LAPAROSCOPIC	
  SURGERY	
  
COMPLICATIONS	
  
Jim	
  Bentley	
  
Laparoscopic	
  Complications	
  
§  Often	
  considered	
  as	
  minimally	
  invasive	
  
surgery	
  but	
  risk	
  is	...
Complications	
  
§  Generally	
  safe	
  but	
  does	
  have	
  mortality	
  
(0.03%-­‐0.49%)	
  
§  In	
  gynecology	
...
Complications	
  	
  
§  Injury	
  to	
  adjacent	
  organs	
  
§  Bleeding	
  from	
  solid	
  organs	
  (liver	
  and	...
Patient	
  risk	
  factors	
  
§  Previous	
  abdominal	
  or	
  pelvic	
  surgery	
  
§  Previous	
  intra-­‐abdominal	...
Set-­‐Up	
  Phase	
  
§  Positioning	
  
§  Catheter	
  
§  NG	
  tube	
  
§  Access	
  
SOGC	
  Laparoscopy	
  Guideline	
  
SOGC	
  Guideline	
  
§  LUQ	
  entry	
  considered	
  with	
  adhesions/	
  surgery	
  
§  Veress	
  needle	
  tests	
 ...
Positioning	
  
§  Patient	
  safety	
  
§  Comfort	
  for	
  surgeon	
  
and	
  assistants	
  
§  Provide	
  access	
 ...
Peripheral	
  nerve	
  injury	
  
ú  Poor	
  patient	
  position	
  
ú  Pressure	
  from	
  surgeon/	
  assistants	
  
ú...
Peripheral	
  nerve	
  injury	
  
§  Brachial	
  Plexus	
  injury	
  
ú  Arms	
  abducted	
  >	
  90o	
  
ú  Deep	
  tr...
Positioning	
  
§  Supine	
  for	
  trocar	
  
insertion	
  
§  Position	
  of	
  umbilicus	
  
vs.	
  aorta	
  
Trocar	
  Insertion:	
  
anatomy	
  
Anatomy:Video	
  
Trocar	
  Insertion:	
  
anatomy	
  
Method	
  of	
  Access	
  
§  Classical	
  veress	
  needle	
  
§  Direct	
  trocar	
  
§  Open	
  
Port	
  site	
  bleeding	
  
Trocar	
  Site	
  Hernias	
  
§  Hernias	
  are	
  well	
  reported	
  
§  Ports	
  greater	
  than	
  10	
  mm	
  
ú  ...
Trocar	
  Injury	
  
Vascular	
  Injuries	
  
§  Trauma	
  to	
  a	
  large	
  vessel	
  
§  Risk	
  of	
  major	
  vessel	
  injury	
  1/100...
Hernia	
  Prevention	
  “J”	
  needle	
  
“J”needle	
  (2)	
  
“J”	
  needle	
  (3)	
  
Port	
  site	
  closure	
  
Gastro-­‐Intestinal	
  Injury	
  
§  risk1.8/1000	
  
§  Mechanical	
  or	
  thermal	
  
§  Mechanical	
  commonest	
  ...
Risk	
  factors	
  for	
  GI	
  injury	
  
ú  Previous	
  laparotomy	
  (midline>pfannensteil)	
  
ú  Previous	
  genera...
GI	
  Injury	
  
§  If	
  at	
  risk	
  need	
  bowel	
  prep	
  	
  (fleet	
  enema)	
  
§  NG	
  to	
  decompress	
  th...
GI	
  thermal	
  Injury	
  
§  Three	
  main	
  causes	
  
ú  Defective	
  insulation	
  
ú  Lateral	
  thermal	
  spre...
Thermal	
  injury	
  
§  Direct	
  coupling	
  
Insulation	
  failure	
  
Capacitive	
  coupling	
  
§  Risk	
  factors:	
  
