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GASTROINTESTINAL IMAGING
119

Common Postoperative Findings

Unique to Laparoscopic Surgery1
Nicole M. Hindman, MD
Stella Kang, MD The interpretation of images obtained in patients who have re-
Manish S. Parikh, MD cently undergone abdominal or pelvic surgery is challenging, in
part because procedures that were previously performed with open
Abbreviations: NOTES = natural orifice trans- surgical techniques are increasingly being performed with mini-
luminal endoscopic surgery, SILS = single-inci- mally invasive (laparoscopic) techniques. Thus, it is important to be
sion laparoscopic surgery, TAPP = transabdomi-
nal preperitoneal, TEP = totally extraperitoneal
familiar with the normal approach used for laparoscopic surgeries.
The authors describe the indications for various laparoscopic surgi-
RadioGraphics 2014; 34:119–138
cal procedures (eg, cholecystectomy, appendectomy, hernia repair)
Published online 10.1148/rg.341125181 as well as normal postoperative findings. For example, port site her-
Content Codes: nias are more commonly encountered in patients with trocar sites
1
From the Departments of Radiology (N.M.H., greater than 10 mm and occur at classic entry sites (eg, the perium-
S.K.) and Surgery (M.S.P.), NYU School of bilical region). Similarly, preperitoneal air can be encountered post-
Medicine, 660 First Ave, New York, NY 10016.
Presented as an education exhibit at the 2011
operatively, often secondary to trocar dislodgement during difficult
RSNA Annual Meeting. Received August 21, entry or positioning. In addition, intraperitoneal placement of mesh
2012; revision requested October 30 and re- during commonly performed ventral or incisional hernia repairs
ceived January 7, 2013; accepted March 1.
For this journal-based SA-CME activity, the typically leads to postoperative seroma formation. Familiarity with
authors, editor, and reviewers have no financial normal findings after commonly performed laparoscopic surgical
relationships to disclose. Address correspon-
dence to N.M.H. (e-mail: nicole.hindman@
procedures in the abdomen and pelvis allows accurate diagnosis of
nyumc.org). common complications and avoidance of diagnostic pitfalls.
©
RSNA, 2014 • radiographics.rsna.org
ONLINE-ONLY SA-CME
LEARNING OBJECTIVES
After completing this journal-based SA-
CME activity, participants will be able to: Introduction
■■List the advantages of laparoscopic Abdominopelvic surgeries are increasingly being performed with
surgery over traditional open surgery. minimally invasive techniques. This trend began in the 1960s with
■■Discuss common postlaparoscopic gynecologists performing diagnostic laparoscopies and was adopted
findings that can be mistaken for disease. by other surgeons in the 1980s to include cholecystectomies and
■■Identifycommon complications of appendectomies. Currently, about 750,000 laparoscopic cholecys-
laparoscopic surgery.
tectomies are performed in the United States each year, account-
See www.rsna.org/education/search/RG.
ing for 90% of all cholecystectomies (1–3). The rapid acceptance
of laparoscopic techniques reflects the advantages of decreased
hospital stay, decreased postoperative pain, shorter-term postop-
erative ileus, improved wound healing and mobility, smaller scar
(improved cosmesis), earlier return to daily activity, decreased cost,
and increased patient satisfaction. The challenges of minimally
invasive procedures are related to the specialized surgical skills in-
volved, including patient setup, entering the peritoneal cavity, main-
taining pneumoperitoneum, use of a camera, cutting and suturing
with laparoscopic graspers, extracting specimens, and closing entry
sites. The changes in the surgical approach and technique (from
120  January-February 2014 radiographics.rsna.org

open to laparoscopic) have altered the expected Surgical Entry

postoperative imaging findings in these patients. Access to the peritoneal cavity is the first step in
Familiarity with normal postlaparoscopic findings laparoscopic entry. Safe insertion of laparoscopic
in commonly performed abdominopelvic surgical trocars requires knowledge of the anatomy of the
procedures allows accurate diagnosis of com- abdominal wall and underlying organs. Access
mon complications and avoidance of diagnostic devices traverse the skin, subcutaneous fat, fascia,
pitfalls. In this article, we discuss the surgical preperitoneal fat, and parietal peritoneum. The
techniques and the normal and abnormal postop- layers of the abdominal wall are variable depend-
erative imaging appearances of findings related to ing on the access site chosen.
laparoscopic entry, pneumoperitoneum, and the For example, the midline of the abdomen
intraoperative procedure. (periumbilical region) is a preferred access route
for multiple laparoscopic procedures secondary
General Laparoscopic Principles to the paucity of vessels and nerves in this region,
Laparoscopic surgery requires appropriate at- which limits the potential for injury. At the mid-
tention to patient selection and positioning, sur- line, the layers include the skin, the subcutane-
geon positioning in the operating room, trocar ous fat, and a single fascial layer (from the fascia
placement, and entry choice. The ideal patient enveloping the transversalis, internal oblique, and
for laparoscopic surgery (and for open surgery external oblique muscles).
as well) will have no history of prior surgical Another common access site is the left subcos-
procedures and minimal or no medical comor- tal margin, where the border with the ribs provides
bidities. Conditions that increase the number support to the abdominal wall during trocar in-
of intraabdominal adhesions (prior surgical sertion. At this level, the layers of the abdominal
procedures, endometriosis, pelvic inflammatory wall include the skin, subcutaneous fat, anterior
disease) will increase the chances of an intraop- rectus fascia, rectus muscle, posterior rectus fascia,
erative complication. Other conditions that in- transversalis fascia, preperitoneal fat, and parietal
crease the risk of complications include cirrhosis peritoneum. The major vessel in this region is the
and portal hypertension (secondary to large an- superior epigastric artery, which courses inferior to
terior abdominal wall varices, which can cause the rectus abdominis muscle at the midline; how-
extensive bleeding, and large volume ascites, ever, lateral to the rectus abdominis muscle, at the
which can make visualization difficult); marked Spigelian line (where the external oblique, internal
bowel distention (which increases the likelihood oblique, and transversalis fasciae fuse), the region
of bowel injury); large abdominopelvic masses is avascular. Deep nerves and vessels run anterior
(secondary to limited exposure); cardiopulmo- to the transversalis muscle.
nary disease; ongoing sepsis; and acute trauma. For pelvic surgeries, the suprapubic region
Patients with these risk factors may already be is used for access; at this level of the abdominal
hypotensive and thus unable to tolerate carbon wall, there are multiple vessels, including the
dioxide insufflation, since this procedure will deep inferior and superficial inferior epigastric
increase pressure in the abdomen and decrease arteries and the superficial and deep circumflex
venous return. Finally, as with all surgical proce- iliac arteries, as well as the accompanying nerves.
dures, the complication rate is related to the sur- To avoid injuring these structures, access is typi-
geon’s experience and the number of procedures cally performed in the midline, medial and supe-
performed (4,5). rior to the anterosuperior iliac spine.
Laparoscopic entry can be performed with an
Surgical Technique open (Hasson) or closed (Veress needle or optical
trocar) technique.
Setup
The basic requirements for setup include the Open (Hasson) Technique
surgical instruments, the camera, and the video A 1-cm periumbilical incision is made in the
monitor. For laparoscopic cholecystectomy, the abdominal wall under direct vision; this incision
“set” consists of trocars, a Veress needle (if appli- may be supraumbilical, infraumbilical, or trans-
cable), an electrocautery hook, a spatula, 5- and verse in the umbilical crease. Many surgeons pre-
10-mm right angle dissectors, endoshears, a chol- fer open cutdown in the midline (periumbilical
angiography clamp, atraumatic 5-mm graspers, a region) because the abdominal wall is thinnest at
clip applier, and 0° and 30° 5- or 10-mm laparo- this location. (For midline approaches, the stom-
scopes. Specific items for advanced laparoscopic ach is decompressed with a naso- or orogastric
surgery can be added to the set as needed. Posi- tube to minimize injury.)
tioning of the surgeon and assistant depends on Under direct vision, the anterior fascia is in-
the procedure being performed. cised to expose the preperitoneal fat (Fig 1) and
RG  •  Volume 34  Number 1 Hindman et al  121

