Complications of laparoscopic surgery

Complications during laparoscopic
surgery
Bethlehem 160312
Anton Langebrekke
Oslo University Hospital
Oslo
Norway
Operative endoscopy
Out-patient procedure
Complications of laparoscopic surgery
 physical
and emotional suffering for
patients
relatives
doctors
 financial
 legal
costs
proceedings
Endoscopic surgery
Risk to operator
 Electric choc
 Skin and corneal burns
 Loss of laparoscopic privilegies
 Loss of patients and referrals
 Malpractic litigation
Norway 1992-1993
2 deaths due to perforation
of retroperitoneal vessels
(Common iliac artery)
Can all surgeons do advanced
laparoscopic surgery?
Probably not:

Few cases available

Surgical volume is decreasing

Few training programs are advanced
Complications of laparoscopic surgery
Prevention

Identify high-risk patients

Properly maintained equipment

Continous training

Knowledge of your instruments

The laparoscopic team work (anesthesianurses-surgeon)
Training
Certification
Credentialing
Training,
training,
training…
…..
Complications of laparoscopic surgery
1 of 4 gynecologists have at least 1
case of Veress or trocar injury.
Half of these injuries required
laparotomy.
Complications of laparoscopic surgery
256 complications from 70607
laparoscopies (3.6/1000) between
90-94
Harkki-Siren & Kurki jan 1997. A nationwide
analysis of laparoscopic complications 1997
Complications of laparoscopic surgery
145 complications from 25764
laparoscopies (5.7/1000)
3.3/1000 severe complications.
2 fatalities,
38 epigastric haemorrhage (1.47/1000)
29 gastro-intestinal damage (1.13/1000)
27 intraabd. vessels (1.05/1000)
>50% of lesions from laparoscopic entry
Jansen et al. Prospective multi-centre study of 72 hospitals in
the Netherlands.
British J Obstet Gynecol 1997;104:595-6.
Complications of laparoscopic surgery
Overall incidence of penetrating
injury:
2,7/1000 patients
Philips, Keith, Hulka. J Reprod Med 1986
Complications of laparoscopic surgery
Example:
during
1984 in the UK: 124548
gynecological laparoscopies.
We
would expect 300-500 serious
complications each year.
Or
in the US: 5000 serious complications
each year.
Complications of laparoscopic surgery

Most experienced laparoscopist have their own
“perfect” laparoscopic method of entry.

No need to change, it will probably not occur
(< 4/1000 severe complications)
This comfortable feeling is not shared
by medical experts in malpractice cases
Complications of laparoscopic surgery
1. Anesthesia related
2. Veress needle and trocar insertions
3. Pneumoperitoneum
4. Surgical injury
5. Closure
Complications of laparoscopic surgery
Insertion techniques:
 classical approach
 direct insertion without Veress
 open laparoscopy
 gasless laparoscopy
 insertion under direct vision
Umbilical incision
Low pressure entry
High pressure entry
Vascular perforation- Aorta
Complications of laparoscopic surgery
Trocar insertion

Sharp trocar? (less force)
 New

bladeless more safe
Second trocar always under direct
vision
Complications of laparoscopic surgery
3. Pneumoperitoneum
1. Emphysema (subcut/preperit/omental)
2. Pneumothorax
3. Pneumomediastinum
4. Gas embolism (more freq. with air)
5. Failure to maintain pneumoperitoneum
6. Cardiac arrhytmias (bradycardia)
7. Hypercarbia
Complications of laparoscopic surgery
Complications associated with
laparoscopic entry include:
failure to gain access to the abd. cavity
damage to a major retro-peritoneal blood vessel
damage to the gastro-intestinal tract
damage to vessels of the abdominal wall
post-laparoscopic bowel herniation
Open laparoscopy Buanes
Open laparoscopy does not reduce the risk of
major complications



