Transcript Laparoscopic Complications

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Complications related to laparoscopy in
gynecologic patients: 0.1 to 10%
Over 50% occurred at entry
20 to 25% not recognize until the postoperative
period.
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One survey between 1980 and 1999:
The incidence of entry access injury:5 to 30 per
10,000 procedures.
Bowel and retroperitoneal vascular injuries:76% of
all injuries
The type and proportion of organ injury during
entry: small bowel (25%), iliac artery (19%), colon
(12%), iliac or other retroperitoneal vein (9%),
secondary branches of a mesenteric vessel (7%),
aorta (6%), inferior vena cava (4%), abdominal wall
vessels (4%), bladder (3%), liver (2%)
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A review of procedures from 1975 to 2002:
Entry-related visceral lesions: 0.3 to 1.3 per 1000
procedures
Entry-related vascular lesions:0.07 to 4.7 per 1000
procedures
The open technique was not associated with fewer
complications than the closed technique
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Most nerve injuries: neurapraxia or nerve
contusion, usually resolve within 6 weeks
Neurotmesis, or complete division of the
nerve: the most severe injury, often resulting
in permanent disability.
Proper patient positioning & knowledge of risk
factors associated with neuropathies are
important
Femoral neuropathy: associates with excessive
hip flexion or abduction, or long operating
times
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Obturator neuropathy:
Radical pelvic surgery or lymph adenectomy
(most common)
Excessive hip flexion (in the obturator foramen,
the nerve lies directly against bone)
Retropubic dissection (paravaginal repair of
lateral defects of the anterior vaginal wall)
Iliohypogastric and ilioinguinal nerves: lateral
trocars (suture ligature and fibrotic entrapment):
avoid extreme lateral trocar placement
Injury to the ilioinguinal and iliohypogastric
nerves can be avoided by placing incisions above
the anterior superior iliac spine.
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Sciatic neuropathy: result of nerve stretching.
It is reported in procedures lasting as short as
35 minutes in free-hanging stirrups
Peroneal nerve: division of sciatic, under the
least amount of tension when the knee and hip
are flexed (the nerve is fixed at the sciatic
notch and the fibular head). Tension along the
nerve is increased with hip flexion when the
knee joint becomes straightened or externally
rotated.
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Patients at increased risk of sciatic nerve
injury: long-legged, obese, or short in
stature.
In hanging-type stirrups, long-legged or
obese patients have a tendency for external
hip rotation, and shorter patients have less
flexion at the knee.
In such cases, stirrups that support the ankle
and calf are more appropriate.
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The most life threatening
Usually laceration of the mesenteric vessels during
insertion of the primary trocar or Veress needle
Injury to the great vessels requires immediate laparotomy
Injury to smaller vessels: usually hemostasis
Injury to the inferior epigastric vessels:
Bipolar forceps through the contra lateral port 
coagulation
Endoscopic fascial closure devices  suture passing
through the fascia and peritoneum
A 30-cc Foley catheter through the trocar site with the
aid of an 8-inch clamp, inflating the balloon: tamponade
Enlarging the trocar site: visualize, clamp, and ligate the
vessel
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The most lethal injury associated with laparoscopy
(mortality rate: 3.6%)
The golden rule of laparoscopic surgery is that
patients gradually get better following the
operation. If a patient continues to have pain,
especially tachycardia or fever, bowel injury must
be suspected
Ileus after laparoscopy is not normal
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The demonstration of free intra-abdominal air on
an upright abdominal radiograph (to diagnose a
ruptured intraperitoneal viscus): This radiographic
sign is generally NOT helpful after laparoscopic
surgery (40% of patients will have >2 cm of free air
at 24 hours postlaparoscopy)
Patients who present after several days have
experienced either delayed necrosis of damaged
bowel, or had a leak which temporarily sealed off.
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Free air may be seen up to a week postoperatively,
but the volume should gradually decrease.
Increasing amounts of intraabdominal air indicates
ruptured viscus until proven otherwise 
Laparotomy is indicated
Patients may have fecal contamination of the
abdominal cavity and still have bowel movements,
be ambulatory and not display peritonitis.
Symptoms from penetrating trauma generally
manifest within 12 to 36 hours, but may occur up
to 5 or 7 days
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As a general rule: Veres needle injury needs no repair
as long as the puncture is not associated with bleeding
Colonic puncture without tearing: non operative
management with antibiotics, copious irrigation and
suction
Stomach perforation: 1 in 3,000 cases, Risk factors:
history of upper abdominal surgery and difficult
induction (gas-distension).
Trocar injury to the stomach requires repair by
laparoscopy or laparotomy, and the abdominal cavity
should be irrigated and suctioned. NG Tube maintain
postoperatively until normal bowel peristalsis
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Veres needle and trocar injury to the small intestine:
injury should be investigated when multiple anterior
abdominal wall adhesions; A lower quadrant
secondary port can be used to view the umbilical
port site.