with the closed technique and the need to close

the fascia at the end of the procedure.

Closed (Veress or
Optical Entry) Technique
The Veress needle is a small-bore (2-mm) needle
with a protective sheath that recoils to cover the
end of the needle. The Veress needle technique
involves making an incision in the skin, usually
in the left subcostal area (to minimize injury
to intraabdominal organs) or the periumbilical
region (Fig 2), with the patient in reverse Tren-
delenburg position. The Veress needle is then
blindly inserted through the incision at a 45°
angle toward the pelvis. There is a subtle pressure
change as the needle enters the abdominal fascia,
with another pressure change as the needle passes
Figure 1.  Drawing illustrates the open (Hasson)
approach, in which a fascial incision and cutdown through the parietal peritoneum. As the needle
into the peritoneal cavity are performed prior enters the peritoneal space, the displaced hub of
to trocar placement. Red = fascia, gray = bowel the needle will retract. The position of the Veress
loops. (Copyright New York University.) needle within the peritoneal cavity is usually con-
firmed by means of aspiration with a syringe and
the “saline drop” test (saline solution should flow
freely into the low-pressure peritoneal cavity).
Optical trocar entry, another type of closed tech-
nique, involves inserting a trocar after the lapa-
roscope has already been placed into the trocar,
which allows the surgeon to watch as the layers of
the abdominal wall are traversed.
The advantages of using a closed technique in-
clude quicker entry into the peritoneal cavity and
quicker closure, since many surgeons do not close
these trocar sites. Some studies have suggested a
reduced risk for port site hernia with such a tech-
nique (6,7). The disadvantage of using a closed
technique is an increased risk of major complica-
tions compared with the open technique (8,9).
The most severe potential complication is vascular
injury, which can be life threatening. Most severe
injuries are due to blind insertion of access devices
(10,11). Although entry choice is the subject of
Figure 2.  Drawing illustrates the closed (Veress)
approach, in which a Veress needle is used to enter
ongoing debate (12,13), conservative recommen-
the abdomen blindly. Red = fascia, gray = bowel dations argue against blind trocar entry techniques
loops. (Copyright New York University.) for primary or secondary trocar placement, espe-
cially before insufflation of the abdomen, so as to
minimize complications (14). Table 1 summarizes
the peritoneal cavity is entered. The surgeon’s the differences between open and closed laparo-
index finger is used to sweep the underside of the scopic entry techniques.
abdominal wall to clear the omentum or bowel
and to confirm the absence of adhesions in the Pneumoperitoneum and
region of the incision. The blunt-ended (Has- Preperitoneal Insufflation
son) trocar is then placed through the incision
and secured with sutures, and the CO2 gas line CO2 Insufflation
is attached to the port to insufflate the abdomen. Regardless of whether an open or closed entry
The advantage of the open technique is the lower technique is used, the technique for CO2 gas
risk of major complications, the most common insufflation is the same. The abdomen is insuf-
of which is bowel injury. Drawbacks of this tech- flated to an intraabdominal pressure of 15 mm
nique include the longer time required compared Hg (or sometimes 20 mm Hg). The volume of
122  January-February 2014 radiographics.rsna.org

Table 1: Open versus Closed Laparoscopic Entry Technique

Parameter Open Technique Closed Technique

Incision/cutdown 1–2-cm periumbilical incision with cutdown of Incision but no cutdown
fascia
Entry Peritoneal cavity entered under direct vision, fol- Blind entry with 2-mm Veress needle
lowed by insertion of a 10–12-mm Hasson trocar
Benefits Peritoneal entry under direct vision, lower risk of Quicker entry into peritoneal cav-
major complications (bowel/vascular injury) ity, no closure required, possible
reduced risk of port site hernia
Limitations Longer time required for entry, need to close fascia Increased risk of major complications
at end of procedure (bowel/vascular injury)

Figure 3.  Dislodged trocars in a 51-year-

old man who had undergone laparoscopic
ventral hernia repair 4 days earlier. Coronal
computed tomographic (CT) image shows
subcutaneous air (arrows) from dislodged
trocars. Fortunately, this finding was clinically
insignificant and resolved spontaneously.

gas needed for insufflation depends on the depth

of anesthesia, use of neuromuscular blockade,
and patient size.