ú  Longer	
  
instruments	
  
ú  Thinner	
  
insulation	
  
ú  High...
Cautery	
  
Other	
  electrosurgical	
  
complications	
  
§  Alternate	
  site	
  burns	
  at	
  the	
  
dispersive	
  site	
  
ú  ...
GI	
  Injury	
  
§  Biggest	
  problem	
  is	
  delay	
  in	
  diagnosis	
  
§  34-­‐62%	
  of	
  injuries	
  noted	
  a...
GI	
  Injury	
  
§  Usually	
  Present	
  <	
  48	
  hrs	
  with	
  peritonitis	
  
§  CO2	
  Gas	
  reabsorbed	
  withi...
Urinary	
  Tract	
  Injuries	
  
§  Bladder	
  and	
  ureters	
  susceptible	
  
§  0.2/1000	
  
Risk	
  Factors:	
  Urinary	
  Tract	
  
Injuries	
  
   Endo	
  
   PID	
  acute	
  or	
  chronic	
  
   Pelvic	
  mal...
Urinary	
  Tract	
  Injury	
  
§  Use	
  foley	
  or	
  empty	
  bladder	
  
§  Risk	
  at	
  LAVH	
  with	
  bladder	
 ...
Identify	
  Ureter	
  
Urinary	
  Tract	
  Injury	
  
§  Bladder/	
  small	
  ureteric	
  injuries	
  can	
  be	
  
repaired	
  primarily	
  wit...
Urinary	
  Tract	
  Injury	
  
§  Bladder	
  injury	
  noted	
  at	
  1.1	
  days	
  
§  Ureteric	
  injury	
  at	
  29....
Other	
  Complications	
  
§  Anaesthetic	
  
ú  Increased	
  CO2	
  
ú  Problems	
  with	
  ventilation	
  pressures	
...
Specimen	
  Retrieval	
  
§  Failure	
  to	
  use	
  appropriate	
  bags/	
  devices	
  
§  Mechanical	
  difficulty	
  
§...
Port	
  site	
  mets	
  
§  Well	
  recognised	
  
ú  Increased	
  with	
  CO2	
  pneumoperitoneum	
  
ú  Increased	
  ...
TABLE 18-4 -- Colon Cancer Recurrences: Laparoscopy Versus Open
Authors Year No. of Patients No. of Port Site Metastases P...
Bleeding	
  Uterine	
  Artery	
  #1	
  
Bleeding	
  Uterine	
  artery	
  #2	
  
Conclusion	
  
§  Laparoscopic	
  surgery	
  does	
  have	
  considerable	
  
advantages	
  
§  Need	
  to	
  be	
  awar...
Upcoming SlideShare
Loading in...5
×

Lap anatomy and complications2012

455

Published on

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
455
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Lap anatomy and complications2012

  1. 1. LAPAROSCOPIC  SURGERY   COMPLICATIONS   Jim  Bentley  
  2. 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. 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. 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. 5. Patient  risk  factors   §  Previous  abdominal  or  pelvic  surgery   §  Previous  intra-­‐abdominal  or  pelvic  disease   process(infection,  neoplasia,  inflammation)   §  Obesity   §  Thinness   §  Anticoagulation  
  6. 6. Set-­‐Up  Phase   §  Positioning   §  Catheter   §  NG  tube   §  Access  
  7. 7. SOGC  Laparoscopy  Guideline  
  8. 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. 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. 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. 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. 12. Positioning   §  Supine  for  trocar   insertion   §  Position  of  umbilicus   vs.  aorta  
  13. 13. Trocar  Insertion:   anatomy  
  14. 14. Anatomy:Video  
  15. 15. Trocar  Insertion:   anatomy  
  16. 16. Method  of  Access   §  Classical  veress  needle   §  Direct  trocar   §  Open  
  17. 17. Port  site  bleeding  
  18. 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. 19. Trocar  Injury  
  20. 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. 21. Hernia  Prevention  “J”  needle  
  22. 22. “J”needle  (2)  
  23. 23. “J”  needle  (3)  
  24. 24. Port  site  closure  
  25. 25. Gastro-­‐Intestinal  Injury   §  risk1.8/1000   §  Mechanical  or  thermal   §  Mechanical  commonest  during  set  up  with   the  veress  needle  or  trocar  
  26. 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. 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. 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. 29. Thermal  injury   §  Direct  coupling  
  30. 30. Insulation  failure  
  31. 31. Capacitive  coupling   §  Risk  factors:   ú  Longer   instruments   ú  Thinner   insulation   ú  Higher  voltage   (coag)   ú  Narrow  trocars   ú  Open  circuits  
  32. 32. Cautery  
  33. 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. 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. 35. GI  Injury   §  Usually  Present  <  48  hrs  with  peritonitis   §  CO2  Gas  reabsorbed  within  48  hrs   §  Explore  early  as  delay  may  be  catastrophic    
  36. 36. Urinary  Tract  Injuries   §  Bladder  and  ureters  susceptible   §  0.2/1000  
  37. 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. 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. 39. Identify  Ureter  
  40. 40. Urinary  Tract  Injury   §  Bladder/  small  ureteric  injuries  can  be   repaired  primarily  with  stents     §  Thermal  injury  requires  resection  
  41. 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. 42. Other  Complications   §  Anaesthetic   ú  Increased  CO2   ú  Problems  with  ventilation  pressures   ú  Arrhythmias   ú  Pain   §  Subcutaneous  emphysema/   pneumomediastinum   §  Wound  infection  
  43. 43. Specimen  Retrieval   §  Failure  to  use  appropriate  bags/  devices   §  Mechanical  difficulty   §  Spillage  of  irritant  material,  e.g.  Ovarian   Dermoid   §  Infectious  material  leak    
  44. 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. 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. 46. Bleeding  Uterine  Artery  #1  
  47. 47. Bleeding  Uterine  artery  #2  
  48. 48. Conclusion   §  Laparoscopic  surgery  does  have  considerable   advantages   §  Need  to  be  aware  of  all  potential   complications    and  have  methods  available  to   fix!  

×