Nezhat, Ceana - Complications MC 4 SLS

P REVEN T I ON , R ECOGN I T I ON AN D
M AN AGEM EN T OF V ASCU L AR
C OM PL I CAT I ON S D U RI N G
L APAROSCOPI C AN D R OB OT I C
SU RGERY
Cean a N ezh at , M D
At l an t a, Geor gi a
w w w .N ezh at .com
D ISCLOSURE

Con su lt a n t : Lu m en is, Ka r l St or z E n doscopyAm er ica

Ot h er : Medica l Advisor – P la sm a Su r gica l
Scien t ific Advisor y Boa r d – Su r giQu est
COMP LICATIONS




Un a voida ble
Kn owledge of a n a t om y
Su r gica l skill
Su ppor t
COMP LICATIONS O UTCOME
Recognition
Prevention
Management
F IRST P AP E R ON L AP AROSCOP IC T RE ATME NT
OF S TAGE IV E NDOME TRIOSIS

Nezh a t et a l. La ser la pa r oscopy for t h e t r ea t m en t
of en dom et r iosis. F er t ilit y & St er ilit y (1986) 45,
778-783.

P r esen t ed a t AAGL a n n u a l m eet in g in 1984

Nezh a t C. et a l. Videola ser oscopy: a n ew
m oda lit y for t h e t r ea t m en t of en dom et r iosis a n d
ot h er disea ses of r epr odu ct ive or ga n s. Colposc
Gyn ecol La ser Su r g (1986) 24, 221.
"Wh er ever in t h e body a ca vit y exist s or a ca vit y
ca n be cr ea t ed, oper a t ive la pa r oscopy is in dica t ed
a n d pr oba bly pr efer a ble. Th e lim it in g fa ct or s a r e:
skill a n d exper ien ce of t h e su r geon a n d t h e
a va ila bilit y of pr oper in st r u m en t a t ion .”
Nezhat et al, Operative laparoscopy (minimally invasive surgery):
state of the art. Journal of Gynecologic Surgery 1992;8:111-41.
CYST , R E XTE RNAL I LIAC
1.03
T RE ATME NT
OF VASCULAR INJ URY
1.Prompt recognition is key in successful treatment
2. Conversion to open repair
3.Laparoscopic repair has been described

Nezh a t C, Nezh a t F , Nezh a t C. Nezh a t 's Oper a t ive Gyn ecologic La pa r oscopy a n d H yst er oscopy. 3r d ed.. New Yor k, NY:
Ca m br idge Un iver sit y P r ess; 2008
SP E CIAL
CONSIDE RATION IN VASCULAR
INJ URY RE P AIR
Su r geon ’s skills
 Recon st r u ct ion
 Dim in ish ed visibilit y
 Specia l in st r u m en t a t ion

•Nezhat C, Nezhat F
, Nezhat C. Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy. 3rd ed. New York, NY: Cambridge University Press; 2008
O PERAT I N G R OOM T EAM WORK
AM ON G P H YSI CI AN S AN D N U RSES:
T EAM WORK I N T H E E YE OF T H E
B EH OL D ER
M ak ar y M A, Sex t on J B , F r ei sch l ag J A, H ol zm u el l er
CG, M i l l m an EA, Row en L , Pr on ov ost PJ .
J ou r n al of t h e Am er i can Col l ege of Su r geon s
Vol . 202, N o. 5, M ay 2006
A P P ROP RIATE Q UE STIONS
IN R E VIE WING A C ASE R E P ORT
1.
2.
3.
4.
Wh a t wer e t h e ea r ly wa r n in g sign s t h a t t h is
cou ld be developin g?
If on e h a d kn own it wa s com in g, cou ld t h e t ea m
h a ve been bet t er pr epa r ed?
On ce con fr on t ed wit h t h e pr oblem , wh a t wa s
don e cor r ect ly a n d wh a t cou ld be don e bet t er
t h e n ext t im e?
Cou ld t h is ca se sh ed ligh t on a m ech a n ism of
disea se?
T ROCAR I NJ URIE S

Tr oca r in ju r y is on e of t h e m ost ser iou s a n d
pot en t ia lly pr even t a ble com plica t ion s

Disposa ble t r oca r s h a ve fea t u r es in t en ded t o
pr even t t h ese in ju r ies
T ROCAR

INJ URIE S IN LAP AROSCOP IC SURGE RY
Bh oyr u l S, Vier r a MA, Nezh a t CR, Kr u m m el TM,
Wa y LW.. J Am Coll Su r g. 2001 J u n ;192(6):67783.
R ESU L T S: T YPES OF TROCAR I NJURI ES REPORTED
TO TH E FDA FROM 1993 TO 1996
T r ocar I n j u r y
Deat hs
Non-fat al vascular injur ies
Non-fat al viscer al injur ies
Abdominal wall hemat omas
Unclassified
N o.
32
382
176
30
8
Tot al
628
CONCLUSIONS

Va scu la r in ju r ies a r e m or e likely t o be fa t a l if
t h ey in volve t h e a or t a or in fer ior ven a ca va
CONCLUSIONS