Trocars
With respect to the choice of trocar size, 10-mm
trocars allow flexibility and use of different di-
ameters of dissectors, clip appliers, and other in-
struments such as stapling devices. On the other
hand, 5-mm trocar sites do not typically need
to be closed and are adequate for most graspers
and 5-mm clip appliers. Certain types of trocars
(eg, radially dilating trocars) do not necessarily
require fascial closure. Nevertheless, to prevent
postoperative port site hernia, most authors rec-
ommend fascial closure with trocars 10 mm or
larger (15,16). Port site hernias from 5-mm tro-
cars, although rare, have been reported.

Normal Radiologic
Findings after Trocar Place- postlaparoscopic finding for a surgical emergency
ment and Pneumoperitoneum (eg, necrotizing fasciitis). Necrotizing fasciitis oc-
If the CO2 pressure rapidly increases to more curring after laparoscopic surgery is rare, usually
than 12–15 mm Hg, the trocar may be displaced manifests later (~10 days) after surgery, and is
into the preperitoneal space; however, this is usually associated with peri-incisional erythema,
not necessarily a complication. Prolonged in- foul-smelling drainage from the wound, fever,
sufflations into the abdominal wall may lead to and pain (17,18).
subcutaneous emphysema, which may reach the Preperitoneal air can also be seen in certain
patient’s neck and face. This crepitus usually re- laparoscopic procedures in which there is de-
solves after the abdomen is desufflated and has liberate insufflation of the preperitoneal space,
minimal clinical sequelae. On postoperative im- such as laparoscopic inguinal hernia repair.
ages, subcutaneous air will be seen in the anterior There are two common techniques for lapa-
abdominal wall (Fig 3). The key to radiologic roscopic inguinal hernia repair, both of which
interpretation is not to mistake this common involve dissection and mesh placement in the
RG  •  Volume 34  Number 1 Hindman et al  123

repaired without two separate groin incisions)

(19–22), recurrent hernias (since TEP-TAPP
repair can be performed in a previously undis-
sected tissue plane) (23), and patient preference.
Laparoscopic inguinal hernia repair is gener-
ally thought to be less painful and to allow an
earlier return to work than open inguinal hernia
repair. Although recurrence rates were originally
thought to be slightly higher with laparoscopic
inguinal hernia repair, subsequent studies have
Figure 4.  Drawing illustrates surgical entry into the shown that in experienced hands, the recurrence
preperitoneal space by means of placement of a balloon rates are comparable (24–26).
dissector or trocar (gray) into the plane between the
rectus muscle and the posterior rectus sheath and peri- Complications Related to Trocar
toneum. (Copyright New York University.) Placement and Pneumoperitoneum
Entry access complications are relatively uncom-
mon, with reports to the U.S. Food and Drug
Administration suggesting a prevalence of 5–30
per 10,000 procedures; however, underreporting
of complications is likely. Bowel and retroperi-
toneal vascular injuries account for 76% of all
injuries; one-half of the bowel injuries were not
recognized until more than 24 hours after sur-
gery. As mentioned earlier, most severe injuries
are due to blind insertion of access devices (Fig
5) (10,11,27). Fatalities resulting from trocar
injuries, although rare (32 deaths were reported
to the U.S. Food and Drug Administration for
the period from January 1, 1997 through June
30, 2002), are usually (74% of cases) secondary
to blood loss from vascular injury to (in descend-
ing order of frequency) the aorta, iliac artery, or
inferior vena cava (9). Fatal and nonfatal injury
has been reported in the small bowel (25.4% of
cases), iliac artery (18.5%), colon (12.2%), iliac
Figure 5.  Drawing (vasculature emphasized) illus-
trates correct surgical port placement for laparoscopic or other retroperitoneal vein (8.9%), secondary
pelvic surgery. Three trocars (gray) are shown overlying branches of a mesenteric vessel (7.3%), aorta
the aorta, left common iliac artery, and bladder, respec- (6.4%), inferior vena cava (4.4%), abdominal
tively; thus, injury to these anatomic structures can wall vessels (3.8%), bladder (3.3%), liver (2.3%),
occur upon entry. Triangle = intended surgical region. major visceral vessel (1.7%), stomach (1.6%),
(Copyright New York University.) and other locations (<4.2%) (28). The most
common complications related to trocar place-
ment or pneumoperitoneum include hematoma,
preperitoneal space. One technique is known vascular injury, bowel injury, urinary tract injury,
as totally extraperitoneal (TEP) hernia repair, wound infection, port site dehiscence and hernia,
in which the preperitoneal space is directly and port site metastases. These complications are
entered by establishing a plane posterior to described in the following paragraphs.
the rectus muscle but anterior to the posterior
rectus sheath (Fig 4). Once this space has been Hematoma
entered, insufflation expands the preperitoneal Anterior abdominal wall hematomas can result
working space for dissection and subsequent from delayed bleeding from trocar sites. The
mesh placement. The other technique is trans- hematoma is thought to occur secondary to un-
abdominal preperitoneal (TAPP) hernia repair, recognized injury to tiny perforating vessels in
in which the surgery is intraperitoneal and the the subcutaneous fat, likely injured during tro-
preperitoneal space is opened under direct vi- car placement. These small bleeding vessels may
sion by creating a peritoneal flap. Indications be difficult to recognize intraoperatively, since
for laparoscopic inguinal hernia repair include the bleeding vessel may be tamponaded by pres-
bilateral hernias (since both hernias can be sure from the trocars and pneumoperitoneum.
124  January-February 2014 radiographics.rsna.org

Figure 6.  Subcutaneous hematoma in a 31-year-old woman who presented with pain 2 days after undergoing
laparoscopic ovarian cystectomy. Axial (a) and coronal (b) CT images demonstrate a high-attenuation subcuta-
neous hematoma in the left anterior abdominal wall (arrow) at the lateral trocar site.

