Darker side of Laparoscopy, an aspect directed towards surgery residents

1. DARKER SIDE OF
LAPROSCOPY
MODERATOR – DR MALKIAT SINGH
PRESENTER- DR. GEETANJLI CHOPRA

2. INTRODUCTION
 Laparoscopy, also known as keyhole surgery or minimally invasive surgery,
now preferred over traditional open surgery :
 Smaller incisions and thus less post-operative pain.
 Faster recovery and shorter hospital stays.
 Reduced risk of infection and smaller scars.
 It has become a standard and highly valued technique for both diagnosis and
therapy across many surgical specialties.

3. LIMITATIONS OF LAPROSCOPY
 Need more training of surgeon.
 (Usually) blind entry into the peritoneal cavity
 Restricted vision (fixed angle of view; limitations resulting from smoke, fog or
bleeding; dependence of camera assistant),
 Loss of tactile feedback
 Dependence on hand–eye coordination
 Difficulty with haemostasis
 Difficult Extraction of large specimens &Necessity of specimen fragmentation
(morcellation) prior to evacuation
 Effects of intra-abdominal pressure (overstretching of nerves, impaired ventilation),
 Physical and chemical effects of the insufflation gas (CO2),

4. PNEUMOPERITONEUM
AND ITS
PHYSIOLOGICAL
EFFECT

5. PNEUMOPERITONEUM
 Carbon dioxide is the gas of choice used for insufflation in MIS, as it is nontoxic,
nonflammable, rapidly soluble in blood, easily eliminated by the lungs, and
relatively inexpensive .
 The absorption rate of CO2 is influenced by -
1. partial pressure gradient between the cavity and the blood,
2. its diffusion coefficient,
3. the surface area of the cavity,
4.the perfusion of the walls of the cavity .
 Intraperitoneal insufflation with CO2 is associated with an initial rapid rise in
pCO2 during the first 15 min and followed by plateau or second phase of slower change.

6. PHYSIOLOGICAL EFFECTS OF
PNEUMOPERITONEUM

7. EFFECTS ON PERITONEAL LINING

8. INFLAMMATION
 Intentional or accidental peritoneal injury induces a local acute phase
reaction, namely, inflammation .
 Cellular infiltration and the release of proinflammatory cytokines such as IL-
6, IL-1, and TNF-α.
 In 2007, Papparella et al. reported that peritoneal insufflation with CO2 in
rats was associated with eosinophils, mastocytes, and macrophages 2 h after
laparoscopic surgery.
 In addition to gas type, insufflation pressure was reported to affect
peritoneal mucosa integrity and cellular infiltration.

9. ACIDOSIS
 Carbon dioxide induces the acidification of fluids, as it has the potential to induce
carbonic acid reaction .
 Wong et al. compared the insufflation effect of different gas types on pH modifications
in pigs. They found that only CO2 was associated with acute peritoneal acidosis,
whereas nitrous oxide and helium were not.
 In addition, peritoneal acidification was more severe with higher-pressure
insufflation (12–15 versus 5–8 mmHg) .
 The heated and humidified group showed lower pH reduction compared to that of
standard laparoscopy.

10. OXIDATIVE STRESS
 Increased IAP might compromise splanchnic perfusion and capillary microcirculation
and lead to reduced oxygen content and related ischemia–reperfusion injury with the
consequent production of reactive oxygen species (ROS).
 ROS release, microcirculation impairment, and tissue hypoxia are the first steps of
peritoneal injury, ranging from mesothelial denudation to inflammation and adhesion
development.
 In addition to minimizing intra-abdominal pressure, ischemic preconditioning was
investigated as a method to reduce laparoscopy-induced oxidative stress.

11. MESOTHELIAL MODIFICATIONS
 The peritoneum is constituted by a single layer of mesothelial cells with an
underlying basal membrane and connective tissue containing immune cells,
fibroblasts, collagen, and blood vessels.
 Cellular retraction and bulging up, intercellular clefts, and the exposition of
basal lamina from 60 to 120 minutes after pneumoperitoneum release.
 Therefore, the preservation of the mesothelial lining is crucial for reducing
postsurgical adhesions.
 Mesothelial integrity was restored 2 days after surgery.

