedures The most common cause of bowel damage during a laparoscopy is a trocar injury (qv). During a laparoscopic operative procedure, however, the use of monopolar diathermy may give rise to bowel perforation, and resultant deaths have been reported, t° Formerly, laparoscopic sterilization was the most common cause of diathermy bowel injury," and this can be avoided using non-electrical methods such as the Filshie clip. However, with the advent of more complex laparoscopic operations, the incidence of inadvertent collateral diathermy damage is likely to rise, and it is important to know how to avoid it.
117
Diathermy injuries to the intestine rarely present immediately, but rather 4-11 days postoperatively, owing to the delayed necrosis typical of electrical burns." It is, therefore, vital to avoid accidental contact with the bowel during diathermy haemostasis or dissection, and the most important principle is to keep the cautery tip in view at all times. It is easy to allow the diathermy device to stray into the periphery of the visual field or beyond, but the laparoscopist must concentrate on maintaining a clear view of the operation site at all times. An adequate pneumoperitoneum is also critical, and loss of pressure during a procedure may result in the bowel being brought into contact with an active diathermy probe. When this happens, diathermy must cease until the pneumoperitoneum is fully re-established. Finally, the shafts of the electrocautery instruments must be inspected regularly to detect defects in insulation that might lead to electrical arcing and consequent injury. Newer bipolar devices may be safer, ~2but there is no substitute for care and constant vigilance.
REPAIR OF BOWEL INJURIES A competent gynaecologist should be able to deal with a superficial or minor bowel injury, and a simple repair technique is described. Major injuries are more difficult to manage, however, and most gynaecologists will rightly seek the assistance of a gastrointestinal surgeon.
Superficial and minor injuries Many superficial injuries require no intervention, but if the muscle layer is divided down to the mucosa, it is prudent to deal with it in the same way as an injury where the mucosa has been breached. The simplest method for closing a minor defect is to use a single layer of interrupted serosubmucosal sutures; 3/0 absorbable or non-absorbable braided material is suitable (e.g. Vicryl or Nurulon). The technique involves placing sutures 4 mm apart and 4 mm from the cut edge of the bowel through the serosa, muscle layers and submucosa, but leaving the mucosa undisturbed. This approach should be used for minor injuries of both the small and the large bowel. Exteriorization of the colon for a small defect with minimal tissue loss is unnecessary if a careful primary closure is carried out.
Major injuries These should be divided into small and large bowel injuries. The small bowel injury is usually dealt with by a resection and primary anastomosis. The anastomosis is best done using the interrupted single-layer appositional serosubmucosal technique, as described above; this is associated with the lowest reported
118
Current Obstetrics & Gynaecology
leakage rate u and is both simple and adaptable to most situations. Major injuries of the large bowel are more difficult to manage, and in many cases a colostomy, with or without resection of the affected segment, will be required. This may involve a complex procedure, and the judgement and expertise of an experienced gastrointestinal surgeon is clearly required in such cases. Finally, in all penetrating intestinal injuries, contamination of the peritoneal cavity by intestinal contents must be minimized. Thig is achieved by rapid isolation of the injury using soft bowel clamps, and by prompt and thorough peritoneal lavage. It is also important that the patient should receive systemic antibiotics as early as possible, and if prophylactic antibiotics are not already being used, '4 the anaesthetist should be asked to give intravenous cephalosporin and metronidazole as soon as the injury has been recognized. REFERENCES 1. Krebs HB. Intestinal injury in gynaecologic surgery: a ten year experience. Am J Obstet Gynecol 1986; 155:509-514 2. Ellis H. The aetiology of post-operative adhesions. Br J Surg 1962; 50:10 3. Reich H. Laparoscopic bowel injury. Surg Laparosc Endosc 1992; 2:74-78
