title: Bowel injury in robotic gynecologic surgery: risk factors and management options. A systematic review.
abstract: OBJECTIVE
  We sought to analyze the published literature on bowel injuries in patients undergoing gynecologic robotic surgery with the aim to determine its incidence, predisposing factors, and treatment options.
  
  
  METHODS
  Studies included in this analysis were identified by searching PubMed Central, OVID Medline, EMBASE, Cochrane, and ClinicalTrials.gov databases. References for all studies were also reviewed. Time frame for data analysis spanned from November 2001 through December 2014.
  
  
  METHODS
  All English-language studies reporting the incidence of bowel injury or complications during robotic gynecologic surgery were included. Studies with data duplication, not in English, case reports, or studies that did not explicitly define bowel injury incidence were excluded.
  
  
  METHODS
  The Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies were used to complete the systematic review with the exception of scoring study quality and a single primary reviewer.
  
  
  RESULTS
  In all, 370 full-text articles were reviewed and 144 met the inclusion criteria. There were 84 bowel injuries recorded in 13,444 patients for an incidence of 1 in 160 (0.62%; 95% confidence interval, 0.50-0.76%). There were no significant differences in incidence of bowel injury by procedure type. The anatomic location of injury, etiology, and management were rarely reported. Of the bowel injuries, 87% were recognized intraoperatively and the majority (58%) managed via a minimally invasive approach. Of 13,444 patients, 3 (0.02%) (95% confidence interval, 0.01-0.07%) died in the immediate postoperative period and no deaths were a result of a bowel injury.
  
  
  CONCLUSIONS
  The overall incidence of bowel injury in robotic-assisted gynecologic surgery is 1 in 160. When the location of bowel injuries were specified, they most commonly occurred in the colon and rectum and most were managed via a minimally invasive approach.
authors.affiliation: Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, DE. Electronic address: tpicerno@christianacare.org.
authors.forename: Toni
authors.initials: T
authors.lastname: Picerno
authors.affiliation: Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, DE.
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Sloan
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Pedro
authors.initials: P
authors.lastname: Escobar
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Pedro T
authors.initials: PT
authors.lastname: Ramirez
mesh_terms: D003106:Colon / Q000293:injuries*; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000009:adverse effects*; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000453:epidemiology / Q000209:etiology*; D010535:Laparoscopy / Q000009:adverse effects; D012007:Rectum / Q000293:injuries*; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000009:adverse effects*
keywords: bowel surgery; robotic surgery; surgical complications