I would prefer a through peritoneal toilet and simple closure as the gut is not diseased.

I am agree with Dr.Iqbal, I would prefer a simple closure for the case. If there is the paresis of the whole small intestine, I would add the Miller-Abbott tube insertion.

I agree, peritoneal toilet, closure and if patient septic then feeding tube, perhaps.

I prefer to heal the perforation with two-layer simple closure. Afterwards abdominal lavage with huge amount of saline and placing at least two drains to prevent septic complications like abscess.

single layer extra-mucosal repair... after a thorough lavage.... that should suffice.

Single layer extramucosal repair if the hole is in the anti mesenteric border and lavage plus drainage. Consider segmental resection if perforation in the mesenteric border.

Thorough peritoneal lavage with copious amounts of normal saline, suture-repair of the bowel wall in two layers and drains (douglas pouch, paracolic gutter, subhepatic space). 

I don't have any evidence-based answer on this, but I would think that segmental bowel resection would carry a relatively higher risk for anastomotic leakage that simple primary suture in an inflammatory environment as such.

very important that one should keep in mind that Hassan's technique is not foolproof,injuries can occur.what I do routinely and teach is to check for needle site and trochar site areas.Of course every body does it,Snice the perf is less than 24 hours,expecting contamination is less,simple closure after through peritoneal toilet and drainage is normally suffice.However followup should be careful to see the drain fluid is normal .

So here's what had actually occurred:  in repairing the enterotomy with a single layer closure in transverse fashion, an occult injury to the back-wall of the bowel (into the mesentery) had been missed.  The Jackson-Pratt drainage was extensive and the abdomen continued to show signs of peritonitis.  At re-re-operation the intra-mesenteric abscesses were resected along with the previously repaired portion of small bowel with an end-to-end anastomosis....

The open technique of Hasson is not foolproof, as Dr. Reddy states, especially if adhesions immobilize the small bowel.

Dr.Aanning,

And where was not any bruise/bluish discoloration of the mesenterium or appearance of some gas bubbles provoked by a gentle compression against the injured place of the intestinal loop? Indeed, the antimesenterial site is more diffecult to revise. Surgeons have been learning for years how to perform it carefully, and this manoevre is not always possible during laparoscopic approach.

Dr. Borodach - 

Good point!  The surgeon had noted the anti-mesenteric enterotomy and simply repaired it - without freeing up this small bowel segment for a more thorough examination...

It is not common for Hassan trochar to produce a counter puncture.However it is very common for a sharp tipped one to produce counter puncture.

Probably a simple closure if the enterotomy is not too complex

I want to thank all the above contributors for their thoughts...The literature states that enterotomies with the Hasson method are very rare and so to also have a "counter puncture" must be even rarer indeed...Finally, it goes without saying that this example should raise our suspicion of an occult through-and-through perforation in any trauma to the small bowel, especially when a possible perforation to the back wall of the bowel (or near-perforation with subsequent breakdown of the bowel wall) is hidden within the mesentery...

There is a 'golden low of abdominal emergency' that have been saving many lives for a century, or some of the kind. It postulated that there should be some even number of wounds to the intestine, especially the small one: 2, 4, and 6, etc, so to say "the presumption that the injuries to the intestine are almost always paired, and some odd number including a single wound is rather exception".

Dr. Borodach - Yes, you are totally correct!...I do remember being taught that principle while a resident...and the admonition to fully mobilize the bowel in order to allow a thorough inspection of its integrity...Thank you!

Do a thorough lavage.. Examine the gut for possible through and through injury / injury to adjacent underlying segment of the gut. A 1 cm ileal laceration can be primarily closed laparoscpically...

Simple closure of small intestinal puncture is adequate and safe, but you should examine the whole gut to avoid missing another injury.

Hasson'n method of pneumoperitoneum is rarely causing bowel injury according to the literature, however this could happened and the reasons are :1. Fixation of the bowel by previous laparotomy or peritonitis.

2. Poor trocar insertion technique. 

In this case it is not clear whether the injury happened by first trocar or right side trocar?

this can be  judged by the size and site of injury and also by knowing whether 5 or 10 mm trocars are used at which site.

It's coming without saying that bowel injury Should be always assumed as through and through injury rather than single injury.Checking the other side of the bowel to exclude this possibility is crucial.

The management of small bowel enterotomy in this case is by primary closure in majority of cases. Resection and reanastomosis would be an aggressive approach . For colonic injuries this is different and several options including bringing the site of injury as stoma , primary closure and drainage is depending on time of diagnosis ,degree of contamination ,bowel preparation status and surgeon experience .

It is very unfortunate but hopefully a lesson for the primary surgeon to check both sides of the bowel before closing the abdomen!

Agreed either completely or to some extent with all the colleagues, moreover, I feel enriched with the collective experience.

However, I think I should add something to the topic. Stab (and not only these) wounds to the intestine want  instrumental method of their detection to be invented, precise and simple at the same time. It might be some chemical detector, for example, that of the presence of the amylase on the serosa of a funny loop. Or another sort, so to say, a pH indicator. Or another way of detection of the intestinal contents sensitive enough up to their mircodoses.

First, enterotomy for an elective cholecystectomy is extremely rare. The question posed is regarding which method of damage control (repair method) has better outcomes. There is no clear answer to the question because there simply is not enough data, and the prudent medical decision maker will depend on the intraoperative finding - not what is in the books or in the literature. Either simple repair or re-anastomosis will work depending on the context of the patient and the operative field.

