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Climent et al. Mini-invasive Surg 2018;2:45 I http://dx.doi.org/10.20517/2574-1225.2018.62 Page 5 of 13

[33]
lacerated, with high propensity to bleed . Managing bleeding from the pre-sacral veins is challenging;
conventional methods such as direct sutures often fail and may exacerbate bleeding. It is often necessary to
pack the pelvis with large swabs, the direct pressure arresting haemorrhage. A “second-look laparotomy”
is required in 24-48 h to remove the packs, as leaving a large volume of foreign body in situ can increase
[34]
the risk of pelvic sepsis . Sterile thumbtacks could be used as an alternative, but they are ineffective in
case of diffuse haemorrhage, and some authors report chronic pain and anastomotic fistulas related to
[33]
their placement in the presacral space . Other techniques have been suggested such as topical haemostatic
[32]
agents , direct or indirect coagulation with spray electrocautery, argon or bipolar coagulation. Suture
ligation of the presacral veins in circles with 4-0 silk suture thread is an alternative with good control of
[34]
bleeding if other techniques fail .
Iatrogenic splenic injury is described in 2% of left-sided colonic resections, caused by inadvertent traction or
[35]
capsular tear due to adhesions during splenic flexure mobilization . Splenectomy is typically a last resort,
with spleen conserving manoeuvres such as splenorrhapy or application of topical haemostatic agents
preferable, as splenectomy has life-long implications for patients such as overwhelming post-splenectomy
infection (OPSI). In order to prevent OPSI, the polyvalent pneumococcal vaccine, Haemophilus influenzae
type b conjugate vaccine and the meningococcal polysaccharide vaccine are administered within 2 weeks
of splenectomy. The use of antibiotics might reduce but not abolish OPSI, although it’s use is based on
[36]
limited evidence .
Limited haematochezia with the first bowel movement is not unusual after surgery, described in 6.5%
[37]
of cases , but severe bleeding can be quite challenging because of the risk of compromising a healing
anastomosis. Treatment should initially involve prompt resuscitation, including blood transfusion
depending on patient’s clinical status, age and comorbidities. If bleeding per rectum does not stop
spontaneously, endoscopic assessment of anastomosis is undertaken, with copious lavage reported as being
successful in securing haemostasis, reserving surgical intervention when there is failure to arrest bleeding
or haemodynamic instability [37,38] . When dealing with low anastomoses, an examination under anaesthesia
with transanal suture placement or rectal packing is effective. If these measures fail, one is committed to
taking down the anastomosis.

Urinary injury
Urinary injury, namely to the bladder or ureter, occurs in 2%-2.8% of LAR [1,39] . Ureteric injury may occur
during the mobilisation of sigmoid colon, when elevating the mesocolon off the retroperitoneum or along
[39]
the lateral pelvic sidewall, on entry into the pelvis . Ureteral injury may be diagnosed intraoperatively,
[40]
but unfortunately, 50%-70% of cases the diagnosis is made post-operatively with a high volume of serous
fluid in the pelvic drain with low urinary output or localised peritonitis. To confirm ureter disruption, a
[40]
cystoscopy and a retrograde pyelogram can be performed, ideally following a CT-Urogram .
If diagnosed intra-operatively, the ureter may be repaired primarily with an end-to-end anastomosis
over a JJ-ureteral stent with absorbable sutures; some authors reporting this successful approach
[8]
laparoscopically . When a long defect is discovered, or the ureter has been transacted using an energy
device, management is dictated by the location of the defect, techniques such as the ureteroneocystostomy
[40]
with or without vesico-psoas hitch or a Boari tubularized flap may be required .

Bladder injury is commonly associated with electrocoagulation tears during the dissection of the rectum
anterior wall. Intermittent suturing with absorbable sutures and leaving of urethral catheter in situ
[40]
for 7-10 days is necessary . A post-operative cystogram is mandatory prior to removing the urinary
catheter. Where there is suspicion of urinary tract injury administration of intravenous indigo-carmine or
[41]
methylene blue, which are excreted in the urine, may be beneficial in identifying a defect .