Figure 7.  Retroperitoneal abscess in a 72-year-old

man who had undergone laparoscopic ventral hernia
repair 7 days earlier. Axial CT image demonstrates
air within the anterior left subcutaneous port site
(arrowhead) and mottled air and pus within the left
retroperitoneal space (arrow). The left-sided trocar
dislodged multiple times intraoperatively, causing
bleeding in and widening of the port site. This he-
matoma expanded into the retroperitoneum, which
subsequently became infected (abscess). At the time
of imaging-guided drainage, there was a 300-mL col-
lection of frank pus.

Bleeding then typically occurs within 1 hour of

removing the instruments (29). Clinical mani-
festations of hematomas include swelling, pain,
ecchymoses of the anterior abdominal wall, and primary trocar or Veress needle at the umbilicus
external bleeding from the trocar site. On CT (30,31). Laceration of the inferior epigastric
images, anterior abdominal wall hematomas artery is the most common vascular injury dur-
manifest as high-attenuation collections (usually ing placement of lateral trocars. Major vascular
30–80 HU) within the subcutaneous soft tissues injury during access for laparoscopic surgery
(Fig 6). Abdominal wall hematomas that are occurs in 0.3%–1.0% of procedures (11,30–32).
clinically stable at physical examination can be Vascular injury may not be appreciated im-
managed conservatively with pressure dressings; mediately, either because the port tamponades
the hematocrit and clinical examination can be the bleeding muscle or subcutaneous vessel, or
used to follow up the patient. The hematoma because there is bleeding out of the surgical field
may drain spontaneously through one or more (either into the mesentery or retroperitoneum)
port sites. In most cases, no intervention is nec- rather than into the peritoneal cavity. Injury to
essary, and drainage will typically cease sponta- the aorta or iliac arteries during access is usu-
neously. Surgical intervention may be required ally recognized intraoperatively and can lead to
if the patient is unstable, or if the hematoma is rapid exsanguination and death unless promptly
rapidly expanding or becomes superinfected (eg, repaired (Fig 8) (11,30–32). The vascular struc-
an abscess) (Fig 7). ture injured is related to the surgical site; thus,
the aorta is injured more commonly with laparo-
Vascular Injury scopic cholecystectomy, whereas the iliac vessels
Vascular injury usually occurs from laceration are injured more commonly during appendec-
of the mesenteric vessels during insertion of the tomy and gynecologic procedures (9).
RG  •  Volume 34  Number 1 Hindman et al  125

Figure 8.  Injury to the inferior mesenteric artery dur-

ing closed trocar entry in a 33-year-old woman who had
undergone laparoscopic myomectomy earlier the same
day. (a, b) Axial (a) and coronal (b) arterial phase CT
images demonstrate an eccentric outpouching (arrow)
of the left inferior mesenteric artery. (c) Fluoroscopic
image from a selective angiographic study of the inferior
mesenteric artery reveals a trauma-related pseudoaneu-
rysm (arrow).

Bowel Injury CO2), it may be possible to defer repair, since the

Bowel injury is rare (reported prevalence of 1% needle is small (16-gauge) and the hole will typi-
in patients undergoing laparoscopic surgery) cally heal spontaneously. In contrast, a perfora-
but can be a serious complication, especially if tion due to trocar injury (typically from a 10-mm
unrecognized at the time of surgery. Delay in di- instrument) results in an enterotomy that will
agnosis increases the risk of fecal peritonitis, en- require surgical repair.
terocutaneous fistula formation, sepsis, and death Symptoms from unrecognized bowel injury
(27,33,34). generally manifest within 12–36 hours but may
The small bowel is the most commonly injured occur up to 5–7 days after surgery. If a patient
gastrointestinal structure during access for lapa- has severe abdominal pain (which may some-
roscopic surgery; however, injury to the stomach, times be difficult to distinguish from common
liver, and colon have been reported with subcos- postoperative pain), especially in the presence of
tal access techniques (35). Decompressing the tachycardia or fever, bowel injury should be sus-
stomach with a nasogastric tube prior to upper pected and reexploration may be indicated. Ra-
abdominal access may minimize the potential for diographic findings that are worrisome for bowel
injury to the stomach. injury include persistent postoperative ileus
One-half of all bowel injuries occur during (since ileus after laparoscopy is uncommon) and
initial peritoneal access. Injury to the bowel may increasing amounts of free intraabdominal air on
result from insertion of the pneumoperitoneum serial radiographs. Free air is normally seen (see
needle, placement of the laparoscopic trocar, “Volume of Intraperitoneal Free Air after Laparo-
electrosurgical injury, or trauma during dissec- scopic Surgery”). Specific findings at CT include
tion. For puncture of the bowel with the pneu- free intraperitoneal or mesenteric air, extravasa-
moperitoneum needle (before insufflation with tion of oral contrast material, focal bowel wall
126  January-February 2014 radiographics.rsna.org

Figure 9.  Missed bowel injury in an 80-year-old woman who had undergone laparoscopic cholecystectomy
3 days earlier. (a, b) Axial (a) and coronal (b) CT images demonstrate free air over the liver (large arrow in
b), thickened small bowel in the right lower quadrant (arrowhead), and peritoneal enhancement (arrow in a,
small arrow in b). (c) Intraoperative photograph shows adhesions (arrow) between the ileum and the anterior
abdominal wall. Unintended enterotomy of this loop of ileum occurred after entry, during lysis of adhesions.