An u n r ecogn ized bowel in ju r y is h igh ly let h a l
M AJ OR VASCULAR INJ URY AND
LAP AROSCOP Y
Ia t r ogen ic va scu la r t r a u m a
CO2 em bolism du r in g in su ffla t ion
H a n n ey RM, Alle KM, Cr ega n P C. Ma jor va scu la r in ju r y a n d la pa r oscopy. Au st N Z J Su r g. 1995 J u l;65(7):5335.
U MBILICAL B LE E D
30
A ORTIC I NJ URY
20
E P IGASTRIC
28
R IP
33
M ONOP OLAR S CISSORS R
E XTE RNAL I LIAC
48
B RANCH VE NA C AVA
52
L E F T E XTE RNAL I LIAC
56
PLASMA J E T
1.28
1.31
V ASCULAR I NJ URY - R OBOT
48
EL I ROBOTIC
1.05
STAP LE R L E XTE RNAL I LIAC
52
SCISSORS E XTE RNAL I LIAC
44
PRE SACRAL
44
D E VICE S
USE D F OR DISSE CTION AND
H E MOSTASIS IN LAP AROSCOP IC SURGE RY
Su r gica l clip
 Su t u r e liga t ion
 Su r gica l st a pler
 E lect r osu r ger y
 Adva n ced bipola r sea lin g syst em s Ult r a son ic
desicca t ion
 Ra diofr equ en cy sea la n t s
 H a em ost a t ic a gen t s

H E MOSTATIC

AGE NTS
Beca u se con t r ol of bleedin g by su t u r es or ca u t er y is
n ot a lwa ys effect ive or pr a ct ica l, a va r iet y of pr odu ct s
h a ve been developed t o a ch ieve bleedin g con t r ol by
a lt er n a t ive m ea n s:

H em ost a t ic a gen t s
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Sea la n t s
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Used t o h a lt bleedin g
Applied dir ect ly t o a bleedin g sit e
Wor k in t h e pr esen ce of a ct ively flowin g blood
Used t o pr even t t h e lea ka ge of liqu ids, ga ses a n d solids fr om
su r gica l sit es
Applied t o dr y or cla m ped t issu e su r fa ces t o cr ea t e a ba r r ier
Glu es/a dh esives

Used t o a t t a ch t issu es
A RISTA- AH
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Ar ist a a bsor bs t h e ser u m (liqu id por t ion of t h e blood) a n d
cr ea t es a sca ffold t o su ppor t t h e fibr in m esh
Biologica lly in er t
No bovin e, por cin e or h u m a n blood, pr ot ein or t issu e
sou r ces
Syn t h esized fr om pla n t m a t er ia l
No r isk of vir a l disea se t r a n sm ission
E n zym a t ica lly degr a ded wit h in 24 h ou r s
A fa st a ct in g, ver sa t ile clot t in g a gen t t h a t pr odu ces a n
“in st a n t gellin g” followed by t h e for m a t ion of a fibr in m esh
in 1-2 m in u t es
Ra pid con t r ol of bleedin g
ea sily ir r iga t ed
Cost a n d t im e sa vin gs
COSE AL
Biocom pa t ible polyet h ylen e glycol polym er t h a t
r a pidly cr oss-lin ks wit h
 P r ot ein s in t issu e t o im m edia t ely a dh er e t o t h e
a r ea of a pplica t ion
 In dica t ed for u se in va scu la r r econ st r u ct ion s t o
a ch ieve a dju n ct ive
 H em ost a sis by m ech a n ica lly sea lin g a r ea s of
lea ka ge.
 F u lly syn t h et ic, n ot con t a in in g a n y a n im a l or
h u m a n pr ot ein s or
 Glu t er a ldeh yde
 Su ccessfu lly a dh er es t o syn t h et ic m a t er ia ls

F LOSE AL
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F losea l in dica t ed in su r gica l pr ocedu r e except in
oph la t m ic su r ger ies.
F ossil m a t r ix con t a in s bovin e- dr ived gela t in
m a t r ix com pon en t s a n d a h u m a n t r om bin com pon en t .
Don ’t u se in pa t ien t s wh o a r e a ller gic t o m a t er ia ls in
bovin e, on skin in cision s, do n ot in ject or com pr ess
flosea l m a t r ix in t o t h e blood vessels.
F losea l is in dica t ed in in va sive*1 or su r gica lly
in va sive*2 pr ocedu r es a s a n a dju n ct t o h em ost a sis
wh en con t r ol of bleedin g by liga t u r e or con ven t ion a l
pr ocedu r es is in effect ive or im pr a ct ica l
F LO S E AL
36
V ASCULAR C LIP S
24
V E IN S UTURING
42
A RTE RY R E P AIR C LIP S
AND
S UTURE
1.08
SUGGE STE D R E ADING
SUGGE STE D R E ADING
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Thank you
Ceana Nezhat, MD
www.Nezhat.com
Q U EST I ON S?