a 36 year old , para 2 female with a history of chronic right adnexal pain was admitted for a laparoscopic right salpingo - oophorectomy .
the patient experienced worsening right ovarian pain which did not improve despite nonsteroidal anti - inflammatory medications .
an ultrasound revealed a 4 cm complex ovarian mass which did not change in size with serial ultrasounds .
previous surgeries included an abdominal hysterectomy for a fibroid uterus , laparoscopic left salpingooophorectomy and lysis of adhesions for pelvic pain , an appendectomy , two previous cesarean sections , a bilateral tubal ligation and an inguinal herniorrhapy as a teenager .
the patient underwent general endotracheal anesthesia and was prepped and draped in the usual manner after being placed in the dorsolithotomy position . after making a small incision in the umbilicus
, a veress needle with its 2 mm trocar was carefully inserted into the abdomen with the panniculus elevated .
the saline drop test revealed patency , and the veress needle was attached to the co2 for the pneumoperitoneum .
the co2 was immediately stopped , the veress needle removed and a 2 mm microlaparoscope ( minisite gold ; u.s .
surgical corp . , norwalk , ct ) inserted into the trocar , which revealed bowel lumen with stool .
a second 2 mm trocar was placed in the right lower quadrant , and the microlaparoscope revealed a perforation into the anti - mesenteric border of the ileum .
was inserted under direct visualization lateral to the right rectus muscle at the level of the umbilicus .
the 2 mm umbilical trocar was replaced with a new one of the same diameter . at the site of the small bowel entry ,
after irrigating the pelvic and abdominal cavities with 3 liters of normal saline with no further fecal spillage or bleeding , the decision was made to not suture the site of entry into the small bowel .
postoperatively , the patient had a nasogastric tube inserted , was placed on famotidine ( pepcid ) 20 mg every 12 hours and was given antibiotics consisting of ampicillin , gentamicin and clindamycin intravenously .
on the evening of surgery , the patient developed a fever of 101.2 degrees fahrenheit .
on postoperative day one , she had a single temperature spike of 100.9 after being afebrile .
on postoperative day three , she had a small bowel movement , was advanced to a regular diet and discharged home in the afternoon on oral cephalexin . at her
one week postoperative visit she remained afebrile , tolerating her diet and with no complaints .
one month after surgery she was symptom free and her chronic right adnexal pain was gone .
most of the current data on laparoscopic complications is based on case reports and small series .
open laparoscopy was developed to reduce the risk of blind entry into the peritoneal cavity .
however , injury to the bowel has been reported to occur at the same rate with this technique .
recent advances in microlaparoscopy have allowed us to perform both diagnostic and operative procedures through 2 mm trocars . in our patient ,
a microlaparoscope inserted through the entry site confirmed the complication . had we performed traditional laparoscopy using a 10 mm trocar , the site of bowel injury would have required suturing , possibly a laparotomy . in cases where the site of perforation is free of adhesions and in need of repair
, the bowel can be sutured externally by withdrawing the bowel through a 12 mm trocar .
our minimally invasive , conservative approach to this complication was possible because no further fecal material leaked through the site of perforation and the diameter of the injury was small .
we felt that suturing in this case was unnecessary because the margins were regular , hemostatic and self - sealing .
the stool that was forced through this site probably was a result of the increased intraluminal pressure in the bowel from the co2 insufflation .
after copious irrigation with normal saline and no further spillage , we felt that the patient 's morbidity would be greater with suturing of the bowel if it produced bleeding or further spillage .
except for an initial fever , the patient responded well to conservative management with bowel decompression , antibiotic therapy and close observation .
conditions requiring a laparotomy following a bowel perforation include any sign of peritonitis , persistent fever , ileus or prolonged vomiting .
we believe that some small bowel perforations from 2 mm instrumentation can be managed conservatively without suturing provided that the site of injury is not actively leaking stool nor bleeding .
 although laparoscopy is one of the most common surgical procedures done today , bowel perforations can and do occur during the initial insertion of the veress needle and/or trocar . 
 recent advances in microlaparoscopy have reduced the morbidity of this complication when encountered . 
 we report a case of small bowel perforation following insertion of a veress needle with its 2 mm trocar and our minimally invasive intra - operative and postoperative management of the patient . 