all complications during laparoscopy, trouble prevention and trouble shooting during complications of laparoscopic surgery

1. Dr. S. Easwaramoorthy
Lotus hospital
Erode

2.  Position related injuries
 Access related Injuries
 Due to Pneumoperitoneum
 During Surgery
 Post operative complications

3. Brachial plexus
Ulnar nerve
Femoral nerve
Common peroneal nerve

4.  Position related injuries
 Access related Injuries
 Due to Pneumoperitoneum
 During Surgery
 Post operative complications

5.  Entry to free peritoneal cavity
 No Injury to
 Major vessels
 Aorta/IVC/Iliac vessels
 Bowel
 Bladder
 Other viscera

6.  Anaesthetised patient
 Relaxed abdomen
 Empty stomach
 Empty bladder
 Prepared bowel
 Experienced team
 Excellent equipments

7.  Injury to
 Vessel
 Bladder
 Bowel
During the insertion of Veress needle and Trocars

8. Pop test and Drop test

9.  Abdominal wall
 Inferior epigastric artery
 Intra peritoneal
 Omentum
 Mesenteric vessels
 Retroperitoneal
 Aorta
 IVC
 Iliac vessels

11. Control of Bleeding
•Diathermy
•Figure of 8 suture
•Foley’s balloon

12.  Shock
 Hemorrhage
 Retro peritoneal hematoma
 Co2 embolism

13. Incidence of major vascular injuries occurred in
34 patients (0.05%) with 3 deaths
after 77,604 lap cholecystectomy
•Aorta : 12
•IVC : 4
•Aorta/IVC : 1
•Iliac vessels : 17
Deziel et al
Am. J. Surg 1993: 165: 9-14

14.  Don’t panic
 Trocar in situ
 Seek help/Arrange for blood
 Immediate laparotomy
 Vascular control

15. Harrith Hasson, Chicago

16.  Eliminates the risk of major vascular injury
 Reduces the chance of bowel injury
 Recognizes and rectifies the bowel penetration
Hasson, H.M. (1971) A modified instrument and method for laparoscopy.
Am. J. Obstet. Gynecol., 110, 886–887

17. When it can happen?
 Needle in side a vessel/ liver
 Exposed vascular area
 Argon plasma coagulation
How to recognize?
 Hypotension and hypoxia
 Sudden drop in ETco2
 Mill wheel murmur
How to manage?
 Stop pneumoperitoneum and vent it out
 Head down and left lateral position
 Aspiration of air through central line

18.  During Access
 During Veress needle insertion
 Primary trocar insertion
 Secondary trocar insertion
 Dissection/Retraction
 Release of adhesions
 Diathermy use
 Pilot error
 Insulation failure
 Coupling

19.  Adhesions present in 75% of cases after
previous surgery
 May be right under
 Also further away
 Adhesions present in 10% of cases in virgin
abdomen
 Sonographic mapping

20. No Previous surgery 0-0.6%
Previous laparoscopy 0-15%
Laparotomy through Pfannensteil incision 20-28%
Laparotomy though midline incision 50-60%

21.  Alternative sites
LUQ RLQ

22.  With or without
pneumoperitoneum
 Under vision
 Layer by layer
controlled entry

23.  During Access
 During Veress needle insertion
 Primary trocar insertion
 Secondary trocar insertion
 Dissection/Retraction
 Diathermy use
 Pilot error
 Insulation failure
 Coupling current

24.  Position related injuries
 Access related Injuries
 Due to Pneumoperitoneum
 During Surgery
 Post operative complications

25. Cardiac HR
Decrease in CO
Increase in SVR
Decrease in Venous return
Respiratory Increase in Air way pressure
Decrease in FRC
Decrease in Compliance
Acidosis
Vascular Decrease in Venous return
Compression of splanchnic bed
Neurohormonal Catecholamine release
Renin
Cortisol
Vasopressin
Trouble Prevention
•IAP < 12mm
•Pre op volume loading
•Hyperventillation
•PEEP
•Monitor
•End tidal Co2
•PCWP
•Trans eso Echo

26.  Hypercapnia and acid base
disturbance
 Abdominal pain (H2CO3)

27.  Position related injuries
 Access related Injuries
 Due to Pneumoperitoneum
 During Surgery
 Post operative complications

28. Injury During
1 Bile duct injury Lap cholecystectomy
2 Bladder injury Lap hysterectomy
3 Ureteric injury Lap colectomy , hysterectomy
4 Bowel injury Adhesiolysis
5 Pneumothorax Lap fundoplication
•Inadvertent division
•Dissection & traction injury
•Diathermy induced
•Staples

29. Classical BDI during Lap Chole

30. You see What U want to See

31.  Position related injuries
 Access related Injuries
 Due to Pneumoperitoneum
 During Surgery
 Post operative complications

32.  Port Site sepsis
 Mycobacterium Chelonae
 Port site hernia
 Suture all ports 10mm & >
 Port site recurrence
 GB cancer

33.  Adequate training reduces laparoscopy related
complications
 Trouble shooting guidelines are mandatory
 Conversion to open should not be seen as
failure.