defects, and nonenhancing bowel wall; less spe- of urinary tract injury postoperatively (hematuria,
cific findings include bowel wall thickening, free low urine output, inability to void); most of these
fluid, peritoneal enhancement, and mesenteric patients proceed directly to cystoscopy without
stranding (Fig 9) (36). Missed (ie, unrecognized) being imaged. At CT, bladder injuries can mani-
bowel injuries have been shown to have a higher fest with fluid-attenuation urine surrounding
mortality rate (37). the bladder within the pelvis or with blood clot
within the bladder.
Urinary Tract Injury Ureteral injury is becoming more common
Injury to the urinary tract usually occurs to as a result of the increasing number of laparo-
the bladder during secondary trocar insertion. scopically assisted vaginal hysterectomies being
Bladder injury can be minimized by placing the performed, although such injury can occur dur-
secondary trocar under direct vision and making ing any laparoscopic surgical procedure (39).
certain that the bladder is decompressed with use Thermal ureteral injuries are caused by excessive
of a Foley catheter prior to trocar placement. use of an energy source adjacent to the ureter. At
Thermal injury to the bladder generally results CT, acute ureteral injuries manifest with extrava-
from dissection during laparoscopic hysterectomy sation of urine adjacent to the injured ureteral
or with dissection and destruction of endometrio- segment, which has fluid attenuation if there is no
sis (38). No treatment is generally required if the contrast material in the ureter. Delayed ureteral
bladder is punctured with a pneumoperitoneum injuries may manifest as a stricture of the injured
needle. In contrast, a perforation due to trocar ureteral segment; these injuries can manifest days
injury (typically from a 10-mm instrument) must to months after surgery if they are not recognized
be repaired immediately and the Foley catheter intraoperatively (Fig 10) (40). They are best man-
left in place. If the perforation is not recognized, aged with resection of the damaged portion and
the patient will generally present with symptoms reimplantation of the ureter. If such an injury is
RG  •  Volume 34  Number 1 Hindman et al  127

Figure 10.  Ureteral stricture in a 43-year-old man

who had undergone laparoscopic sigmoidectomy 2
months earlier. (a, b) Coronal CT images through
the left collecting system demonstrate hydrouretero-
nephrosis to the midpoint of the left ureter (arrow
in b). (c) Oblique coronal CT image shows the cut-
off point in the left midureter (arrow). Laparoscopic
reexploration revealed that the stricture was second-
ary to granulomatous foreign-body reaction from
adjacent surgical clips.

present, infections are treated with drainage,

packing, and antibiotics as appropriate.

Port Site Dehiscence and Hernia

Port site dehiscence and hernia are important
complications to recognize and should be closed to
prevent obstruction or strangulation of bowel. Port
site dehiscence is separation of the fascia in which
left untreated, a genitourinary fistula (eg, uretero- the skin remains closed and may rarely occur in
alimentary, ureterocutaneous, or ureterouterine the early postoperative period (Fig 11). A port site
fistula) may develop. evisceration occurs when both the fascia and the
skin over the defect open. A port site hernia occurs
Wound Infection later, usually more than 30 days after a defect in
Wound infection is less common after laparo- the fascia occurs, and a hernia sac is formed (Fig
scopic than open procedures; however, prompt 12). Port site hernias are relatively uncommon in
recognition is important to avoid morbidity the literature, with a reported prevalence of 0.5%
(41). The umbilicus is more commonly associ- among patients undergoing laparoscopic surgery
ated with infection of the surgical site than are (43). The risk of developing an incisional hernia is
other trocar sites, a finding that correlates with associated with the use of trocars over 12 mm in
the use of the umbilicus as a specimen extrac- size (15,16), larger-diameter ports for specimen
tion site (42). Wound infections are prevented removal, older age, higher body mass index, length
with appropriate administration of antibiotic of procedure, and increased tissue manipulation
prophylaxis, sterile technique, and use of speci- (with associated fascial weakening). Most authors
men bags during specimen extraction. Once close ports greater than 10 mm (16).
128  January-February 2014 radiographics.rsna.org

Figure 11.  Port site dehiscence in a 58-year-old man who had undergone laparoscopic colorectal surgery
1 day earlier. Axial (a) and coronal (b) CT images demonstrate herniation of fat with associated fat strand-
ing (arrow) through the lateral 10-mm trocar site.

Figure 12.  Small bowel obstruction secondary to a port site hernia in a 60-year-old man who
had undergone laparoscopic sigmoidectomy 1 month earlier. Axial (a) and coronal (b) CT im-
ages demonstrate a “knuckle” of small bowel in the right lower quadrant port site (arrow), with
dilated proximal small bowel and collapsed distal small bowel, findings that are compatible
with a small bowel obstruction. The specimen was extracted through a port at this location.

Port Site Metastasis in patients with advanced intraperitoneal malig-

The term port site metastasis refers to cancer nant disease, instillation of agents to prevent tu-
growth at the trocar site following laparoscopic mor growth, and use of a wound protector during
oncology surgery. This entity has been observed as specimen extraction. If a patient with malignancy
little as 10 days after laparoscopy. Port site metas- undergoes postlaparoscopic exploration, excision
tasis occurs after 1%–2% of laparoscopic proce- of port sites is a consideration if feasible. However,
dures performed in the presence of intraperitoneal port site metastases occur with a similar frequency
malignancy, especially in the setting of advanced as wound metastases after open surgery (44,45);
disease and ascites (44). Purported mechanisms thus, not all authors believe that laparoscopy
include hematogenous spread or direct contamina- should be avoided in this population.
tion by tumor cells, secondary effects from pneu-
moperitoneum (theorized to be from increased Radiologic Pitfalls and
pressure displacing tumor cells into the wound), Complications of Commonly
and surgical technique (Fig 13). Although it is Performed Laparoscopic Surgeries
not clear whether port site metastases can be In this section, we discuss two common pitfalls in
prevented, a number of preventive measures have the interpretation of laparoscopic findings: (a) vol-
been suggested, such as avoidance of laparoscopy ume of intraperitoneal free air after laparoscopic
RG  •  Volume 34  Number 1 Hindman et al  129

Figure 13.  Port site metastasis in a 93-year-old woman with a history of metastatic endometrial cancer
who had undergone laparoscopic exploration for small bowel obstruction 6 months earlier. Axial (a)
and coronal (b) CT images show a well-circumscribed, high-attenuation anterior abdominal wall mass
(arrow) that demonstrated interval growth on follow-up images, a finding that is compatible with a port
site metastasis.

Figure 14.  Drawing illustrates laparoscopic ventral

hernia repair. The bowel is reduced from the hernia,
but the hernia sac (brown) is not resected. Mesh
(gray with black strings) is placed over the hernia
defect intraperitoneally (pink = peritoneal surface).
(Copyright New York University.)