12. NORMAL MESOTHELIUM FOCAL MESOTHELIUM HYPERPLASIA
AFTER PNEUMOPERITONEUM

13. ADHESION DEVELOPMENT
 Peritoneal adhesions result in the abnormal repair of the peritoneum caused by
surgical trauma, inflammation, and infection and there is formation of fibrin plug .
 Normally, the fibrin deposit is entirely removed from the fibrinolytic system, and
mesothelial regeneration is achieved in about 8 days .
 Fibrinolytic activity can be compromised causing fibroblast proliferation and
adherence development.
 In fact, in 2004, Binda et al. noted that hypothermia in an animal model prevented
the formation of adhesions through a reduction in cellular oxygen needs.
 Subsequently, better results were obtained when humidifying the insufflated gas
and adding 3% O2 .

15. HEMODYNAMIC CHANGES
 It is a result of mechanical and neurohormonal responses.
 The increased IAP caused by pneumoperitoneum produces vascular
compression of the IVC, aorta, splanchnic and renal vasculature; this shifts
the peripheral vascular volume to the central venous compartment, causing an
initial increase in venous return.
 The drop in CO is attributed to the decreased venous return caused by IVC
compression and the pooling of the venous blood in the lower extremities.
 There is also an increase in afterload with an increase in IAP, seen as an increase
in mean arterial pressure (MAP) and systemic vascular resistance (SVR) that
contribute to the decrease in CO.

17. SVR
INCREASED
• Increased compression of abdominal arteries and humoral factor release (vasopressin, renin)
have caused increased afterload
STROKE
VOLUME
DECREASE
• Decreases when IAP = 14 to 15 mmHg
• Interventions -• Trendelenburg position • Adequate hydration • Compression of the lower
extremities
CARDIAC
OUTPUT/
CARDIAC
INDEX
DECREASE
• Noticed with intraabdominal pressures of 8 to 12 mmHg, with significant reduction at 16 mmHg
• 5 to 10 minutes after initial decrease, it will partially reverse and increase back to baseline
• Interventions • Wrapping of legs • Optimize intravascular volume
ARTERIAL BP
INCREASE
• At intraabdominal pressures as low as 14 mmHg
• Up to 35% increase in MAP
• Mechanism - Increased afterload caused from pneumoperitoneum

18. HUMORAL
FACTORS
INCREASE
• Increased dopamine, vasopressin, epinephrine, norepinephrine and cortisol.
• Vasopressin is the most significant mediator
• Catecholamine level increase secondary to stress response
OTHER CVS
FACTORS
• Distention of the vagus nerve during insufflation
• Bradycardia is sometimes observed
• Increased intraabdominal pressure can reduce lower extremity blood flow velocity
HYPERCAPNI
A
• Hypercapnia (50 to 70 mmHg) can cause increased physiologic effects - Increased CBF ,
Peripheral vasodilation , Pulmonary vasoconstriction & Increase risk of cardiac
dysrhythmias.
• RX- Controlled ventilation - Increase of 20 to 30 % in minute ventilation

19. PULMONARY CHANGES
 Insufflation of the abdominal cavity results in shifting the abdominal wall
outwards and the diaphragm upwards, resulting in an increase IAP and
reduction of thoracic volume, respectively.
 Respiratory compliance is reduced by 50% when the peritoneal cavity is
insufflated to a pressure of 15 mm Hg .
 Increases in IAP and volume impede diaphragmatic movement resulting in
decreased FRC and an increase in alveolar dead space.
 Pulmonary functions reduced with the decrease in lung compliance include
FEV1, TLC , and VC ,these changes can predispose to the development of
VENTILATION – PERFUSION mismatch, leading to hypoxemia.

21. EFFECT ON CNS
 It has been proposed that increased IAP and ITP as well as impaired CSF
absorption during insufflation impedes drainage of the lumbar venous plexus
and induces an increase in the vascular compartment of the sacral space
causing the rise in ICP
.
 Additionally, hypercarbia is known to cause cerebral vasodilation, which
causes an increased ICP.
 Trendelenburg position worsens the increase in ICP during insufflation.

