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How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
How to Deal with Access Injury: Digestive and Vascular
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How to Deal with Access Injury: Digestive and Vascular

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  • 1. How to deal with ACCESS INJURY: digestive and vascular George S. Ferzli MD, FACS Professor of Surgery SUNY HSC, Brooklyn, NY
  • 2. PREVENTION is the best way to deal with access injury. Laparoscopic access varies on an individual patient basis.
  • 3. Entry into abdomen Patient considerations: <ul><li>Thin skin? </li></ul><ul><li>Child? </li></ul><ul><li>Pregnant, </li></ul><ul><li>or pelvic mass? </li></ul><ul><li>Ventral hernia, </li></ul><ul><li>or bowel </li></ul><ul><li>distension? </li></ul><ul><li>Previous </li></ul><ul><li>surgery or </li></ul><ul><li>PID ? </li></ul><ul><li>Obese? </li></ul>
  • 4. Abdominal wall <ul><li>Epigastric vessels </li></ul><ul><li>Nerves </li></ul><ul><li>Bladder </li></ul>
  • 5. Epigastric vessels - Injury <ul><li>Injury to abdominal wall blood vessels </li></ul><ul><li>Incidence of 0.2–2.0% </li></ul><ul><li>May see blood externally around port site or drip internally at peritoneal entry site </li></ul><ul><li>Injury may be unrecognized secondary to tamponade by trocar / pneumo-peritoneum </li></ul><ul><li>Transillumination may not identify deep epigastic vessels, especially in obese patients </li></ul>
  • 6. Epigastric vessels – Prevention <ul><ul><li>Place trocars in midline or lateral to rectus muscles </li></ul></ul><ul><ul><li>At completion of case, examine port sites after trocar removal to assess for unrecognized bleeding </li></ul></ul>Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182
  • 7. Epigastric vessels- Management <ul><li>Cautery / ligation from within the peritoneal cavity </li></ul><ul><li>Cautery / suture-ligation via cutdown over the trocar site </li></ul><ul><li>Suture-ligation through the abdominal wall with Keith needle / endoscopic suture passer </li></ul>
  • 8. Anatomic distribution of nerves across anterior abdominal wall <ul><li>Ilioinguinal nerve </li></ul>Iliohypogastric nerve (adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)
  • 9. Incision line/trocar sites vs. nerve distribution Iliohypogastric n. Ilioinguinal n. Epigastric a. Trocar site Pfannenstiel incision (adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)
  • 10. Bladder injury- <ul><li>Incidence of laparoscopic bladder injury 0.02%-8.3%* </li></ul><ul><li>The bladder can be injured upon entry into abdomen or during laparoscopic procedure </li></ul><ul><li>Bladder injury may go un-recognized until end of surgery </li></ul><ul><li>Signs of possibly bladder injury </li></ul><ul><ul><li>- Urine leak from port site </li></ul></ul><ul><ul><li>(extra- or intra-abdominally) </li></ul></ul><ul><ul><li>Blood or gas in foley bag </li></ul></ul><ul><li>Risk factors for injury </li></ul><ul><ul><li>Adhesions, endometriosis, prior radiation, bladder diverticulum </li></ul></ul>Nehzat C et al. Laparoscopic management of intentional and unintentional cystostomy. Jnl Urol 1996; 156:1400 Armenakas N et al. Iatrogenic bladder perforations. JACS 2004; 198:78
  • 11. Bladder injury- Management <ul><li>Mobilize the bladder around injury </li></ul><ul><ul><li>- Expose / inspect bladder wall, </li></ul></ul><ul><ul><li>ureteral orifices, bladder neck </li></ul></ul><ul><ul><li>- Allows for tension-free repair </li></ul></ul><ul><li>One or two layer repair using </li></ul><ul><li>absorbable sutures </li></ul><ul><ul><li>- Avoid staples or non-absorbable sutures </li></ul></ul><ul><ul><li>- Nidus for calculi, granulomas, recurrent UTI, etc </li></ul></ul><ul><li>Foley catheter drainage post-op for 7-10 days </li></ul>
  • 12. Tools: Laparoscopic entry systems <ul><li>BLIND NON-VISUAL ENTRY </li></ul><ul><ul><li>Insufflated entry </li></ul></ul><ul><ul><li>Closed conventional trocar </li></ul></ul><ul><ul><li>High pressure trocar entry </li></ul></ul><ul><ul><li>Radially expanding trocar entry </li></ul></ul><ul><ul><li>Non-Insufflated </li></ul></ul><ul><ul><li>Direct sharp trocar entry </li></ul></ul><ul><ul><li>Open Hasson’s trocar entry </li></ul></ul><ul><ul><li>Gassless laparoscopy </li></ul></ul>Hassan Veress Ternamian, Artin, MD, FRCSC. Laparoscopic Entry Safety.
  • 13. Tools: Laparoscopic entry systems <ul><li>VISUAL ENTRY </li></ul><ul><li>Optical trocar </li></ul><ul><li>Endopath Optiview </li></ul><ul><li>VISIPORT </li></ul><ul><li>Visual cannula </li></ul><ul><li>ENDOTIP Endoscopic Threaded Imaging Port </li></ul><ul><li>Optical Veress mini-laparoscope </li></ul>Optiview Ternamian, Artin, MD, FRCSC. Laparoscopic Entry Safety.
