Lap anatomy and complications2012

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  • 1. LAPAROSCOPIC  SURGERY   COMPLICATIONS   Jim  Bentley  
  • 2. Laparoscopic  Complications   §  Often  considered  as  minimally  invasive   surgery  but  risk  is  not.   §  Has  specific  risks  and  complications   §  Most  complications  occur  during  the  setup   phase  (60-­‐75%)   §  Complications  8.9%  laparoscopy  vs.  15.2%   laparotomy  (metaanalysis)  
  • 3. Complications   §  Generally  safe  but  does  have  mortality   (0.03%-­‐0.49%)   §  In  gynecology  LAVH  most  commonly   associated  with  complications   §  Adnexal  surgery  next   §  Generally  more  complex  surgery/  earlier  on  a   learning  curve  will  lead  to  more  complications  
  • 4. Complications     §  Injury  to  adjacent  organs   §  Bleeding  from  solid  organs  (liver  and  spleen)   §  Vascular  injuries   §  Puncture/perforation/cauterization  of  the   bowel   §  Transection/perforation  of  bile  ducts   §  Perforation  of  the  bladder   §  Puncture/perforation  of  the  uterus   §  Complications  of  abdominal  access   §  Port  site  hernia   §  Wound  infection   §  Also  see  Injury  to  adjacent  organs   §  Complications  of  specimen  removal   §  Port  site  recurrence  of  cancer   §  Splenosis   §  Endometriosis   §  Complications  of  the  pneumoperitoneum   §  Pneumothorax   §  Pneumomediastinum   §  Gas  embolus   §  Subcutaneous  emphysema  
  • 5. Patient  risk  factors   §  Previous  abdominal  or  pelvic  surgery   §  Previous  intra-­‐abdominal  or  pelvic  disease   process(infection,  neoplasia,  inflammation)   §  Obesity   §  Thinness   §  Anticoagulation  
  • 6. Set-­‐Up  Phase   §  Positioning   §  Catheter   §  NG  tube   §  Access  
  • 7. SOGC  Laparoscopy  Guideline  
  • 8. SOGC  Guideline   §  LUQ  entry  considered  with  adhesions/  surgery   §  Veress  needle  tests  don’t  work;  do  not  waggle   §  Attach  the  CO2  as  pressure  <  10  mm  Hg  is  indicative  of  being  in   cavity   §  Elevation  is  not  helpful   §  Vary  angle  according  to  BMI   §  Use  pressure  and  not  volume  to  determine  adequacy  of   insufflation;  high  pressures  do  not  effect  healthy  women   §  May  use  Hassan  technique  but  not  done  by  Gyn;  Open=veress   §  Direct  insertion  OK   §  Shielded  trocars  OK   §  Radially  expanding  trocars  not  recommended   §  Visual  entry  OK  but  not  superior  
  • 9. Positioning   §  Patient  safety   §  Comfort  for  surgeon   and  assistants   §  Provide  access  for   surgery   §  Use  moveable  stirrups   §  Arms  at  side  (wrapped)   §  Bed  that  can  be   lowered  (45  cm  of   floor)  
  • 10. Peripheral  nerve  injury   ú  Poor  patient  position   ú  Pressure  from  surgeon/  assistants   ú  Rarely  from  disection  (  exception  is  obturator  and   genitofemoral  nerve)   §  Perineal  nerve  injury   ú  Nerve  compression  against  stirrups     ú  Loss  in  sensation  lat  aspect  of  foot  and  leg  with  a   foot  drop   ú  Take  care  with  appropriate  stirrups  and  position  
  • 11. Peripheral  nerve  injury   §  Brachial  Plexus  injury   ú  Arms  abducted  >  90o   ú  Deep  trendelenburg  position   ú  Surgeon  leaning  against  arms   ú  Diagnosed:       damage  to  C5-­‐C6  roots  with  loss  of  flexion  of  elbow   and  aduction  of  shoulder   ú  Prevention:      Place  arms  at  side      Tuck  arms  with  padding      Large  patients  use  arm  boards  
  • 12. Positioning   §  Supine  for  trocar   insertion   §  Position  of  umbilicus   vs.  aorta  
  • 13. Trocar  Insertion:   anatomy  
  • 14. Anatomy:Video  
  • 15. Trocar  Insertion:   anatomy  
  • 16. Method  of  Access   §  Classical  veress  needle   §  Direct  trocar   §  Open  
  • 17. Port  site  bleeding  
  • 18. Trocar  Site  Hernias   §  Hernias  are  well  reported   §  Ports  greater  than  10  mm   ú  21  per  100000  cases   ú  17.9%  despite  fascial  closure   ú  86.3%  with  trocars  greater  than  10  mm   ú  Close  port  sites  
  • 19. Trocar  Injury  
  • 20. Vascular  Injuries   §  Trauma  to  a  large  vessel   §  Risk  of  major  vessel  injury  1/1000   §  Large  vessels  need  a  laparotomy  and   appropriate  consultation   §  Smaller  vessels  can  be  controlled  with  bipolar   cautery,  clips,  pressure  
  • 21. Hernia  Prevention  “J”  needle  
  • 22. “J”needle  (2)  
  • 23. “J”  needle  (3)  
  • 24. Port  site  closure  
  • 25. Gastro-­‐Intestinal  Injury   §  risk1.8/1000   §  Mechanical  or  thermal   §  Mechanical  commonest  during  set  up  with   the  veress  needle  or  trocar  
  • 26. Risk  factors  for  GI  injury   ú  Previous  laparotomy  (midline>pfannensteil)   ú  Previous  generalized  peritonitis(  inc.  ruptured   appendix)   ú  Previous  bowel  obstruction  or  resection   ú  Previous  intraabdominal  cancer,  rads,  chemo   ú  Inflammatory  bowel  disease   ú  PID   ú  Endometriosis  
  • 27. GI  Injury   §  If  at  risk  need  bowel  prep    (fleet  enema)   §  NG  to  decompress  the  stomach   §  Veress  needle  aspiration   ú  If  in  can  remove  and  reinsert  checking  site   §  Trocar  Injuries   ú  If  in  put  a  foley  down  the  sheath  and  then  laparotomy   with  appropriate  consultation   ú  Can  repair  small  lesions  in  small  and  large  bowel  
  • 28. GI  thermal  Injury   §  Three  main  causes   ú  Defective  insulation   ú  Lateral  thermal  spread  with  a  source  too  close  to  the   bowel   ú  Contact  with  the  bowel  during  activation   §  Suspect  with  persistently  blanched  bowel   ú  Need  to  resect  with  5  cm  margin      Classical  recommendation,  not  always  necessary.  
