Gastro intestinal injury incidental to obstetrical and gynecological operation is a rare event and lack of published information makes it harder to compare and review the findings. Our findings showed that 32% of all gastro intestinal injuries occurred in total abdominal hysterectomy. The most common site that was injured in total abdominal hysterectomy was the cecum (62.5%). Injuries during dilatation and curettage occurred in 20% of cases. The most common injury site in dilatation and curettage was the small bowel (80%). There was only one gastric injury (4%) in this series that was seen in patients who had surgery for ovarian cysts. Usually gastric injury can be caused during laparoscopy (13). The small bowel was injured in 36% of cases. However in the study by kerb et al. (10), this rate was 75% while Bhatte et al found this rate to be 61.9% (9, 10); these results are different from our findings and this may be due to the type of surgery that involves mainly the large intestine. 44% of patients had a history of previous pelvic or abdominal surgery. In one study this rate was 64.3% (9). Patients with a history of abdominal surgery scar are at high risk for intestinal injuries (13). This may be due to intestinal adhesions following previous pelvic or abdominal surgery (11). Suspicion of high-risk patients, exact examination of all bowel and even intraoperative colonoscopy is recommended to prevent injuries and for early recognition and management (14). In 36% of cases the cause of injury was the surgical error resident of obstetrics and gynecology. In other studies, there is no mention of the surgery operation and therefore it is not possible to compare the findings in this field. However all of residents of obstetrics and gynecology must be trained in prevention and management of these injuries (9). 52% of injuries were diagnosed during the operation and 48% were diagnosed after the surgery. In a study on laparoscopic surgery, one-third of intestinal injuries were diagnosed during the operation (5). This difference may be because we reviewed all types of surgery but in the Sabharwal study, only injuries during laparoscopic hysterectomy were assessed. Missed bowel injuries are more common in laparoscopic surgery, where thermal injury to the bowel may not be obvious intra-operatively (15). In our study 48 percent of injuries were diagnosed in the postoperative period. Considering that only 8 percent of the procedures were laparoscopic, this high percent of missed injuries is of concern. The mean time of injury diagnosis was 2.8 ± 0.9 days (0 - 4 days). It was different from the Chapron et al study on laparoscopic operation, in which mean time of injury diagnosis was 4.0 ± 5.4 days (16).
Intra-operative detection of injuries is of great importance, since delayed diagnosis increases morbidity, and repair of the injury in an infected and inflamed abdomen may even lead to placement of a colostomy (17). Management of injury in 56% of patients was primarily by repair. In one study all injuries were repaired by intestinal closure, resection of the small bowel or colostomy (9). Mild injuries to the small and large bowel can be repaired by intestinal closure but extensive injuries need resections (11). Today, all of the gynecologic surgeons must be trained in techniques to avoid and repair gastro intestinal injuries. Especially, when there is a previous abdominal scar, they should be cautious to enter peritoneal or pelvic cavity. As intra-operative colonoscopy is not available in many centers, the only way to decrease iatrogenic injuries and prevent missed injuries is exact examination of the abdomen, gentle dissection of the tissues and high suspicion of high- risk patients with previous abdominal operations. Laparoscopic procedures are becoming more and more prevalent and special attention should be given to teach precise techniques and instrument utilization to prevent occult iatrogenic injuries.