  • 14. Veress needle <ul><li>Trendelenburg </li></ul><ul><li>Elevation </li></ul><ul><li>Direction of needle </li></ul><ul><li>Manometry test </li></ul><ul><li>Hissing sound test </li></ul><ul><li>Palmer test </li></ul><ul><li>Aspiration test: bowel contents or urine (remove Veress) blood (leave in place) </li></ul><ul><li>In out 5cc </li></ul><ul><li>Drop test – flow 1 liter per minute </li></ul>
  • 15. Veress needle <ul><li>Palmer’s entry point (LUQ) </li></ul><ul><li>3cm below costal margin, midclavicular </li></ul><ul><li>Do not waggle the Veress </li></ul><ul><li>1.6mm - 1cm ( II - 1A* ) </li></ul><ul><li>45° angle in non-obese </li></ul><ul><li>(umbilicus below aortic bifurcation) </li></ul><ul><li>90° angle in obese ( II - 2B* ) </li></ul><ul><li>(umbilicus above aortic bifurcation) </li></ul><ul><li>Use short Veress to allow for better </li></ul><ul><li>control and tactile sensation </li></ul>Palmer’s entry point Bifurcation variability. 45° 90° * Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47
  • 16. Open laparoscopy Hasson <ul><li>Vascular injury less than bowel injury </li></ul><ul><li>Viscera unusually cling to the point of trocar insertion </li></ul><ul><li>0.061 bowel injury </li></ul><ul><li>Partial or through and through </li></ul><ul><li>Usually noticed immediately </li></ul>Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47
  • 17. Guidelines <ul><li>Veress intraperitoneal pressure (VIP) is a reliable indicator (II-1A*) </li></ul><ul><li>Elevation of abdominal wall not routinely recommended (II-2B*) </li></ul><ul><li>No evidence that open entry technique is superior or inferior to other entry techniques (II-2C*) </li></ul><ul><li>Radially expanding trocars are not recommended as being superior to traditional trocars (1A*) </li></ul><ul><li>Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury (2B*) </li></ul><ul><li>Left upper quadrant (LUQ-Palmer’s) laparoscopic entry should be considered in patients with umbilical hernia or periumbilical adhesions (II-2A*) </li></ul><ul><li>There is no evidence that the use of shielded trocars results in fewer visceral and vascular injuries (2B*) </li></ul>*Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47
  • 18. Vascular injury <ul><li>Incidence 0.01%-0.05%; Mortality 8-17% </li></ul><ul><li>Incidence closed > open technique </li></ul><ul><li>Warning signs: </li></ul><ul><ul><li>- Blood from Veress needle </li></ul></ul><ul><ul><li>- Sudden hypotension </li></ul></ul><ul><ul><li>- Hemoperitoneum open camera entry </li></ul></ul><ul><ul><li>- Retroperitoneal hematoma </li></ul></ul><ul><li>Once recognized, majority of major vascular injuries require conversion </li></ul>Harkki-Sirren P et al. Major Complications of laparoscopy: Follow-up Finnish study. Obst Gyned 1999; 94:95 Deziel DJ et cl. Complications of laproscopic cholecystectomy. Am J Surg 1993; 165:9 Saville L et al. Laparoscopy and major retroperitoneal vascular injuries. Surg Endosc 1995; 9:1096 Chapron et al. Major vascular injuries during gynecologic laparoscopy. JACS 1997
  • 19. Vascular injury- Management <ul><li>Early diagnosis is critical to </li></ul><ul><li>minimize morbidity/mortality </li></ul><ul><li>For most major vessel injuries, </li></ul><ul><li>the rule is to convert to laparotomy </li></ul><ul><li>Minor injuries (e.g. omental bleeding) may be managed laparoscopically </li></ul><ul><li>Appropriate vascular principles apply to any repair </li></ul>
  • 20. Bowel injury <ul><li>Incidence of 0.1%-0.7%* </li></ul><ul><li>Caused by Veress or trocar </li></ul><ul><li>puncture </li></ul><ul><li>Penetrating injuries usually </li></ul><ul><li>recognized intra-operatively </li></ul><ul><li>Timely diagnosis / treatment requires </li></ul><ul><li>high index of suspicion and minimizes </li></ul><ul><li>morbidity / mortality </li></ul>Schrenk P et al. Mechanism, management and prevention of laparoscopic bowel injuries. Gastroin Endosc 1996; 43:572 Bishoff J et al. Laparoscopic bowel injury: Incidence and clinical presentation. J Urol 1999; 161:887
  • 21. Management of injuries detected at initial access <ul><ul><li>TIPS: </li></ul></ul><ul><ul><li>Puncture injuries & serosal tears may be repaired with simple intra-corporeal suturing avoiding need for conversion </li></ul></ul><ul><ul><li>Extensive injuries to colon or those requiring resection / reanastamosis may require laparoscopic diverting ostomy </li></ul></ul><ul><ul><li>Endoloop bowel injury easy to find and reduces contamination </li></ul></ul>Veress injury Fecal odor / aspiration test Find another entry and excise site of injury Sharp trocar injuries Serosa (superficial) No further treatment Deep (through and through) Close transversely (if <1/2 direction of bowel Small bowel Brownish fluid Careful inspection Segmental resection if >1/2 mesenteric supply interrupted
  • 22. Second trocar insertion <ul><li>Use two hands </li></ul><ul><li>Under direct vision ALWAYS </li></ul><ul><li>Generous skin incision </li></ul><ul><li>Use corkscrew motion rather than pushing </li></ul><ul><li>Clear adhesions </li></ul><ul><li>Remember it is much harder to defend 2nd trocar injury. </li></ul>
  • 23. After second trocar insertion <ul><li>TIP: </li></ul><ul><li>If there are doubts about a bleeding injury at the first incision site, switch the camera to the second site and inspect the first site visually. </li></ul><ul><li>Hemodynamic instability – open immediately </li></ul>
  • 24. Conclusion Cautious Careful Preventive

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