vj

1. Complications of Laparoscopy Entry
by Resident /
Steven Nabil Fouad

2. INTRODUCTION
 the improvement of surgical instruments and
techniques enables the surgeon to perform even
major operations using the laparoscopic
approach.
 the initial entry is usually performed in a blind
fashion. Blind entry may result in vessel or organ
damage, especially in patients who have
undergone previous surgery and the formation of
hernias ,, patient must be counsled about tis
complication before opeartion

3. Trocar Insertion
 Elevation of the abdominal wall by sufficient
pneumoperitoneum is a precondition for safe
trocar insertion.
 The optic trocar may be placed indirectly (10 mm)
or in two steps, inserting a 5-mm trocar first and
then dilating to 10 mm.
 In case the surgeon anticipates any bleeding, or
suspects adherence of the bowel in the umbilical
region, the primary trocar site must be visualized
from a secondary port site, such as the lower
abdominal wall

4. Trochar Sites
 The first trocar should be inserted in the
subumbilical region using a semilunar or straight
incision for camera
 The placement for the working trocars depends
on the operation :
-Another trocar is used in the epigastrium which is
the main right working port for lap cholecystectomy
-If the operative focus is located in the pelvis trocars
can be inserted in the lower abdominal wall.

5. Alternative site
 Indications for the use of Palmer's point are the
following:
 • Patients who have undergone previous
abdominal surgery and/or those with
suspected intra-abdominal adhesions
 • Patients with previous longitudinal
abdominal incision
 • Very obese patients

6. Alternative site

7. Ancillary trocars
All ancillary trocars must be
inserted under direct vision&
The inferior epigastric vessels
must be avoided

8. Complications in Port Placement
 Complications of laparoscopy can be divided into
early complications & late complications.
 Laparoscopic entry lesions may be classified as
follows:
• Type 1 injuries—Damage to major blood vessels or
the bowel in a normal location, caused by entering
with the Veress needle or the primary trocars .
• Type 2 injuries—Damage to vessels in the
abdominal wall and to the bowel adherent to the
abdominal wall.

9. Vascular and Visceral Lesions
During Port Placement
 Vascular lesions :
- in the abdominal wall
(superficial and epigastric vessels) or the intra-
abdominal aspect (vessels of the mesentery,
omentum, iliac arteries and veins, or the
aorta/vena cava).
-Vessel injury may lead to a parietal hematoma or
intraperitoneal hemorrhage

10. - In addition, CO2 is highly soluble in plasma.
Large volumes can be lethal and are liable to
cause immediate death
-Even partial entrance of the Veress needle into
the lumen of a vessel may cause a gas embolism.

11. Visceral Lesions
 Visceral lesions include injury to the greater
omentum, the stomach, the bowel, the liver, or
the spleen, depending on the entry site; and the
level of filling of the hollow organs. Therefore, a
gastric tube must be placed at the beginning of
the operation, especially when using Palmer's
point or the Lee-Huanjg point.
 penetration of the bowel can be identified by the
aspiration of gas or the presence of ambiguous or
malodorous fluid. Injury to the liver or the spleen
would lead to the aspiration of blood

12. Early & late complication
# Early complication :
 Vascular injury ;
-Major vessel injury during retroperitoneal
Dissection as, the distal abdominal aorta and the
common as well as external and internal iliac
arteries lie in the retroperitoneal space.
-that need Early recognition to minimize
bleeding, and conversion to laparotomy when the
bleeding cannot be compressed laparoscopically

13. Early complication
 Bowel Lesions ;
-Abdominal access and the creation of a
pneumoperitoneum bear a significant risk of
bowel injury.
-Although bowel injuries are uncommon, they
constitute a major cause of mortality.

14. -Unlike major vessel injuries, which are seen
immediately, many bowel injuries remain
concealed at the time of the procedure.
Patients may present postoperatively with
specific or unspecific symptoms of peritonitis.
Persistent pyrexia, tachycardia, or an ileus
-mangement of bowel lesion :
*a partial excision and suturing .
*resection of lacerated areas could be
necessary, including end-to-end anastomosis .
*a temporary ileostomy.

15. Bladder and Ureter Injuries
 Intraoperative viewing of the ureter is always
necessary when performing surgery in the
ureteric area.
 Urinary-tract injuries in connection with
laparoscopic surgery very rare.
 Bladder injuries may be less serious than
ureteral injuries as Injury to the ureter is
greatly compounded by its late identification
after the operation .

16. Late Complications
 referred to as secondary lesions
1. secondary bowel lesions associated with
peritonitis
2. massive intra-abdominal infection
3. Small vascular lesions may remain unnoticed
until a hematoma appears.
4. Some ureteral lesions remain unidentified
until the development of an urinoma; this may
occur several days after surgery.

17. Conclusion
 all surgeons should be familiar with
alternative entry sites and techniques in order
to resolve any type of obstacle or complication.
 All surgical procedures, including port
placement, even under direct vision, are
associated with immanent risks.

18. References
 1. Alkatout I, Bojahr B, Dittmann L, et al.. Precarious
preoperative diagnostics and hints for the laparoscopic excision
of uterine adenomatoid tumors: Two exemplary cases and
literature review. Fertil Steril 2011;95:1119 [PubMed] [Google
Scholar]
 2. Alkatout I, Stuhlmann-Laeisz C, Mettler L, Jonat W,
Schollmeyer T. Organ-preserving management of ovarian
pregnancies by laparoscopic approach. Fertil Steril 2011;95:2467.
[PubMed] [Google Scholar]
 3. Royal College of Obstetricians and Gynaecologists (RCOG).
Green-top Guideline No.49: Laparoscopic Injuries. London:
RCOG; 2008:1 [Google Scholar]

19. 4. Vilos GA, Vilos AG, Abu-Rafea B, Hollett-Caines J, Nikkhah-Abyaneh Z,
Edris F. Three simple steps during closed laparoscopic entry may minimize
major injuries. Surg Endosc 2009;23:758. [PubMed] [Google Scholar]
5. Vilos GA, Ternamian A, Dempster J, Laberge PY; Society of Obstetricians
and Gynaecologists of Canada. Laparoscopic entry: A review of techniques,
technologies, and complications [in English & French]. J Obstet Gynaecol
Can 2007;29:433. [PubMed] [Google Scholar]
6. Magrina JF. Complications of laparoscopic surgery. Clin Obstet Gynecol
2002;45:469. [PubMed] [Google Scholar]
7. Hurd WW, Bude RO, DeLancey JO, Pearl ML. The relationship of the
umbilicus to the aortic bifurcation: Implications for laparoscopic technique.
Obstet Gynecol 1992;80:48. [PubMed] [Google Scholar]
8. Hurd WH, Bude RO, DeLancey JO, Gauvin JM, Aisen AM. Abdominal
wall characterization with magnetic resonance imaging and computed
tomography: The effect of obesity on the laparoscopic approach. J Reprod
Med