MIS  Complications: Managing the  Emergency Consultation MIS  Complications: Managing the  Emergency Consultation MIS  Com...
Is there a laparoscopic surgeon in the house? A 12 year old boy has inserted an eyebrow pencil into his penis.  CT scan sh...
When is there an urgent need  for a laparoscopic surgeon? <ul><li>Before an operation begins </li></ul><ul><li>Upon entry ...
I. Before an operation begins: <ul><ul><li>Assistance with port- </li></ul></ul><ul><ul><li>placement decisions </li></ul>...
I. Before an operation begins: <ul><ul><ul><li>Difficulty in entry with  Veress / Hassan </li></ul></ul></ul>
I. Before an operation begins: <ul><ul><li>Assistance with access  </li></ul></ul><ul><ul><li>in an obese patient </li></u...
I. Before an operation begins: <ul><li>Assistance with  </li></ul><ul><li>access into a  </li></ul><ul><li>re-operative ab...
II. Upon entry into the abdomen- Untoward events <ul><li>Injury to abdominal wall blood vessels </li></ul><ul><li>Incidenc...
Injury to abdominal wall blood vessels- Prevention <ul><ul><li>Place trocars in midline or lateral to rectus muscles </li>...
Injury to abdominal wall  blood vessels- Management <ul><li>Cautery / ligation from within the peritoneal cavity </li></ul...
<ul><li>Entry into the abdomen - Vascular injury </li></ul><ul><li>Incidence 0.01%-0.05%;  Mortality 8-17% </li></ul><ul><...
Vascular injury- Management <ul><li>Early diagnosis is critical to  </li></ul><ul><li>minimize morbidity/mortality </li></...
<ul><li>Difficulty visualizing intra-peritoneal space </li></ul><ul><li>Assistance with adhesiolysis </li></ul><ul><ul><li...
<ul><li>Intra-peritoneal space - Management </li></ul><ul><ul><li>Enhanced view with 30 º scope, use multiple  </li></ul><...
<ul><li>Injury to an intra-abdominal structure Bowel injury </li></ul><ul><li>Incidence of 0.1%-0.7%* </li></ul><ul><li>Ca...
Bowel injury- Management <ul><li>Repair of injuries detected at initial surgery: </li></ul><ul><ul><li>Puncture injuries &...
<ul><li>Injury to an intra-abdominal structure Bladder injury   </li></ul><ul><li>The bladder can be injured upon entry in...
Bladder injury <ul><li>Incidence of laparoscopic bladder injury 0.02%-8.3%* </li></ul><ul><li>Procedures most commonly ass...
Bladder injury- Management <ul><li>Mobilize the bladder around injury  </li></ul><ul><ul><li>- Expose / inspect bladder wa...
<ul><li>Upon discovery of an injury to an intra-abdominal structure Ureteral injury </li></ul><ul><li>Incidence -  0.1-1.4...
Ureteral injury- Prevention <ul><li>Pre-op ureteral stenting </li></ul><ul><ul><li>- Does not reduce rate of injury but  <...
Ureteral injury- Diagnosis <ul><li>Direct inspection of site of possible injury </li></ul><ul><li>Extravasation of urine <...
Ureteral injury- Management <ul><li>In collaboration with  </li></ul><ul><li>urologist </li></ul><ul><li>Cystoscopy and st...
<ul><li>Use of diagnostic laparoscopy  in critical care setting </li></ul><ul><li>Increasing use of laparoscopy in ICU set...
Consultation  with an advanced laparoscopist  plays a critical role when… <ul><li>His/her participation resulted in reduce...
So what happened  to the eyebrow pencil? … a laparoscopic surgeon saved the day! 1 2 3 4
Thank You!
Liability and the  laparoscopic consultation <ul><li>Consulting colleagues and patients are grateful </li></ul><ul><li>how...
Upcoming SlideShare
Loading in …5
×

MIS Complications: Managing the Emergency Consultation

2,023 views

Published on

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

No Downloads
Views
Total views
2,023
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
128
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

