Complications of Laparoscopy

1. Complications of
Laparoscopy

2. Always Consider
● Previous abdominal surgery
● Previous Laparatomy, rate of complication=2.7% (1)
● Difficulty or complexity of Laparoscopic procedure
● Low / High BMI
● Previous Adhesions ( PID, tumors, endometriosis …. )
● Experience, Respect of anatomy and safety techniques
1- (DeStefano, 1997)
Patient
Surgeon
2

3. Case Study
● Multicenter study, 7 centers in France, 9Y, 29,966 patients
● Mortality: 3.33/100 000
● Overall complication rate:4.64/100
● Risk is directly proportional to the complexity of the
procedure (p=0.00001)
● 1 out of 3 complications (34.1%) happened in the early stage
of surgery (trocar entry)
● 1 out of 4 complications (28.6%) not recognized at the time of
surgery
Chapron C et.al.2001
3

4. Risk of infra-umbilical adhesions
0
15
30
45
60
Category 1 Category 3
%
4
1-Patients without previous
surgery 0.68%
2-Patients with previous
laparoscopy 1,6%
3-Patients with previous P-
fannenstiel 19,8%
4-Patients with previous
longitudinal laparotomy
51,7%
Audebert, Fertil Steril 2000

5. Benefits of Surgeon’s experience
● Statistically significant decrease in bowel injuries (p=0.0003)
● Statistically significant decrease in serious complications that
require laparotomy during standard laparoscopic operations
(p=0.01)
● Statistically significant increase in laparoscopic treatment of
complications (p=0.0001)
5
Chapron C et.al.2001

6. •Laparoscopic surgery is not
inherently dangerous for patients
presenting with benign
gynecological pathologies.
•The potential risk of complications
should no longer be advanced as an
argument against using
laparoscopic surgery rather than
laparotomy 6

7. Know the Timeline for Complications
● Immediate postoperative / first 24 hours:
❖ Vessel/vascular injury
● 48-72 hours postoperative:
❖ Ureteral injury
● Days to weeks:
❖ Bowel injury
7

8. Equipment Positional
Insufflation
Electrical
Energy
8

9. 9
Wound hernia Genitourinary
Bowel
injury
Vascular
injury
Trocar
placement

10. Positional Complications
● Brachial plexus - arm extension > 90
● Perineal nerve - lateral pressure
● Femoral & Sciatic nerve -compression
● Shoulder brace
● Return electrode positioning
● Foley catheter
10

11. Equipment
11
● Always check the equipment before each surgery

12. Electrical
Injury
•Always keep the
tips of your
instruments in the
center of the
screen, while
applying energy!
12

13. Never use two different power sources in the abdomen in the
same time:
13

14. Insufflation Failures
● Obese patients
● Thin Patients
● Patients with abdominal scars
14

15. Alternative Insufflation Techniques
● Transumbilical
● Direct
● Open laparoscopy (Hasson technique)
● Transuterine insufflations
● Subcostal insufflations (Palmers point)
15

16. Vascular Injury
16
● Abdominal wall bleeding
❖ Inferior epigastric artery
● Intra peritoneal vessel injury
❖ Mesenteric, ovarian, uterine artery
● Retro peritoneal major vessel injury
❖ Iliac, vena cava, aorta

17. 17

18. Sites of Verres needle insertion
1-Umbilical
2-Left subcostal
3-Median supraumbelical
4-Median supra-pubic
5-Left iliac fossa
6-Transcervical 18

19. 19
Bifurcation of the Aorta,
Umbilicus and BMI

20. 20
Palpation of the Aortic
bifurcation

21. 21
Weight < 75 Kg
Angle of isertion = 45°
95 kg> Weight > 75 Kg
Angle of insertion = 45°- 90
Weight > 95 Kg
Angle of insertion = 90°

22. Safety Tests Or Checks
22
1) Double click sound
2) The aspiration test,
3) The hanging drop of
saline test,
4) The “hiss” sound test
5) The syringe test.
6) Needle waggling test - to
free an attached organ
from the tip & confirms
intraperitoneal placement-

23. What Is The Most Reliable
Safety Tests ?
23
The Veress intraperitoneal (VIP)
pressure ≤ 6 mm Hg is a
reliable indicator of correct
intraperitoneal placement of
the Veress needle.
Therefore, it is appropriate to
attach the CO2 source to the
Veress needle on entry.
2007(SOGC Practice Guideline.193, 2007 (LII-1 Grade A)

24. Complications Verres Needle &
Pneumoperitoneum
24
1. Extra-peritoneal gas
insufflation
2. Pneumo-omentum
3. Pneumothorax
4. Mediastinal emphysema
5. Gas embolism
6. Blood vessel injury
7. Injury to gastro-intestinal
tract
8. Bladder injury
9. Puncture of liver or spleen
10. CO2 comp.

