Anatomy and Surgical Complications
Several factors determine the complications associated with surgical procedures to include:
- Where the operation is taking place, ie what organ system
- The type of procedure, ie removal of a structure, repair of a structure or organ system
- The size or weight of the structure to be removed
- The number of prior procedures a patient has had
- What type of procedures have been done in the past
- The size of the patient, that is the patients weight
- The medical condition of the patient
1. Where the operation is taking place. Different areas of the body have different complexities regarding the anatomy and relationships between other structures. The pelvis, for example, is very complex with a large number of structures closely related to each other anatomically and functionally. The uterus occupies the base of the pelvis which is like a funnel – the pelvis has 1 limited space. The ureter – the tube that runs from the kidney to the bladder – could not be in a worse place for surgery. It runs on the side of the body and crosses under the uterine artery – the blood supply to the uterus – on its way to the bladder. The ureter is at high risk during pelvic surgical procedures such as hysterectomy and can be as close as one half inch away from the uterus. As the uterus increases in size, it can expand to the side of the pelvis and upward, decreasing the space between itself and the ureter and increasing the risk of surgical injury to the ureter. During the course of hysterectomy, clamps are applied to the uterine artery , which runs directly above the ureter. If there is extensive bleeding and clamps are applied to the uterine artery incorrectly without identifying the ureter, the ureter can easily be clamped or injured. The bladder and rectum likewise are in very close proximity to the uterus. The bladder sits on top of the uterus, the rectum below, forming a sandwich with the uterus being the filling of the sandwich. In many cases it is necessary to dissect the bladder and rectum away from the uterus in order to remove the uterus or fibroids safely, increasing the risk of injury to these structures. The large vessels that feed the legs – the external iliac artery – run on the side of the pelvis in close proximity to the uterine artery and ureter. These structures are also at risk during a surgical procedure. The main structures at risk during pelvic surgery, therefore, include the ureter, bladder, rectum, and large vessels simply because they are in close proximity to the structures being operated on, to include the uterus, ovaries, endometriosis of the pelvis, or other pelvic masses. 
The best way to avoid injury to these structures is to identify the anatomy during the course of the procedure. Although this makes sense, almost all GYN procedures performed today by OB/GYN surgeons do not fully identify the anatomy, especially the ureters, leading to injury. OB/GYN’s concentrate mainly on deliveries and much less on surgery. As a result, the use of retroperitoneal dissection by these doctors is not done routinely for open procedures, and almost never for laparoscopic surgery. The use of RPD allows for full identification of all the anatomy of the pelvis, to include the ureters, large vessels, bowel, and bladder, and decreases complications dramatically. The Women’s Surgery Center uses the retroperitoneal approach for all laparoscopic pelvic surgery, dramatically decreasing or eliminating these complications during surgery. 2 and 3. The type of procedure, ie removal of a structure, repair of a structure or organ system and The size or weight of the structure to be removed. As mentioned above, removal of a large uterus increases risks of bleeding and injury to the ureters, bowel, and bladder. Removal of a large endometrioma – a large cyst of the ovary – also creates problems with surgery. Endometriosis tends to grow into other structures, and often “sticks” to surrounding organ systems. In the pelvis, this will include the ureters, rectum, bladder, large vessels, as well as the small and large bowel within and outside of the pelvis. This type of surgery can be the most challenging, since endometriosis forms dense thick adhesions, or scar tissue, that is difficult to remove from soft structures such as the bowel and bladder. As a result, injury to these structures can occur unless the anatomy is identified, bleeding is controlled, and important structures are dissected out of harms way during the operation. Larger pelvic masses or fibroids further distort the normal anatomy of the pelvis, as does endometriosis, increasing the difficulty of the surgery and complicating the procedure in an already complicated area of the body. Structural repair, such as suspension procedures for prolapsed or “falling” vaginal structures, bladders, and rectum distort the anatomy even more, adding more complexity. To combat these issues, a thorough understanding of the anatomy of the pelvis is absolutely required. Knowledge of the retroperitoneal space and dissection within this space allows the anatomy to be fully identified before proceeding with removal of repair of pelvic structures. The more complete the understanding of the space and the anatomy, the more successful the procedure with less bleeding, fewer complications, and more successful surgery. 