40% of patients will have more than 2 cm of free

air below the diaphragm on upright radiographs
obtained 24 hours after laparoscopy, despite the
absence of any clinical evidence of bowel perfora-
tion (47,48). The normal volume of postoperative
free air on both upright radiographs and CT im-
ages is variable, since resorption of the insufflated
CO2 likely depends on individual patient factors.
Free air may often be seen at radiography up to 9
days after surgery (49) and at CT up to 2 weeks
after surgery (in the authors’ experience), with a
decreasing amount of free air on subsequent im-
surgery, and (b) subcutaneous anterior abdominal ages. Increasing amounts of intraabdominal air
wall seroma after laparoscopic hernia repair. during the period of observation are concerning
for a ruptured viscus.
Volume of Intraperitoneal
Free Air after Laparoscopic Surgery Seroma after Laparo-
The amount of expected postoperative intraperi- scopic Incisional Hernia Repair
toneal free air is slightly less in laparoscopic than With laparoscopic incisional hernia repair (as op-
in open technique (46,47). This is secondary posed to open incisional hernia repair), the bowel
to the rapid absorption of CO2 relative to that is reduced from the hernia, but the hernia sac is
of nitrogen (the main gas in room air, and thus not resected (50). Mesh is placed over the defect
the cause of intraperitoneal free air after open intraperitoneally (Fig 14), creating a dead space.
surgery) and the small incisions limiting entry This space will invariably fill with fluid (seroma)
of room air into the abdomen (47). Because the postoperatively (Fig 15) (51–53).
CO2 pressure for insufflation is preset to 15–20 In contrast, with open incisional hernia repair,
mm Hg, the amount of free air is not subject to the hernia sac is resected and mesh is placed in the
individual surgical technique. Approximately extraperitoneal space between the posterior rectus
130  January-February 2014 radiographics.rsna.org

Figure 15.  Postoperative seroma formation in a 46-year-old man who had undergone laparoscopic ventral
hernia repair 3 days earlier. (a) Preoperative CT image demonstrates a ventral hernia (arrow) containing non-
obstructed small bowel. (b) Postoperative CT image demonstrates the expected normal fluid accumulation
(seroma) (arrow) within the nonresected hernia sac.

Figure 16.  Drawing illustrates open in-

cisional hernia repair. The hernia sac (seen
bulging between the rectus abdominis mus-
culature) (top) is resected (middle), and
mesh is placed in the extraperitoneal space
between the rectus fascia and rectus muscle
(bottom). (Copyright New York University.)

sheath and the rectus muscle (Fig 16). In these

Figure 17.  Abscess in a 51-year-old man who had
cases, a postoperative fluid collection in the ante- undergone open incisional hernia repair 6 days earlier.
rior abdominal wall is an abnormal finding and (a) Preoperative CT image demonstrates a ventral her-
should raise suspicion for an abscess (Fig 17). nia (arrow). (b) Follow-up CT image obtained 6 days
The postoperative seroma seen in patients who after surgery demonstrates a thick-walled subcutane-
have undergone laparoscopic hernia repair will ous collection (arrow). Subsequent drainage showed
be seen in all patients who are imaged within a that the collection contained frank pus, a finding that is
month after surgery; the seroma usually resolves compatible with an abscess.
RG  •  Volume 34  Number 1 Hindman et al  131

Figure 18.  Resolution of hematoma in an 88-year-old

woman who had undergone laparoscopic incisional hernia
repair. (a) Preoperative CT image demonstrates a non­
obstructed incisional hernia (arrow) in the left lower ante-
rior abdominal wall. (b, c) CT images obtained 5 (b) and
17 (c) days after the repair procedure for follow-up of a
large retroperitoneal hematoma from the supratherapeutic
International Normalized Ratio show near-complete reso-
lution of the seroma (arrow).

Stump Appendicitis
after Laparoscopic Appendectomy
Laparoscopic appendectomy was first performed
in 1983 and has rapidly been adopted by surgeons
secondary to the relative ease of learning the sur-
gical procedure (an estimated 20 cases for the
learning curve), as well as the benefits of shorter
length of stay, lower complication rate, and lower
within a month (Fig 18), although it may take 30-day readmission rate (54,55). Despite these
up to 6 weeks to resolve. The key to interpreting advantages, there are recent analyses suggesting
this finding is in knowing the surgical approach an increased (but still rare) incidence of stump
used: Differentiating the postoperative seroma appendicitis (recurrent inflammation of the in-
(a nonsurgical, conservatively managed finding) completely resected base of the appendix) with
from a postoperative abscess is important, since the laparoscopic approach (0.08% of cases) as op-
aspiration of a seroma is contraindicated and may posed to the open approach (0%) (56). Typically,
introduce infection into the surgical site. in laparoscopic appendectomies, the appendix is
Similarly, seromas may occur after laparoscopic dissected down to the base of the cecum and tran-
inguinal hernia repair. Treatment is nonsurgical, sected flush with the cecum (Fig 19).
and aspiration is contraindicated. Inadequate resection of the entire appendix,
In addition, there are four complications whose causing a long appendiceal stump, is thought to
rates of occurrence are higher with a laparoscopic occur in the setting of severe local inflammation,
technique: (a) “stump appendicitis” after laparo- precluding adequate dissection and visualization
scopic appendectomy, (b) biliary injury after of the base of the appendix (57,58). The clinical
laparoscopic cholecystectomy, (c) internal hernia presentation may be acute or subacute and can
after laparoscopic gastric bypass surgery, and occur any time after initial appendectomy (range,
(d) complications related to specimen retrieval 2 months–50 years). At cross-sectional imaging,
and extraction. A summary of the major early an inflamed appendiceal stump is seen (Fig 20)
(<30 days) and late complications of laparoscopic (59); rarely, there is fistulization of this stump to
surgery is presented in Table 2. the abdominal wall (57).
132  January-February 2014 radiographics.rsna.org

Table 2: Complications of Laparoscopic Surgery

Early (<30 days)
  Preperitoneal air (trocar dislodgement or TEP-TAPP hernia repair)
  Port site dehiscence
  Anterior abdominal wall hematoma/bleeding from trocar site
  Wound infection (port site abscess)
  Seroma anterior to the mesh*
  Vascular injury (usually recognized intraoperatively)
  Bowel injury (usually recognized intraoperatively but can be missed and lead to morbidity)
  Biliary injury after laparoscopic cholecystectomy
  Ureteral injuries (strictures, genitourinary fistula)
Late (>30 days)
  Port site hernia
  Port site metastasis
  Stump appendicitis after laparoscopic appendectomy
  Internal hernia after laparoscopic gastric bypass surgery (usually seen relatively late in the
  postoperative period [187–1109 days after surgery])
  Inadvertent retention of specimen bag
*Seroma is actually an expected finding that is seen immediately after laparoscopic hernia
repair; it will resolve spontaneously in 4–6 weeks.