MIS Complications: Managing the Emergency Consultation

  1. 1. MIS Complications: Managing the Emergency Consultation MIS Complications: Managing the Emergency Consultation MIS Complications: Managing the Emergency Consultation George S. Ferzli MD, FACS Professor of Surgery SUNY HSC, Brooklyn, NY George S. Ferzli MD, FACS Professor of Surgery SUNY HSC, Brooklyn, NY George S. Ferzli MD, FACS Professor of Surgery SUNY HSC, Brooklyn, NY
  2. 2. Is there a laparoscopic surgeon in the house? A 12 year old boy has inserted an eyebrow pencil into his penis. CT scan shows the pencil is now lodged in his bladder- - he’s waiting in the emergency room...
  3. 3. When is there an urgent need for a laparoscopic surgeon? <ul><li>Before an operation begins </li></ul><ul><li>Upon entry into the abdomen </li></ul><ul><li>Difficulty visualizing intra-peritoneal space </li></ul><ul><li>Upon discovery of an injury to an intra-abdominal structure </li></ul><ul><li>Use of diagnostic laparoscopy in critical care setting </li></ul>
  4. 4. I. Before an operation begins: <ul><ul><li>Assistance with port- </li></ul></ul><ul><ul><li>placement decisions </li></ul></ul>
  5. 5. I. Before an operation begins: <ul><ul><ul><li>Difficulty in entry with Veress / Hassan </li></ul></ul></ul>
  6. 6. I. Before an operation begins: <ul><ul><li>Assistance with access </li></ul></ul><ul><ul><li>in an obese patient </li></ul></ul>
  7. 7. I. Before an operation begins: <ul><li>Assistance with </li></ul><ul><li>access into a </li></ul><ul><li>re-operative abdomen </li></ul>
  8. 8. II. Upon entry into the abdomen- Untoward events <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>
  9. 9. Injury to abdominal wall blood 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
  10. 10. Injury to abdominal wall blood 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>
  11. 11. <ul><li>Entry into the abdomen - Vascular injury </li></ul><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
  12. 12. 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 </li></ul><ul><li>laparotomy </li></ul><ul><li>Minor injuries (e.g. omental </li></ul><ul><li>bleeding) may be managed </li></ul><ul><li>laparoscopically </li></ul><ul><li>Appropriate vascular principles apply to any repair </li></ul>
  13. 13. <ul><li>Difficulty visualizing intra-peritoneal space </li></ul><ul><li>Assistance with adhesiolysis </li></ul><ul><ul><li>Associated with prior surgery, peritonitis, radiation, inflammation, endometriosis </li></ul></ul>Curet M. Surg Clinic NA; 80:1093
  14. 14. <ul><li>Intra-peritoneal space - Management </li></ul><ul><ul><li>Enhanced view with 30 º scope, use multiple </li></ul></ul><ul><ul><li> ports for visualization </li></ul></ul><ul><ul><li>Judicious placement of additional 5mm ports </li></ul></ul><ul><ul><li>U se sharp dissection whenever possible </li></ul></ul><ul><ul><li>Lyse only adhesions interfering with trocar </li></ul></ul><ul><ul><li>placement or exposure of operative field </li></ul></ul>
  15. 15. <ul><li>Injury to an intra-abdominal structure Bowel injury </li></ul><ul><li>Incidence of 0.1%-0.7%* </li></ul><ul><li>Caused by Veress or trocar puncture, grasping forceps, shears / ultrasonic shears, thermal burns </li></ul><ul><li>Penetrating injuries usually recognized intra-operatively </li></ul><ul><li>Thermal injuries may have delayed presentation </li></ul><ul><li>Timely diagnosis / treatment requires </li></ul><ul><li>high index of suspicion and minimizes 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
  16. 16. Bowel injury- Management <ul><li>Repair of injuries detected at initial surgery: </li></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>Thermal and extensive injuries may require segmental resection / reanastamosis using advanced intra-corporeal skills </li></ul></ul><ul><li>Extensive injuries to colon or those requiring resection / reanastamosis may require laparoscopic diverting ostomy </li></ul>
  17. 17. <ul><li>Injury to an intra-abdominal structure Bladder injury </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>
