Complications of Laparoscopic Gynecologic Surgery

Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Thomas Eakins. The Agnew Clinic, 1889

… why laparoscopy?
• Better recovery
• Shorter hospital stay
• Less post-operative pain
• Lower blood loss
• “Scarless surgery”

Modified lithotomy position, with legs placed in the padded adjustable
stirrups and intermittent pneumatic compression system

Surgeon: left side of the patient
First assistant: right side of the
patient
(Second assistant: between the legs
to use the manipulator)

1. Immobilize the umbilical area (our school uses two small towel clips
on the lateral margins of the peri-umbilical area)
2. Peri-umbilical incision of 10 mm (our school uses horizontal incision
at the inferior border of the umbilical ring)
3. Grasp the shaft of the Veress needle
like a dart and gently pass the needle
into the incision and reach the fascia.
Afterwards, lift abdominal wall below
the umbilicus and gently pass the
Veress needle at 45-degree caudal
angle. We use to lift the umbilical area
with the two small towel clips and then
go perpendicular.
Let’s enter into the abdomen in 10 steps:

5. Saline test (withdraw, instill,
withdraw). If no fluid, blood or feces
came out, you are in the right place.
6. Ask for insufflation: a pressure
below 6-7 mmHg is ok! You are inside
the peritoneum!
7. Wait until the intra-abdominal
pressure will be AT LEAST 10-15
mmHg (RCOG guidelines: 20-25
mmHg). Start with 1 L/min and then
you may increase the flow.
4. Two clicks: the first one will be the piercing of the fascia, the
second one of the peritoneum.

8. Insert the optical trocar through the umbilical incision and hear the
CO2 flow
Abdominal pressure= 8mmHg Abdominal pressure=25mmHg
9. Insert the laparoscope and ask for Trendelenburg.
10. Welcome to the abdominal cavity!

Suprapubic trocar: 3-4 cm above
the symphysis pubis
Lateral trocars: 3 cm medial to
each anterior superior iliac spine
Inf epigastric
Ancillary trocars (under vision!)

Complications (and how to manage them!)

• Vascular injury
• Bowel injury
• Urinary tract injury
• Incisional hernia
• Gas embolism
• Shoulder pain
• Pneumothorax
• Subcutaneous and pre-
peritoneal emphysema
• Cardiac arrhythmia
• Nerve injury
• Venous thrombosis
• Complications arising
from the use of electrical
energy
• Vulvar edema
• Port-Site Metastasis
Complications of gynecologic laparoscopy

Prevention:
- know the anatomy!
- trans-illuminate the abdominal wall to identify superficial
epigastric artery
- put the ancillary trocars (5 mm?) laterally to the obliterated
hypogastric vessels
Recognition:
- it may not be apparent until after the trocar has been removed at
the end of the operation
Management:
- bipolar coagulation
- tamponade
- suturing
Abdominal wall vessels injury

Prevention:
- use the safety checks before to insufflate!
Recognition:
- blood at the saline solution test
- direct laparoscopic visualization
- sudden drop of blood pressure
Management:
- if you are using the Veress needle or the optical trocar, leave it
inside (they produce a mechanical tamponade).
- compression over the aorta (no clamping!)
- conversion to laparotomy and immediate call of resuscitation
staff and vascular surgeons (emergency)
Large retroperitoneal vessels injury

Prevention:
- risk of adhesions: insufflate from Palmer’s point; use
laparoscope-equipped optical trocars (layer-by-layer entry)
- bowel preparation
Recognition:
- fecal material from Veress needle or optical trocar
- sometimes it may occur few days after the surgery (signs of
peritonitis)
Management:
- injury by “cold” instruments: closure by two-layers suture
(consider conversion to laparotomy)
- electrosurgical damage: consider resection before to suture
Bowel injury

Prevention:
- be careful in case of previous c-section
- put a Foley catheter before to start the surgery (empty bladder)
- careful dissection of anterior peritoneum between the uterus
and the bladder (Retzius space)
Recognition:
- in case of suspected injury, instill methylene blue dye into the
bladder
- pelvic drainage
- cystoscopy
Management:
- suture in a single layer, followed by bladder drainage for 7–10
days
Bladder injury

Prevention:
- stent positioning before the surgery
- Hydroprotection: 10–20 ml of normal saline solution injected just
beneath the parietal peritoneum
Recognition:
- in case of suspected injury, indigo carmine may be injected
intravenously to verify if there is any leakage of the dye through the
ureter
- delayed presentation: increase of creatinine, nausea, vomiting,
pain, abdominal distension, ileus
Management:
- call the urologist
- “cold” damage: stent and suture in single layer
- electrosurgical damage: consider resection and re-implantation
Ureteral injury

Prevention:
- careful closure of the fascia
- use of 5 mm trocars as much as possible
Recognition:
- tender swelling over the hernia site, often within 2 weeks of the
operation
- nausea, vomiting, signs of bowel obstruction
Management:
- laparoscopic or laparotomic confirmation and repair
Incisional hernia

Recognition:
- sudden circulatory collapse
- cyanosis
- increase of jugular venous pressure
- characteristic ‘millwheel’ murmur
- high arterial pCO2
- drop in end tidal carbon dioxide concentration.
Management:
- stop CO2 insufflation
- roll the patient on the left side
- call immediately cardiopulmonary resuscitation
Gas embolism

(In case of congenital defect of the diaphragm)
Recognition:
- cyanosis
- Increase of jugular venous pressure
- Increase in airway pressure
Management:
- stop CO2 insufflation
- thoracostomy
Pneumothorax

Very common, it is caused by irritation of the
diaphragmatic nerves by residual CO2 trapped
inside the abdominal cavity
Prevention:
- remove all the CO2 from the abdominal cavity at
the end of the surgery
Shoulder pain

Prevention:
- perpendicular insertion of Veress needle and optical
trocar in obese patients
- use Hasson technique
Recognition:
- bubbling from the peri-umbilical incision during
insufflation
Management:
- use the ancillary access to go between the fascia and
peritoneum and remove the CO2 from this area, before to
enter into the peritoneal cavity
Pre-peritoneal emphysema

Prevention:
- do not increase the flow immediately after the insufflation
Management:
- stop the CO2 insufflation
- anticholinergic agents
Cardiac arrhythmia

Prevention:
- correct positioning of the patient, especially when
undergoing prolonged laparoscopic surgery
Nerve injuries

It is relatively uncommon following laparoscopic
surgery because of earlier mobilization.
Prevention:
- use of stockings and subcutaneous heparin for
prophylaxis in women having major laparoscopic
surgery
- set intra-abdominal pressure below 15 mmHg, in
order to allow a proper venous return from the vena
cava
Venous thrombosis

“You must believe in your hands”

Thanks for your attention!

Complications of Laparoscopic Gynecologic Surgery

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