1. Bladder injuries: Injuries to adjacent organs during hysterectomy are a common complication involving primarily the bladder. bowel. and ureter. It does appear that the rate of bladder injury at the time of hysterectomy is increasing. The literature before the CREST study generally reported rates of less than (0.5% tor bladder injury. The CREST study reported a rate of bladder injury of 0.3% for AH and 1.6% for VH. Bladder in juries occur somewhat more commonly in VH as compared with АН. More recent studies have shown an overall rate of 1%~2% for bladder injury.

Possible explanations for the increased rate of bladder injuries are: (1) possible underreporting in the older literature. (2) an increase in the number of "difficult vaginal hysterectomies" performed, and (3) an increased number of women undergoing hysterectomy who have had prior Cesarean sections. It seems intuitively clear that a major risk for bladder injury at the time of hysterectomy is a history of prior Cesarean section. There are a number of authors who have supported this view. Some studies, however, have disagreed with this proposition. There have been no large prospective studies yet to answer this question definitively. 

Bladder injury with LH can occur during either the iaparoscopic or the vaginal phase of the procedure. Some authors who have reported on LH believe there is an increased risk of bladder injury with this procedure. There is concern that the two-dimensional view trom the video camera increases the odds for inadvertent bladder injury compared with traditional hysterectomy. The reported rate of bladder injury during LH is 1.1%, which is approximately the rate of bladder injury with traditional VH. The rates of bladder injury for LH are derived from the world's most sophisticated laparoscopic institutions and may be higher in community hospitals.

2. Bowel injuries: The risk of bowel injury at the time of hysterectomy is highly correlated with the difficulty of the surgical procedure. Injuries to the bowel predominantly occur in two ways: (1) injury to the small bowel with lysis of adhesions and (2) injury to the rectum with dissection of the posterior cul-de sac. The overall rate of injury to the bowel is 0.3% for AH. 0.4% for VH, and 0.25% for LH. At this point, the rate of bowel injury for LH is not significantly greater than the rate for traditional hysterectomy. Although the laparoscopic method carries the adherent additional risk of multiple trocar insertions, bowel injuries related to trocar placement rarely have been reported in LH. One might expect that as more experience is gained with the laparoscopic procedure, the rate of bowel injury would decrease. However, as more experience is gained with the laparoscopic method, the surgeon may try to perform increasingly difficult procedures by the laparoscopic route. This could result in an increased number of bowel injuries.

3. Ureteral injury: Ureteral injury is similar to bowel injury in that the trequency of occurrence is highly dependent on the difficulty of the procedure. In the CREST study, ureteral injury occurred in 0.2% of AH cases and did not occur with VH. The decreased rate of injury with vaginal hysterectomy is at least partialiy because of the choice of AH for more difficult procedures. Some authors have commented that the technique of VH is inherently protective tor ureteral injury. 

The reported rate ot ureteral injury for LH is 0.2% for a very experienced and skilled surgeon. This figure is equivalent to the injury rate in AH. It is the opinion of this author that the rate in community based hospitals is considerably higher. This is based on personat observation and on informal review of regional malpractice claims.

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