25. 25

26. 26
Extra-peritoneal Gas
Insufflations'
● Recognition :Crepitus under the skin.
● Typical telescopic appearance
Management:
- No treatment
- Gas may be allowed to escape
- Re-introduce through the
same or another site.
Alternative :Open laparoscopy

27. 27
Blood Vessel Injury
● Small: Omental or mesenteric
● Major: Abdominal or pelvic A or V
Recognition:
- Blood returns up the open needle.
- Free blood in the
peritoneal cavity.
- Hematoma.

28. 28
Blood Vessel Injury
● Risky Groups:
• Adhesion
• Obese ,thin or children
Prevention:
- Inserting only as much of the needle
as necessary
- Lifting the abdominal wall,
- Angling the needle towards the
pelvis once thrust through the fascia
with an angle correlated with BMI.

29. 29
Incidence of major vascular lesions relate to Trocar entry :0,5%
Roviaro, Surg Endosc 2002
Wala, Ginekol Pol 2007
Major vascular lesions:
Verres: 21,0%
Trocar: 79,0%
Chapron, Gynecol Obstet Fertil 2008
Trocar
Veress

30. When there is a major vascular injury :
● Early recognition is the key to survival
● Immediate conversion to Laparotomy
● Direct compression on aorta
● IV fluids
● Do not open the peritoneum over a hematoma!
● Call a vascular surgeon !!!
30
Vascular Lesions

31. 31
Injury to Gastro-intestinal Tract
Predisposition:
• Upper abdominal site of insertion.
• Distension:(induction of anaesthesia: Nasogastric T).
• Adhesions of bowel to the
abdominal wall.
Recognition:
• Aspiration through the needle: GIT
fluid.
• Belching, passing of flatus or a
faecal odour

32. 32
Umblical Trocar Placement

33. 33
Primary Trocar Injuries
● Poor technique
• Use of long trocar
• Uncontrolled sudden entry
• Excessive force
• Premature Trendelnburg
• Improper Angle of Entry
• Entry through pseudo- pneumoperitoneum

34. 34

35. 35

36. 36
Lateral Trocars
Inferior epigastric
artery lesions
76,5% of all vascular
complications
0,3% of all complications
Leonard, Acta Obst Ginecol Scand 2000

37. 37
Inferior epigastric artery
1- Superficial artery (transillumination)
2- Deep artery (Direct visualization)

38. 38

39. 39
Bowel Injury
● Not from Veress needle
● Injury may not be apparent for 4-5 days
● Any symptoms of peritonitis (sharp abdominal pain,
vomiting) must be considered as bowel injury unless proven
otherwise
● Use bowel prep

40. Small bowel injury:
● Bands
● Leukocytes
● C - Reactive Protein > 100 MG/L
● Minor operative laparoscopy associated with 0.08% risk of bowel
injury
● Major operative laparoscopy associated with 0.33%
● Injuries decrease significantly with experience
● Delayed diagnosis remains major problem; up to 15% of injuries
not diagnosed during laparoscopy.
● one in five cases of delayed diagnosis results in death
J Am Assoc Gynecol Laparosc,2003;10:9-13
40

41. 41

42. Genitourinary complications
● Bladder…………...Indigo carmine
● If <1cm consider Foley catheter for 7-10 days
● If >1cm laparoscopic 2 layer closure + Foley catheter
● Cystoscope
● Ureter…………….Trace from pelvic brim
● Small non electrical injury - primary repair over stent
42

43. 43

44. Direct trocar introduction
44

45. Optic trocar systems
45

46. Open Laparoscopy
• Patients with previous history of abdominal surgery (longitudinal or
more than one transverse)
• Patients with previous history of peritonitis
• Oncologic patients with possible peritoneal involvement
• Patients with voluminous pelvi-abdominal mass
• Pregnant patients
• Paediatric patients
Obese patients ? 46

47. 47
Open Laparoscopy
Why not in all patients ?!
• Longer operative time
• Bigger scar
• Higher risk of sub-cutaneous
emphysema
• Cost
Hurd, J Reprod Med 1994
• Longer learning curve
Zaraca, J Laparoendosc Adv Surg Tech 1999

48. 48
Gasless Laparoscopy

49. Robotic assisted Laparoscopy
49

50. What is the best technique?
50
No single technique is significantly better in
reduction of the incidence of serious complications
Direct trocar introduction reduces the risk of
extraperitoneal insufflation of CO2, and decreases
the risk of failure and laparotomic conversion.

51. 51
● Always check the equipment before each surgery

52. 52

53. 53

54. 54
● Patient Selection and proper Counseling

55. 55
Take home messages
•Laparoscopic surgery is not inherently dangerous. However, an
easy laparoscopic intervention does not exist
•Surgeon’s experience is one of the most important factors
related to occurrence of serious complications
•Having a complication during surgery is a problem, BUT,
undiscovered problems are disasters.

56. 56

57. Thank You..
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