Figure 19.  Drawings illustrate standard laparoscopic appendectomy tech-

nique. (a) Standard placement of the three ports. (b, c) With use of grasp-
ers, the appendix is lifted up and the mesoappendix (yellow) is dissected to
the base of the cecum and divided with an ultrasonic scalpel (b). The appen-
dix is then transected flush with the cecum with a laparoscopic stapler (c).
(d) The appendiceal specimen is placed in a specimen bag. (Fig 19 copy-
right New York University.)
RG  •  Volume 34  Number 1 Hindman et al  133

Figure 20.  Stump appendicitis in a 36-year-old woman who had undergone laparoscopic appendectomy
3 years earlier. (a) Axial CT image obtained during the initial episode of appendicitis in 2007 shows a long,
inflamed appendix (arrowheads). Laparoscopic appendectomy was performed. (b, c) Axial (b) and coronal
(c) CT images obtained 3 years later after the patient presented with recurrent right lower quadrant pain
demonstrate inflammation of the nonresected appendiceal base (arrow). (d) Intraoperative photograph
shows a long, nonresected, inflamed appendiceal base (black arrows) that is densely adherent to the base of
the cecum (white arrow).

Biliary Injury after roscopic cholecystectomy is associated with

Laparoscopic Cholecystectomy several factors, including the degree of inflam-
Cholecystectomy was the first general surgical mation of the gallbladder or surgical field (from
procedure in which laparoscopy replaced open concurrent pancreatitis), aberrant anatomy, and
surgery as the standard of care. This occurred surgeon experience (62,63). Generally, major
shortly after the introduction of laparoscopy in bile duct injury occurs secondary to mistaking
the 1980s. The rapid acceptance of this tech- the common bile duct or common hepatic duct
nique was related to the advantages of reduced for the cystic duct and inadvertently ligating one
cost, decreased length of stay, and improved of the former ducts, causing acute biliary ob-
patient satisfaction. Initially, there was a lack struction (64). Rarely, injury to these structures
of data comparing the open and laparoscopic occurs from a stricture secondary to thermal
approaches for cholecystectomies; however, injury during dissection. Imaging studies dem-
several subsequent studies have consistently onstrate diffuse or segmental intrahepatic biliary
shown a higher risk for biliary injury with the dilatation, with surgical clips at the point of ob-
laparoscopic approach (0.5% versus 0.01%) struction (65). Another relatively common com-
(2,3,60,61). Major bile duct injury during lapa- plication is a biliary leak from the cystic duct
134  January-February 2014 radiographics.rsna.org

Figure 21.  Postoperative biloma in a 60-year-old man who presented with pain 3 days after undergoing
laparoscopic cholecystectomy. Axial (a) and coronal (b) CT images show extensive fluid (arrows) that is inti-
mately associated with the porta hepatis, a finding that is worrisome for a biloma. Injury to the common bile
duct was noted at reexploration.

Figure 22.  Internal hernia causing obstruction of the excluded stomach and
biliopancreatic limb in a 61-year-old man who had undergone laparoscopic
gastric bypass repair 1 year earlier. (a, b) Axial CT scans demonstrate dilata-
tion of the excluded stomach (arrow in a) and a swirling mesentery (arrow in
b), findings that are compatible with obstruction of the biliopancreatic limb,
likely secondary to internal hernia. Reexploration revealed an internal hernia
obstructing the biliopancreatic limb. (c) Drawing depicts a dilated, obstructed
gastric remnant and biliopancreatic limb secondary to an internal hernia (bot-
tom right). (Copyright New York University.)

stump; these leaks may sometimes be seen as a

biloma in the gallbladder fossa at cross-sectional
imaging (Fig 21).

Internal Hernia after

Laparoscopic Gastric Bypass Surgery
Although internal hernia occurs more frequently
after laparoscopic than after open gastric bypass
surgery, the overall incidence for laparoscopic surgery is thought to be secondary to the mini-
surgery is relatively low (3.3% of cases). The mal amount of scarring it induces (compared
lower frequency of occurrence for laparoscopic with open surgery, in which the mesenteric de-
RG  •  Volume 34  Number 1 Hindman et al  135

Figure 23.  Retained specimen in a 65-year-old man.

(a) Original CT image demonstrates a large hiatal
hernia. Laparoscopic repair of the hernia was per-
formed with Collis gastroplasty and placement of mul-
tiple meshes. The patient presented with right lower
quadrant pain 4 days later. (b) CT image shows mesh
at the hiatus (arrows), along with a right-sided seroma
(arrowhead). (c) CT image shows the low-attenuation
stomach in a specimen bag (*) adjacent to the bladder
(arrow). The specimen was inadvertently left in the
abdomen at the time of surgery.