4. Hasson HM. Modified instrument and method for laparoscopy. Am J Obstet Gynecol 1971; 110:886-887 5. Pcnfield AJ. How to prevent complications of open laparoscopy. J Reprod Med 1985; 30:660-663 6. Sigman HH, Fried GM, Garzon et al. Risk of blind versus open approach to celiotomy for laparoscopic surgery. Surg Laparosc Endosc 1993; 3:296-299 7. Hurd WW, Randolf JF, Holmberg RA, Pearl ML, Hubbell GE Open laparoscopy without special instruments or sutures: comparison with a closed technique. J Reprod Med 1994; 39: 393-397 8. Petrucco OM, Gillespie A. The neodymium YAG laser and the resectoscope for the treatment of menorrhagia. Med J Aust 1991; 154:518-520 9. Hucke J, Campo RL, DeBruyne F, Freikha AA. Hysteroscopic resection of submucous myoma. Geburtshilfe Frauenheilkd 1992; 52:214-218 I0. Peterson HB, Ory HW, Grecnspan JR, Tyler CW Jr. Deaths associated with laparoscopic sterilization by unipolar electrocoagulating devices 1978 and 1979. Am J Obstet Gynecol 1981; 139:141-143 1I. Maudsley RF, Qizilbash AH. Thermal injury to the bowel as a complication of laparoscopic sterilization. Can J Surg 1979; 22:232-234 12. Ryder RM, Hulke JF. Bladder and bowel injury and electrodissection with Kleppinger bipolar forceps, A clinicopathological study. J Reprod Med 1993; 38:595-598 13. Matheson NA, Mclntosh CA, Krukowski ZH. Continuing experience with single layer appositional anastomosis in the large bowel. BrJ Surg 1985; 70:SI04-106 14. Keighley MRB. Sepsis and the use of antibiotic cover in colorectal surgery. In: Keighley MRB, Williams NS (eds). Surgery of the Anus, Rectum and Colon. WB Saunders 1993: 66-101
© 1997Pearson ProfessionalLtd
(1997}7, 115-118
Operative techniques
Bowel damage during gynaecological surgery
R . J. C. Steele
Little has been written a b o u t bowel damage during gynaecological surgery, as it represents a rare complication. However, the female genital tract is adjacent to the rectum, sigmoid colon and pelvic small bowel, and in the presence o f adhesions, endometriosis, inflammation or malignancy, bowel damage may be difficult to avoid.
spillage. A major injury can be defined as breaching of the mucosa in multiple adjacent sites or in association with significant loss of tissue. The importance of this classification lies in the treatment of the injury; superficial damage needs little or no intervention and minor injuries can be dealt with by primary closure. Major injuries, on the other hand, require intestinal resection with anastomosis or even, in the case of the large bowel, stoma formation.
In this chapter, the problem o f bowel injury will be considered under the following headings: • Recognition and classification • Injury during access Laparotomy Laparoscopy • Injury during procedure Division of adhesions Hysterectomy and oophorectomy Vaginal and intrauterine procedures Laparoscopic procedures • Repair Superficial and minor injuries Major injuries.
INJURY DURING ACCESS Laparotomy One of the most common causes of bowel injury is laceration during entrance into the peritoneal cavity; it is almost always the small bowel that is affected, and adhesions from previous surgery are usually present) The small bowel often becomes adherent to the undersurface of a laparotomy wound, probably as a result of ischaemia produced by tight closure of the peritoneum, 2 and the presence of a previous laparotomy wound should alert the surgeon to this possibility. If a different incision is to be used (e.g. a Pfannenstiel in the presence of a midline scar) the problem may be averted. If, however, the same wound is to be used, it is advisable to extend the incision beyond the boundaries of the scar so that access to the peritoneal cavity can be gained at some distance from the likely site of adhesions. In addition, when the deep fascia has been divided, great care must be
RECOGNITION AND CLASSIFICATION Injury to the bowel can be classified as superficial, minor and major.' Superficial injury implies damage to the serosa or muscular layer that spares the mucosal layer. In a minor injury there is an isolated breach of the mucosa that can be recognized by the presence of a small hole in the lumen surrounded by a pouting mucosal surface. In the small bowel, frothy bile stained fluid may issue from the defect, whereas in the large bowel there is the risk of frank faecal