  • 29. Thermal  injury   §  Direct  coupling  
  • 30. Insulation  failure  
  • 31. Capacitive  coupling   §  Risk  factors:   ú  Longer   instruments   ú  Thinner   insulation   ú  Higher  voltage   (coag)   ú  Narrow  trocars   ú  Open  circuits  
  • 32. Cautery  
  • 33. Other  electrosurgical   complications   §  Alternate  site  burns  at  the   dispersive  site   ú  Partial  detachment   ú  Manufacturing/quality  defect   ú  Placement  over  moist  skin,   bony  prominence   §  Caution  with  pacemakers   ú  Monopolar  currents  may   override/  reset  pacemakers  
  • 34. GI  Injury   §  Biggest  problem  is  delay  in  diagnosis   §  34-­‐62%  of  injuries  noted  at  time  of  surgery   §  Average  time  to  small  bowel  perf  3.3  days   §  Average  time  with  large  bowel  perf  2-­‐10  days  
  • 35. GI  Injury   §  Usually  Present  <  48  hrs  with  peritonitis   §  CO2  Gas  reabsorbed  within  48  hrs   §  Explore  early  as  delay  may  be  catastrophic    
  • 36. Urinary  Tract  Injuries   §  Bladder  and  ureters  susceptible   §  0.2/1000  
  • 37. Risk  Factors:  Urinary  Tract   Injuries      Endo      PID  acute  or  chronic      Pelvic  malignancy      Previous  pelvic  surgery      Previous  pelvic  radiation      Bladder  wall  diverticula      Adhesions      Distended  bladder  wall      Surgery  during  pp  or  lactation      age  
  • 38. Urinary  Tract  Injury   §  Use  foley  or  empty  bladder   §  Risk  at  LAVH  with  bladder  dissection   §  Ureteric  injury  with  adnexal  surgery   ú  Identify  and  retract  
  • 39. Identify  Ureter  
  • 40. Urinary  Tract  Injury   §  Bladder/  small  ureteric  injuries  can  be   repaired  primarily  with  stents     §  Thermal  injury  requires  resection  
  • 41. Urinary  Tract  Injury   §  Bladder  injury  noted  at  1.1  days   §  Ureteric  injury  at  29.4  days     ú  Be  aware  of  low  urine  output   ú  Ascites  /  peritonitis   ú  Investigate  with  IVP  cysto  and  retrograde  
  • 42. Other  Complications   §  Anaesthetic   ú  Increased  CO2   ú  Problems  with  ventilation  pressures   ú  Arrhythmias   ú  Pain   §  Subcutaneous  emphysema/   pneumomediastinum   §  Wound  infection  
  • 43. Specimen  Retrieval   §  Failure  to  use  appropriate  bags/  devices   §  Mechanical  difficulty   §  Spillage  of  irritant  material,  e.g.  Ovarian   Dermoid   §  Infectious  material  leak    
  • 44. Port  site  mets   §  Well  recognised   ú  Increased  with  CO2  pneumoperitoneum   ú  Increased  intra  abdominal  pressures   ú  Excessive  manipulation   ú  Failure  to  use  bags   §  May  occur  in  similar  rates  to  open  cases?  
  • 45. TABLE 18-4 -- Colon Cancer Recurrences: Laparoscopy Versus Open Authors Year No. of Patients No. of Port Site Metastases Percentage of Port Site Metastases Guillou et al 1993 59 1 1.7 Franklin et al 1996 191 0 0 Gellman et al 1996 58 1 1.7 Kwok et al1996 83 1 1.2 Vukasin et al 1996 451 5 1.1 Fleshman et al 1996 372 4 1.1 Lacy et al 1997 106 0 0 Fielding et al 1997 149 2 1.3 Larach et al 1997 108 0 0 Croce et al 1997 134 1 0.9 Khalili et al 1998 80 0 0 Bouvet et al 1998 91 0 0 Kawamura et al 1999 67 (gasless) 0 0 Leung et al1999 217 1 0.65 Poulin et al 1999 172 0 0 Schiedeck et al 2000 399 1 0.25 Total 1737 17 1 From Zmora O, Gervaz P, Wexner SD: Trocar site recurrence in laparoscopic surgery for colorectal cancer. Surg Endosc 15:790, 2001.
  • 46. Bleeding  Uterine  Artery  #1  
  • 47. Bleeding  Uterine  artery  #2  
  • 48. Conclusion   §  Laparoscopic  surgery  does  have  considerable   advantages   §  Need  to  be  aware  of  all  potential   complications    and  have  methods  available  to   fix!