fects close by scarring down postoperatively, as Complications Related to

generally more scarring is induced by laparotomy Specimen Retrieval and Extraction
[open surgery]) (66). Most internal hernias Unique to the laparoscopic procedure is the need
(77%) manifest relatively late in the postopera- to remove the resected organ or specimen (eg,
tive period (187–1109 days after surgery), with appendix, gallbladder, sigmoid colon, or uterus)
the key clinical finding being sudden or severe through the abdominal wall toward the end of the
abdominal pain (seen in 97% of patients with in- procedure (70). Most surgeons advocate placement
ternal hernias) (67). Radiologically, the findings of the specimen in a specimen bag before extrac-
that cause concern for an internal hernia depend tion through the abdominal wall to avoid wound
on the level of the obstruction: Obstruction of infections or seeding of the port site by disease
the excluded stomach and biliopancreatic limb (70). Complications related to specimen extraction
will manifest as dilatation of the gastric remnant; include wound infection (0%–9% of cases), port
herniation into a small bowel mesenteric defect site hernias (often secondary to widening of the
causes a cluster of dilated small bowel loops with port incision to accommodate a large specimen)
mesenteric edema and crowded vessels, often (0%–2%), and incision site recurrence (0%–1.3%)
with an abrupt mesenteric twist or “swirl sign” (71). Rarely, the specimen itself may inadvertently
(Fig 22) (68,69). These findings necessitate be left in the patient’s abdominal cavity; if this
emergent surgical intervention, since delay in oversight is not recognized before closing the pa-
diagnosis can lead to ischemia or infarction of tient, it may manifest as an abscess or fluid-filled
the bowel, increasing postoperative morbidity or collection at imaging (Fig 23). A summary of the
mortality (69). Diagnosis of an internal hernia most common pitfalls in the interpretation of post-
after bypass surgery is complex: A swirl sign in operative imaging findings that are unique to lapa-
isolation is not a specific or sensitive finding, and roscopic surgery is provided in Table 3.
there may be only dilatation of the gastric rem-
nant, biliopancreatic limb, or alimentary (Roux) Future Directions
limb. Any dilated bowel after gastric bypass sur- To add to the complicated postoperative find-
gery (especially the bypassed limb) is abnormal ings at imaging, surgeons have begun tackling
and should warrant surgical consultation. increasingly minimal invasive techniques for
136  January-February 2014 radiographics.rsna.org

Table 3: Common Pitfalls in the Interpretation of Postoperative Imaging Findings Unique to Laparo-
scopic Surgery

Finding Cause Misinterpretation

Preperitoneal Trocar dislodgement during insufflation or deliber- Necrotizing fasciitis; overzealous insuf-
free air ate insufflation of the preperitoneal space (TEP- flation of CO2 into the abdomen,
TAPP hernia repair) with CO2 escaping into the preperi-
toneal space from the port sites*
Seroma anterior Laparoscopic hernia repair, in which the bowel is Abscess
to mesh reduced from the hernia sac but not resected and
the mesh is placed intraperitoneally, creating a
dead space that fills with fluid
Port site metas- Intraperitoneal malignancies (seen in 1%–2% of Subcutaneous injection granuloma,
tasis cases) infection
Specimen bag Specimen is inadvertently left in the patient (rare)† Normal viscus (eg, bladder, small
nonretrieval bowel, ovarian cyst)
*This phenomenon does not occur because the CO2 pressure for insufflation is preset to 15–20 mm Hg.
†The specimen bag may be very subtle, having the appearance of a fluid-filled structure.

laparoscopic surgery, including single-incision Conclusions

laparoscopic surgery (SILS) and natural orifice In the evaluation of patients who have under-
transluminal endoscopic surgery (NOTES). gone minimally invasive surgery, it is important
SILS is a laparoscopic approach in which a to be familiar with the normal imaging appear-
single 2–3-cm incision at the umbilicus is used ances of the different types of surgical interven-
to place a multichannel port; this procedure is tion. Familiarity with normal postlaparoscopic
technically more challenging than conventional findings in commonly performed abdominopel-
laparoscopy due to several factors, including loss vic surgical procedures allows accurate diagnosis
of triangulation (the camera and working instru- of common complications and helps avoid diag-
ments are parallel to each other), hand clashing nostic pitfalls.
(in which the surgeon’s hands inadvertently
Acknowledgment.—The authors wish to thank Mar-
collide owing to the multiplicity of instruments tha Helmers for the illustrations in Figures 1, 2, 4, 5,
entering the abdomen through a single port), and 14.
and decreased visualization due to suboptimal
instrument or camera position (72,73). The References
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TM
This journal-based SA-CME activity has been approved for AMA PRA Category 1 Credit . See www.rsna.org/education/search/RG.
Teaching Points January-February Issue 2014

Common Postoperative Findings Unique to Laparoscopic Surgery

Nicole M. Hindman, MD • Stella Kang, MD • Manish S. Parikh, MD
RadioGraphics 2014; 34:119–138 • Published online 10.1148/rg.341125181 • Content Codes:

Page 121
Although entry choice is the subject of ongoing debate, conservative recommendations argue against blind
trocar entry techniques for primary or secondary trocar placement, especially before insufflation of the
abdomen, so as to minimize complications.

Page 122
Prolonged insufflations into the abdominal wall may lead to subcutaneous emphysema, which may reach
the patient’s neck and face. This crepitus usually resolves after the abdomen is desufflated and has mini-
mal clinical sequelae. On postoperative images, subcutaneous air will be seen in the anterior abdominal
wall. The key to radiologic interpretation is not to mistake this common postlaparoscopic finding for a
surgical emergency (eg, necrotizing fasciitis).

Pages 125–126
Radiographic findings that are worrisome for bowel injury include persistent postoperative ileus (since
ileus after laparoscopy is uncommon) and increasing amounts of free intraabdominal air on serial radio-
graphs. Free air is normally seen. Specific findings at CT include free intraperitoneal or mesenteric air,
extravasation of oral contrast material, focal bowel wall defects, and nonenhancing bowel wall; less specif-
ic findings include bowel wall thickening, free fluid, peritoneal enhancement, and mesenteric stranding.

Pages 130–131
The postoperative seroma seen in patients who have undergone laparoscopic hernia repair will be seen
in all patients who are imaged within a month after surgery; the seroma usually resolves within a month,
although it may take up to 6 weeks to resolve. The key to interpreting this finding is in knowing the surgi-
cal approach used: Differentiating the postoperative seroma (a nonsurgical, conservatively managed find-
ing) from a postoperative abscess is important, since aspiration of a seroma is contraindicated and may
introduce infection into the surgical site.

Page 135
Most internal hernias (77%) manifest relatively late in the postoperative period (187–1109 days after
surgery), with the key clinical finding being sudden or severe abdominal pain (seen in 97% of patients
with internal hernias). Radiologically, the findings that cause concern for an internal hernia depend on
the level of the obstruction: Obstruction of the excluded stomach and biliopancreatic limb will manifest
as dilatation of the gastric remnant; herniation into a small bowel mesenteric defect causes a cluster of
dilated small bowel loops with mesenteric edema and crowded vessels, often with an abrupt mesenteric
twist or “swirl sign.”