R. J. C. Steele, Readerin Surgery,Dcpt of Surgery,University Hospital, QueensMedicalCentre, Nottingham, UK.
115
116
Current Obstetrics & Gynaecology
taken to distinguish between the peritoneum and the serosal surface of bowel. When the bowel is adherent to the wound, it is helpful to hold up the fascial edges with tissue forceps and to dissect the bowel free before extending the wound further. This is best achieved by applying gentle traction on the bowel to demonstrate the ideal site of division for the adhesions, but if the bowel is firmly stuck it is better to dissect off some of the fascia and leave it attached to the serosa than to risk bowel perforation. Laparoseopy The bowel can be injured at laparoscopy either by insertion of the Veress needle or by insertion of the trocar after the pneumoperitoneum has been established. Veress needle injuries are rare, and are usually self-limiting, requiring no specific intervention? Trocar injuries, however, are serious and tend to affect the small bowel when it is adherent to the underlying abdominal wall, or the transverse colon when it is dilated. ~ The small bowel is likely to be adherent when there has been previous surgery, and even previous laparoscopy can result in a loop of bowel sticking to the undersurface of the periumbilical wound. Such bowel may be injured by the insertion of the trocar, but this is likely to go unnoticed during the procedure as it will be hidden from view by the trocar sheath. All patients undergoing laparoscopy should, therefore, be carefully examined for signs of peritonitis before being discharged home. Equally, it is important that special care is taken during laparoscopy in patients who have had previous intraabdominal surgery, and for such patients an open technique for inserting the laparoscope has much to commend it. A simple method for achieving open laparoscopy is to make a subumbilical incision, deepening it along the inferior surface of the umbilicus to the deep fascia. The fascia is then grasped firmly with Kocher's forceps and drawn up to the surface, where it is incised with heavy scissors. Strong sutures (preferably on small but heavy 5/8 circular needles) are placed at each of the lateral ends of this incision, and the underlying peritoneum picked up by fine artery forceps and incised. It should then be possible to insert a little finger into the peritoneal cavity and ensure that there is no underlying bowel that could be damaged. A 'Hasson' type cannula' with a blunt trocar is then inserted, and an air-tight seal is ensured by a conical sleeve that can move up and down the shaft of the cannula (Fig.). The sutures in the wound are then tied to the wings on the sleeve to ensure a good seal and to prevent slippage of the cannula. This technique does not entirely rule out the possibility of bowel injury,5 but comparative studies indi-
Figure A disposableversion of the Hasson-typecannula used for open laparoscopy.
cate that the open method is less likely to cause such damage when compared with the closed Veress needle method? In addition, if bowel damage does occur with open laparoscopy, it will almost certainly be recognized at the time of operation, which is not necessarily the case with blind trocar insertion. Open laparoscopy is not without its problems however, and leakage of C027 makes a high-flow insufllator mandatory. In addition, there is an impression that wound infection and haematoma may be more common than with the closed technique? In general, therefore, the open technique should be considered when there has been previous abdominal surgery, but use of the Veress needle remains the standard approach and is acceptably safe in the unoperated patient.
INJURY DURING PROCEDURE Division of adhesions
As with all abdominal surgery, division of adhesions to the bowel carries the risk of damage, and in pelvic procedures difficult access makes this risk more acute. Again, gentle traction on the bowel to be freed, and counter traction by the assistant on the adherent structures, is the key to displaying the correct line of division. The adhesions can be separated using scissors, a knife or a hand-held diathermy, but if the latter is used great care must be taken to avoid thermal injury to the intestinal wall. When the adhesions are dense or vascular, and particularly if endometriosis is present, the process is much more hazardous. Under these circumstances an obvious line of division may not present itself, and it is safer to divide the adhesions well away from the bowel wall and accept adherent tissue left on the bowel. In extreme circumstances bowel damage may be inevitable, and if this is recognized a formal resection is preferable to uncontrolled leakage.