4. The number of prior procedures the patient has had. Open surgical procedures cause scar tissue, or adhesions. Scar tissue is formed due to trauma to the bowel and structures of the pelvis, or to poor surgical technique or bleeding during or after surgery. Open surgeries require the use of large retractors, with “packing” of the bowel or removal of the bowel from the operative field. Packing “scratches” the bowel surface, which cause adhesions. In many ways, these scratches are similar to sandpaper roughing up the surface of the bowel. The roughed up surfaces stick to other structures in the pelvis, such as uterus, tubes or ovaries, or to additional bowel loops themselves. Extensive bowel adhesions can cause bowel dysfunction and obstruction in some cases. Patients with one or more open surgeries, therefore, have a much higher risk of having scar tissue involving the bowel loops than does someone with no surgeries. Prior laparoscopic procedures do cause scar tissue as well, but much less so since the bowel is not packed away as in open surgery. One of the major causes of complications during surgical procedures is injury to the bowel during lysis, or cutting, of adhesions involving the uterus, tubes, and ovaries. Lysis of bowel loops is called enterolysis (entero = bowel) and essentially is removing scarred bowel away from other bowel loops and from pelvic organs. During the course of enterolysis it is possible to injure or “nick” a bowel loop, which needs to be identified and repaired. If it is not repaired and goes unrecognized, bowel content can seep into the pelvic and abdominal cavities, creating severe infection that will require an open surgical procedure to fix or resect the injury, sometimes with the need for colostomy – a bag – to drain the bowel to the outside. Expertise in enterolysis avoids injury, and also converts open surgical procedures into laparoscopic procedures. One of the most important skills of an advanced laparoscopic surgeon is the ability to perform lysis of adhesions between bowel loops and pelvic structures quickly and safely, and to be able to fix an injured loop of bowel during enterolysis laparoscopically. The physicians of Women’s Surgery Center specialize in laparoscopic enterolysis, resulting in an extremely low rate of open surgeries and allowing for almost all patients with prior open procedures to have their surgeries performed safely with laparoscopy. Bowel injuries are repaired laparoscopically in most cases, with some more advanced cases of enterolysis requiring a small incision (2 inches or less) and repair of bowel loops. Bowel resection can also be performed if needed to remove badly scarred areas of bowel so the adhesions will not reform in the future. 
5. What type of procedures have been done in the past. More complicated procedures done prior such as open bowel resection or prior gyn procedures for malignancy will increase the risk of subsequent surgeries. Adhesions are the main reason for this. In more advanced prior surgeries, the anatomy can be completely distorted, and normalization of the anatomy needs to be performed in order to proceed with removal or repair during the present surgery. In some cases if the anatomy is so distorted that it is not possible to normalize or identify the anatomy, a laparoscopic surgery will need to be stopped and converted to open. At Women’s Surgery Center this rarely happens, but is usually due to extensive scar tissue in which the anatomy cannot be seen, or in cases of malignancy. If open surgery does occur, it is performed with the safety of the patient in mind. 6. and 7 Patient size and medical complications. Heavier patients create challenges for surgeons, especially for pelvic surgeons. In order to accomplish laparoscopic pelvic surgery, patients need to be placed in a head down position so that bowel moves up and out of the pelvis to allow for visualization of the uterus, tubes, and ovaries. Heavy patients have much more fat in the bowel, and cannot tolerate the head down position for extended periods of time. The combination of these factors decreases exposure of pelvic structures, which increases complication rates. Visualization is impaired, and bleeding within the pelvis further limits visualization, thereby increasing complications. The solution to these problems requires a surgery that controls blood flow quickly and easily, and can be performed rapidly. Retroperitoneal approaches are very well matched in the management of heavier patients. WSC has published on laparoscopic hysterectomy for very large and obese patients using this technique, with excellent results. It is important to be able to complete laparoscopic surgeries in heavier patients since their complication rates are much higher with open procedures, including wound infection and breakdown, heart and lung issues to include heart attack,, stroke, and pneumonia. Heavier paitents undergoing major surgical procedures may also take longer to ambulate, increasing the risk of blood clots to the legs and lungs. The same issues are true for those patients with multiple medical problems. Laparoscopy decreases the stress of surgery postoperatively with decreased pain, rapid mobilization, shortened hospital stay decreasing exposure to hospital bacteria and infection. Elimination of complicating issues associated with open surgical procedures decreases the incidence of further complications directly related to the patients impaired medical condition. Laparoscopy is well matched in heavier and medically complicated patients, and is the procedure of choice to avoid these complications..