Full-thickness injury of ≥ 5 mm should be repaired
in two layers with an interrupted layer of 3-0
delayed absorbable suture (mucosa and muscularis),
and a serosal layer of 3-0 interrupted silk suture,
perpendicular to the long axis of the intestine (avoid
stricture formation)
Performing by laparoscopy, laparotomy or mini
laparotomy at the umbilical site
Laceration ≥ one half of the luminal diameter 
segmental resection
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Trocar injury to the colon: 1 per 1,000 cases
Significant morbidity compared with small
intestine and stomach
Broad-spectrum antibiotics
Consultation with a surgeon
Small rent with minimal soilage
The defect close in two layers with copious
irrigation
Larger injury without bowel preparation, or injury
involvement intestinal mesentery: colostomy
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Delayed (postoperative) diagnosis: colostomy
Detection of injury to the rectosigmoid colon
(flat tire test): filling the posterior cul-de-sac
with normal saline and performing
proctosigmoidoscopy, or injecting air into the
rectum through a catheter-tipped bulb syringe
and looking laparoscopically for bubbles
Thermal bowel injuries: require wide resection
even though the bowel have a normal
appearance
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Electrosurgical injuries may not become
symptomatic for several days.
Burn injuries require resection of 1 to 2 cm of
viable tissue around the injury site.
The resected loop of bowel should be examined by
the pathologist to ensure that all of the damaged
tissue has been excised.
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Frequency: 0.17%
The fascia should be closed if ≥ 10 mm
Risk factors: multiple ancillary ports, larger
diameter ports, and operative instrumentation,
(stapler), Increased operative times, greater
tissue manipulation, fascial screws  fascial
weakening
Closing the fascia may not entirely prevent
hernia formation: 18% occurred despite fascial
closure.
A defect is usually palpable over the trocar site
incision with Valsalva, or a mass can be seen.
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Bladder injury: 1 in 300 cases.
Injury usually occurs to the bladder during
secondary trocar insertion.
Signs: bloody urine and gas in the urine bag
Higher injury rates with laparoscopic hysterectomy
and bladder neck suspension.
No treatment required if the bladder is punctured
with a pneumoperitoneum needle.
A perforation due to trocar injury should be
sutured
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Risk factors for bladder injury: distended bladder
during suprapubic trocar insertion; previous surgery
& distortion to bladder anatomy; endometriosis
obliterating the anterior cul-de-sac.
If the superior aspect of the bladder cannot be
deciphered, filling the bladder with 300 mL of water
or saline
Intraoperative signs of bladder injury: clear fluid in
the operative field, visible bladder laceration, and gas
distention of the Foley bag.
To adequate diagnosis: methylene blue or indigo
carmine, diluted with 200 to 300 mL of sterile normal
saline, instill through the Foley catheter.
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If the injury is small, uncomplicated, and
isolated: catheter drainage, cystogram on the
10th day of drainage
Surgical repair: if the Foley catheter is unable to
provide adequate drainage because of blood
clots or persistent extravasation, or concomitant
injury to the urethra or ureter.
Laparoscopic repair: if small injury with
adequate exposure, as long as the ureters and
bladder neck are not compromised.
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Overall complication rates for laparoscopy are
decreasing, but ureteral injury has remained
steady at 1%
The greatest risk: laparoscopic hysterectomy
(LAVH is most association)
The usual time to diagnosis in post operation:
between 2 and 7 days (is reported as late as 33
days after surgery)
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Symptoms: abdominal pain, fever, hematuria,
flank pain, or peritonitis.
Leukocytosis is common
In the majority of cases: percutaneous or
cystoscopic stenting
Laparotomy is usually performed for end-toend anastomosis or reimplantation of the
ureter into the bladder (in experienced hands,
repair may be performed laparoscopically).
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prior surgeries, intraabdominal disease
(endometriosis, pelvic inflammatory disease),
extensive bowel distention, very large pelvic
or abdominal masses, extensive
pelvic/intraabdominal adhesions,
cardiopulmonary disease, and diaphragmatic
hernia.
Patients with these conditions are often
better served with a nonlaparoscopic surgical
approach.
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Clinical manifestations: swelling, pain, ecchymoses and
external bleeding from the trocar site.
Hematomas which are stable on physical examination
and by imaging: manage conservatively
The hematoma may drain spontaneously. No
intervention is necessary.
Surgical intervention: if the hematoma is expanding or
becomes abscessed
Delayed hematomas may present 2 or 3 days after
surgery as purple discoloration of a portion of the
abdominal wall and/or back.
They arise from delayed bleeding from vessels in the
abdominal wall.
Observation and correction of anemia usually suffice.