Bowel damage during surgery
Hysterectomy and oophorectomy In the absence of adhesions, a straightforward hysterectomy for menorrhagia should not be complicated by bowel injury, although if the uterus is very bulky the rectum may be at risk. Occasionally, however, the uterus may be attached to the small or the large bowel as part of a malignant process or endometriosis, and an intestinal resection may be required as part of the procedure. This is more common during an oophorectomy for ovarian carcinoma. In diverticular disease, paracolic abscess formation may occur at the point where a colonic loop is adjacent to the uterus or ovary. Attempts at separation of the organs by sharp or blunt dissection are likely to lead to faecal leakage, and should be done with extreme care. Under most circumstances it is better to opt for en-bloc resection of the affected segment of the bowel.
Vaginal and intrauterine procedures Bowel injury occurring during vaginal operations is most common in association with opening of the posterior fornix as part of a vaginal hysterectomy, but should occur in less than 0.5% of cases? When it does occur, it is usually the rectum that is damaged, and if this is suspected, the vaginal incision should be extended to provide adequate exposure of the injury. It should then be possible to close the rectal defect with a single layer of interrupted sutures and then to close the vaginal incision with a single layer continuous suture. On no account should the rectal and vaginal defects be closed together, as this will almost inevitably lead to a recto-vaginal fistula. The most common type of intrauterine procedure is still a dilatation and curettage, and perforation leading to bowel injury occurs in around 0.1% of procedures. A similar rate is seen with pregnancy terminations? Recently, however, myometrial ablation using laser or diathermy resectoscopes has rapidly gained favour, and there have been reports of laserinduced perforation and thermal bowel injury? Likewise, more ambitious intrauterine procedures, such as hysteroscopic resection of fibroids, can result in intestinal damage.9
Laparoscopie procedures The most common cause of bowel damage during a laparoscopy is a trocar injury (qv). During a laparoscopic operative procedure, however, the use of monopolar diathermy may give rise to bowel perforation, and resultant deaths have been reported, t° Formerly, laparoscopic sterilization was the most common cause of diathermy bowel injury," and this can be avoided using non-electrical methods such as the Filshie clip. However, with the advent of more complex laparoscopic operations, the incidence of inadvertent collateral diathermy damage is likely to rise, and it is important to know how to avoid it.
117
Diathermy injuries to the intestine rarely present immediately, but rather 4-11 days postoperatively, owing to the delayed necrosis typical of electrical burns." It is, therefore, vital to avoid accidental contact with the bowel during diathermy haemostasis or dissection, and the most important principle is to keep the cautery tip in view at all times. It is easy to allow the diathermy device to stray into the periphery of the visual field or beyond, but the laparoscopist must concentrate on maintaining a clear view of the operation site at all times. An adequate pneumoperitoneum is also critical, and loss of pressure during a procedure may result in the bowel being brought into contact with an active diathermy probe. When this happens, diathermy must cease until the pneumoperitoneum is fully re-established. Finally, the shafts of the electrocautery instruments must be inspected regularly to detect defects in insulation that might lead to electrical arcing and consequent injury. Newer bipolar devices may be safer, ~2but there is no substitute for care and constant vigilance.
REPAIR OF BOWEL INJURIES A competent gynaecologist should be able to deal with a superficial or minor bowel injury, and a simple repair technique is described. Major injuries are more difficult to manage, however, and most gynaecologists will rightly seek the assistance of a gastrointestinal surgeon.