  18. 18. Bladder injury <ul><li>Incidence of laparoscopic bladder injury 0.02%-8.3%* </li></ul><ul><li>Procedures most commonly associated with bladder injury </li></ul><ul><ul><li>- Lap hysterectomy (40%) </li></ul></ul><ul><ul><li>- Diagnostic laparoscopy (24%) </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
  19. 19. 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- </li></ul></ul><ul><ul><li>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>
  20. 20. <ul><li>Upon discovery of an injury to an intra-abdominal structure Ureteral injury </li></ul><ul><li>Incidence - 0.1-1.4%* </li></ul><ul><li>75% during gyn. procedures </li></ul><ul><li>(1% of lap hysterectomies have </li></ul><ul><li>ureteral injury)** </li></ul><ul><li>Nature of injuries </li></ul><ul><ul><li>- Ligation, transection, laceration, crush, ischemia </li></ul></ul><ul><ul><li>- Cautery injuries (necrosis, stenosis, leak) </li></ul></ul><ul><li>Risk factors </li></ul><ul><ul><li>- Large pelvic mass, dense adhesions, radiation, endometriosis, PID </li></ul></ul>Harkki-Sirren P et al. Major Complications of Laparoscopy: Follow-up Finnish Study. Obst Gyned 1999; 94:95 Chan et al. Am J Obstet Gynecol; 188:1273
  21. 21. Ureteral injury- Prevention <ul><li>Pre-op ureteral stenting </li></ul><ul><ul><li>- Does not reduce rate of injury but </li></ul></ul><ul><ul><li>may allow early recognition and repair </li></ul></ul><ul><li>Ureteral anatomy: </li></ul><ul><ul><li>- In abdomen, vessels approach </li></ul></ul><ul><ul><li>medially </li></ul></ul><ul><ul><li>- In pelvis, vessels approach laterally </li></ul></ul><ul><ul><li>- Expose ureter by incising peritoneum </li></ul></ul><ul><ul><li>laterally in abdomen, medially in </li></ul></ul><ul><ul><li>pelvis </li></ul></ul>Seidman D et al. In Laparoscopic Surgery. McGraw-Hill 2003
  22. 22. Ureteral injury- Diagnosis <ul><li>Direct inspection of site of possible injury </li></ul><ul><li>Extravasation of urine </li></ul><ul><li>Ureteral discoloration or bruising </li></ul><ul><li>Hematuria </li></ul><ul><li>Intraperitoneal spillage of IV dye </li></ul><ul><li>Confirm ureteral integrity by cystoscopy or retrograde ureteral catheterization </li></ul>
  23. 23. Ureteral injury- Management <ul><li>In collaboration with </li></ul><ul><li>urologist </li></ul><ul><li>Cystoscopy and stenting </li></ul><ul><li>may suffice for minor injuries </li></ul><ul><li>Repair of ureteral injuries </li></ul><ul><li>requires significant </li></ul><ul><li>laparoscopic skills </li></ul><ul><ul><li>- Intracorporeal suturing in one </li></ul></ul><ul><ul><li>layer with absorbable suture </li></ul></ul><ul><ul><li>- Repairs should be made over stent </li></ul></ul><ul><ul><li>- Place drain to analyze any urinary </li></ul></ul><ul><ul><li>leak </li></ul></ul>
  24. 24. <ul><li>Use of diagnostic laparoscopy in critical care setting </li></ul><ul><li>Increasing use of laparoscopy in ICU setting </li></ul><ul><ul><li>- For evaluation of bowel in critically-ill post-cardiac surgical patients </li></ul></ul><ul><ul><li>- For assistance during difficult PEG placement </li></ul></ul><ul><li>Precise role requires additional study </li></ul>Pecoraro AP et al. The routine use of diagnostic laparoscopy in the intensive care unit. Surg Endosc. 2001 Jul;15(7):638-41. Epub 2001 May 14. Gagne DJ et al. Bedside diagnostic minilaparoscopy in the intensive care patient. Surgery. 2002 May; 131(5):491-6.
  25. 25. Consultation with an advanced laparoscopist plays a critical role when… <ul><li>His/her participation resulted in reduced morbidity by: </li></ul><ul><ul><li>- Preventing an injury </li></ul></ul><ul><ul><li>- Aiding in diagnosis of an injury </li></ul></ul><ul><ul><li>- Aiding in management of an injury </li></ul></ul><ul><li>Improved laparoscopic skills and learning curve of consulting colleague </li></ul>
  26. 26. So what happened to the eyebrow pencil? … a laparoscopic surgeon saved the day! 1 2 3 4
  27. 27. Thank You!
  28. 28. Liability and the laparoscopic consultation <ul><li>Consulting colleagues and patients are grateful </li></ul><ul><li>however, </li></ul><ul><li>Malpractice insurance is a concern…Beware your fellow General Surgeon peer </li></ul>

×