2 university teams: classic (8324) versus open (1652)
technique
Conversion to laparotomy: significant higher in open group
Risk of major complications is comparable in the 2 groups. (4
versus 3).
4: 1 aorta injury, 3 bowel injuries
3: 2 bowel inuries, 1 postoperative occlusion
Chapron C. et al. Complications during ……. Acta Obstet Gynecol
Scand 2003;82:1125-29.
Complications of laparoscopic surgery
4. Surgical injury
1.
2.
3.
4.
5.
6.
7.
8.
Thermal injury
Dissection injury
Inability to complete procedure
Vascular injury
Bowel injury
Bladder/ureteral injury
Nerve injury
Lymphoedema/lymphocele
Complications of laparoscopic surgery
Vascular injuries
Diagnosis

Return of frank blood

Bleeding may be concealed if confined to
retroperitoneum (occult bleeding)

Unexplained drop in blood pressure and or
tachycardia

Laparotomy must not be delayed if bleeding is
suspected
Complications of laparoscopic surgery
Vascular injuries
Treatment


Epigastric/abd wall vessels:

Coagulation

Tamponade (Foley)

Sutures

Exploration/laparotomy
Major vessel injury

Immediate laparotomy in most cases

Avoid movement of Veress needle

Aortic compression

Inspect post side of vessels (through-and through injury)
Vascular misadventure
Complications of laparoscopic surgery
Vascular perforations
 How to avoid: technique and anatomy.
 Epigastric vessels most common
Epigastric vessel
Epigastric hematoma
Hemostatic clips
Internal iliac vein bleeding
Complications of laparoscopic surgery
Electrosurgery
Prevention by careful technique.
•
Check insulation
•
Tip of instruments always visible
•
Cauterized area isolated
•
Bipolar whenever possible
•
Disposable is disposable
Complications of laparoscopic surgery
Electrosurgery
 Electrosurgical intestinal injuries:
often apparent 4-10 days later
 Traumatic bowel perforations:
symptoms within 12-48h.
Complications of laparoscopic surgery
Electrosurgery
Soderstrom and Levy studied 12 cases of intestinal
perforation (caused by monopolar)
Detailed histology showed that 11/12 were
mechanical trauma and not electrical burns
Neddle/trocar perforation?
Operative technical errors?
Soderstrom RM Levy BS. Bowel injuries.... Cont
Obstet Gynecol 1986;27:41
Complications of laparoscopic surgery
Electrosurgery
 Early reports concerning complications of
electrosurgery were largely exaggerated
 There were errors of technique not
uncontrolled events
Zucker et al. Am J Surg 1991;161:36
Complications of laparoscopic surgery
Gastrointestinal injuries
 High risk:
Previous abdominal surgery
Previous abdominal radiotherapy
Obese patients
 Consider open laparoscopy/ alternative
entry site (Palmer)
 Incidence 1,0-2,7/1000
Chamberlain et al RCOG 1978
Yupze J Reprod Med 1990
Complications of laparoscopic surgery
Gastrointestinal injuries
 Stay open to complications
 Friend with the surgeons
 In this way avoiding complications to
complications
Complications of laparoscopic surgery
Gastrointestinal injuries
 Gastric perforation (oro/nasogastric
tubing)
 Small/large bowel.
Leave trocar in place
Laparoscopic bowel repair
Laparotomy
 Veress needle perforation: heals with
antibiotics
Urogenital Complications
Bladder

Peroperative: Gas in the Foley bag.!

Blue dye in bladder if suspected

Later perforation: uroplania
Bladderperforation
Urogenital Complications
Ureter



If suspected 5 ml Indigocarmin IV with 10
mg Furosemid
Diagnosis in 10 minutes
Cystoscopy can also be used
Ureterlesion
Uretertrauma during pelvic wall surgery
Ureterwindow
Complications of laparoscopic surgery
5. Closure
 Unrecognised bleeding (reduce
pressure)
 Unrecognised visceral injury
 Abdominal wall injuries



Infection
Wound dehiscence
herniation
Complications of laparoscopic surgery
Herniation into a trocar site
 Small bowel obstruction 3-7 days postop.
 Use small trocars whenever possible
 Evacuate all CO2 prior to removing sheat
 Remove under direct vision
 Closure of fascia if trocars >10-12 mm
Postoperative ileus because of bowel
incarceration
It is very dangerous to be right on a
subject on which the established
authorities are wrong.
Fin