Superficial and minor injuries Many superficial injuries require no intervention, but if the muscle layer is divided down to the mucosa, it is prudent to deal with it in the same way as an injury where the mucosa has been breached. The simplest method for closing a minor defect is to use a single layer of interrupted serosubmucosal sutures; 3/0 absorbable or non-absorbable braided material is suitable (e.g. Vicryl or Nurulon). The technique involves placing sutures 4 mm apart and 4 mm from the cut edge of the bowel through the serosa, muscle layers and submucosa, but leaving the mucosa undisturbed. This approach should be used for minor injuries of both the small and the large bowel. Exteriorization of the colon for a small defect with minimal tissue loss is unnecessary if a careful primary closure is carried out.
Major injuries These should be divided into small and large bowel injuries. The small bowel injury is usually dealt with by a resection and primary anastomosis. The anastomosis is best done using the interrupted single-layer appositional serosubmucosal technique, as described above; this is associated with the lowest reported
118
Current Obstetrics & Gynaecology
leakage rate u and is both simple and adaptable to most situations. Major injuries of the large bowel are more difficult to manage, and in many cases a colostomy, with or without resection of the affected segment, will be required. This may involve a complex procedure, and the judgement and expertise of an experienced gastrointestinal surgeon is clearly required in such cases. Finally, in all penetrating intestinal injuries, contamination of the peritoneal cavity by intestinal contents must be minimized. Thig is achieved by rapid isolation of the injury using soft bowel clamps, and by prompt and thorough peritoneal lavage. It is also important that the patient should receive systemic antibiotics as early as possible, and if prophylactic antibiotics are not already being used, '4 the anaesthetist should be asked to give intravenous cephalosporin and metronidazole as soon as the injury has been recognized. REFERENCES 1. Krebs HB. Intestinal injury in gynaecologic surgery: a ten year experience. Am J Obstet Gynecol 1986; 155:509-514 2. Ellis H. The aetiology of post-operative adhesions. Br J Surg 1962; 50:10 3. Reich H. Laparoscopic bowel injury. Surg Laparosc Endosc 1992; 2:74-78
4. Hasson HM. Modified instrument and method for laparoscopy. Am J Obstet Gynecol 1971; 110:886-887 5. Pcnfield AJ. How to prevent complications of open laparoscopy. J Reprod Med 1985; 30:660-663 6. Sigman HH, Fried GM, Garzon et al. Risk of blind versus open approach to celiotomy for laparoscopic surgery. Surg Laparosc Endosc 1993; 3:296-299 7. Hurd WW, Randolf JF, Holmberg RA, Pearl ML, Hubbell GE Open laparoscopy without special instruments or sutures: comparison with a closed technique. J Reprod Med 1994; 39: 393-397 8. Petrucco OM, Gillespie A. The neodymium YAG laser and the resectoscope for the treatment of menorrhagia. Med J Aust 1991; 154:518-520 9. Hucke J, Campo RL, DeBruyne F, Freikha AA. Hysteroscopic resection of submucous myoma. Geburtshilfe Frauenheilkd 1992; 52:214-218 I0. Peterson HB, Ory HW, Grecnspan JR, Tyler CW Jr. Deaths associated with laparoscopic sterilization by unipolar electrocoagulating devices 1978 and 1979. Am J Obstet Gynecol 1981; 139:141-143 1I. Maudsley RF, Qizilbash AH. Thermal injury to the bowel as a complication of laparoscopic sterilization. Can J Surg 1979; 22:232-234 12. Ryder RM, Hulke JF. Bladder and bowel injury and electrodissection with Kleppinger bipolar forceps, A clinicopathological study. J Reprod Med 1993; 38:595-598 13. Matheson NA, Mclntosh CA, Krukowski ZH. Continuing experience with single layer appositional anastomosis in the large bowel. BrJ Surg 1985; 70:SI04-106 14. Keighley MRB. Sepsis and the use of antibiotic cover in colorectal surgery. In: Keighley MRB, Williams NS (eds). Surgery of the Anus, Rectum and Colon. WB Saunders 1993: 66-101