Second, a more immediate issue is the postoperative care. Maybe this is obvious, but the bowel continuity and luminal competency is secondary to the presumed sepsis and inflammatory response. The bowel operative is to check the momentum behind the inflammation. At day 1 of index operation, the patient has yet to seen the full gamut of cytokine storm and the resulting cardiovascular pathophysiology. Too many variables to say, but SEPSIS protocol should be an obvious thought.

Third, two potential long-term consequences must be accepted. One is partial bowel obstruction. Another is choledochoenteric fistula. Whether simple repair or reanastomosis is better at lowering this risk, I do not think is written anywhere. If it is written, I do not believe it.

in your case of early discovery and small injury, freshening the edges with closure in 2 layers is satisfactory

.As there will never be type one data to randomize an event no surgeon wants to experience, the injury once assessed as singular and localized can be managed with primary closure and differ from patient to patient depending on time to presentation, hemodynamic/sepsis status and underlying medical/surgical history.

I would do a simple repair if it is on anti-mesenteric side, involving

We feel that our experience in laparoscopic abdominal surgery and frequent departmental review of complications has led to better patient selection and increased vigilance. Given the complexity and the learning curve of advanced laparoscopic surgery, surgeons are strictly credentialed and monitored. The Director of Laparoscopy and Chairman of Surgery credential all surgeons performing laparoscopic surgery. Other safety measures include:

Trained surgeons scrub directly with surgeons to be credentialed.

Surgeons should seek help in difficult cases, and all surgeons must be willing to scrub in and help each other as necessary.

All outcomes are followed.

Patients with a history of multiple open abdominal surgeries should have the initial trocar placed away from any scars to avoid bowel injury.

In patients with extensive intraabdominal adhesions, difficult anatomy or bleeding, failure to progress during dissection is an indication for expedient conversion to an open procedure.

The presence of bile or enteric contents not secondary to dissection should alert the surgeon to a possible intestinal injury.

Any suspected areas of injury or ischemia should be checked and rechecked.

All gastric anastomoses should be tested for a leak by distention with air under saline submersion and then methylene blue dye. All low colonic anastomoses should be tested by distention with iodine prep solution.

Patients with sudden onset of tachycardia, unexplained fever or any other signs of sepsis postoperatively, require an immediate investigation for unrecognized intraoperative injuries such as inadvertent enterotomy.

We do not advise laparoscopic operations for patients with either acute or chronic bowel obstruction with massive distention.

I such case it seems to me that an error during trocar insertion was obvious, so I think that is nothing of arguing about this. In all cases, trocar insertion is a dangerous step in laparoscopic surgery, this should be done in full visual control. For the first trocar, open access is the safest method especially in patients with previous abdominal surgical history. If the intestinal wound occurs, a thorough examination of the segment should be performed reminding that trocars are so sharp that they can produce lesions on both sides of the intestinal wall. If is more that one lesion, resection of the segment with end to end suture is the procedure that should be chosen. If there is a single perforation with small diameter  and with no evidence of other damages, simple suture in one/two layers is probably the best solution. Extensive peritoneal lavage and peritoneal drainage should end the surgical procedure. 

Maybe it is enough depending on the conditions os the abdominal cavity

24 hours, 1 perforation along the mesenteric margin, 1 liter of succus entericus: probably, it will be possible to suture the wound of the intestine - without seeing the situation, we can only assume the likely outcome of their situation... if the damage to the intestine is significant, it will be necessary to resect the intestine and apply an anastomosis...

Depends on the technical expertise available at the unit!

Enterotomy can occur even in open technique.If detected at the same time, only closure.once peritonitis sets in thorough lavavge with drains and suture it by lap by an experienced surgeon in the immidiate PO period.In delayed cases again through lavage with drains and extereorise the segment either by lap if pt’s GC is stable otherwise by laparotomy.

Enterotomy can occur even in open technique.If detected at the same time, only closure.once peritonitis sets in thorough lavavge with drains and suture it by lap by an experienced surgeon in the immidiate PO period.In delayed cases again through lavage with drains and extereorise the segment either by lap if pt’s GC is stable otherwise by laparotomy.

Enterotomy can occur even in open technique.If detected at the same time, only closure.once peritonitis sets in thorough lavavge with drains and suture it by lap by an experienced surgeon in the immidiate PO period.In delayed cases again through lavage with drains and extereorise the segment either by lap if pt’s GC is stable otherwise by laparotomy.

Enterotomy can occur even in open technique.If detected at the same time, only closure.once peritonitis sets in thorough lavavge with drains and suture it by lap by an experienced surgeon in the immidiate PO period.In delayed cases again through lavage with drains and extereorise the segment either by lap if pt’s GC is stable otherwise by laparotomy.

Enterotomy can occur even in open technique.If detected at the same time, only closure.once peritonitis sets in thorough lavavge with drains and suture it

by lap by an experienced surgeon in the immidiate PO period.In delayed cases again through lavage with drains and extereorise the segment either by lap if pt’s GC is stable otherwise by laparotomy.

Enterotomy can occur even in open technique.If detected at the same time, only closure.once peritonitis sets in thorough lavavge with drains and suture it

by lap by an experienced surgeon in the immidiate PO period.In delayed cases again through lavage with drains and extereorise the segment either by lap if pt’s GC is stable otherwise by laparotomy.