22. KIDNEY
• Oliguria
• Compression of kidneys & inferior vena cava
• Increase in levels of antidiuretic hormone
• Significant reduction in renal blood flow, urine output and GFR.
• Intraabdominal pressure around 24 mmHg release of humoral factors - Vasopressin, renin & aldosterone
LIVER
&SPLEEN
• Intraabdominal pressure = 16 mmHg cause a 68% decrease in hepatic blood flow
• Splanchnic blood flow not disrupted with IAP of 11 to 13 mmHg
• Mesentric and mucosal blood flow can be reduced (40%) in ACS.
OTHERS-
• INCREASED IOP
• INCREASED ICP
• HYPOTHERMIA
• REGURGITATION AND ASPIRATION

24. COMPLICATIONS OF LAPROSCOPY
1. ANAESTHESIA RELATED COMPLICATIONS
2. COMPLICATIONS DUE TO PNEUMOPERITONIUM
3. DIATHERMY-RELATED INJURIES
4. SURGICAL COMPLICATIONS
5. PATIENTS FACTORS RELATED COMPLICATIONS
6. POST OPERATIVE COMPLICATIONS

25. ANAESTHETICS COMPLICATIONS
 Management –
 Endotracheal intubation
 Pharmacological neuromuscular blockade
 Positive pressure ventilation
Inadequate Muscle Relaxation
&Contraction of muscle
during procedure
Difficulty in
Pneumoperitoneum
Causes pain during
port insertion

26. MASK HYPERVENTILATION
 Prior to induction 100% oxygen is given by mask ventilation Hyperventilation
leads to
 1.Distended stomach
 2.Respiratory Dysfunction
 Liable to injury during port insertion Or veress needle insertion.
 Management – Nasogastric tube prior to surgery.

28. ANAESTHESIA
COMPLICATIONS
Cardiovascular complications – increased IAP causes reduces CO and BP fluctuations
and provoke arrythmias
Respiratory complications
1. Hypercarbia -causing respiratory acidosis and increased work of breathing
Positioning-Related Risks: Steep Trendelenburg or lithotomy
positions can increase risk for nerve injury, swelling (edema),
compartment syndrome, or even postoperative visual loss
Allergic Reactions & Medication Effects: Resulting in hypotension,
anaphylaxis, or airway difficulties
Vasovagal Reactions: The procedure or insufficient anesthetic depth can
trigger a vagal response, causing bradycardia, hypotension, or collapse.

29. System Patient Characteristics Complication
A Pregnant patients Certain positioning can increase upper airway oedema
B Severe COPD Rupture of bullae from increased airway pressures
Pulmonary Hypertension Further elevation of pulmonary vascular pressures can lead to
acute right ventricular decompensation
Morbid Obesity Further increases in intra-abdominal pressures lead to worsening
VQ mismatch and hypoxia
C Ischaemic Heart Disease Increased oxygen demand may result in perioperative ischemic
complications
Heart Failure Sudden increases/decreases in preload can cause acute
decompensation with fluid overload or cardiogenic shock
Severe aortic stenosis Patients with a fixed flow valve (unable to generate higher cardiac
outputs) may be at risk of acute cardiac decompensation
D Chronic Kidney Disease Further reductions to eGFR can precipitate an acute kidney injury

30. COMPLICATIONS DUE TO
PNEUMOPERITONEUM AND VERES NEEDLE
 EXTRAPERITONEAL GAS INSUFFLATION
 PNEUMOTHORAX
 GAS EMBOLISM
 BLOOD VESSEL INJURY
 INJURY TO GASTROINTENSTINAL TRACT
 BLADDER INJURY
 COMPLICATIONS FROM DISTENSION MEDIUM

31. SUBCUTANEOUS AND SUBFASCIAL
EMPHYSEMA
Improper insertion of veres needle
Manipulation of instruments often loosens the parietal peritoneum surrounding the instruments and portal of
exit into the peritoneal cavity.
CO2 then infiltrates the loose areolar tissue of the body
Subcutaneous and subfascial emphysema
 Management- It rapidly resolves within 2 – 4 hours postoperatively.

32. PNEUMOTHORAX
Due to true diaphragmatic hernia or Without any apparent cause.
Diagnosis –
1. Presence of rapidly falling Oxygen saturation or PO2
2. Difficult ventilation and decreased breath sounds.
Management –
1. Immediate needle thoracostomy.
2. Aspiration
3. Chest radiograph
4. Placement of chest tube

33. RESPIRATORY DYSFUNCTION
 (a)Gas specific effects -Respiratory Acidosis and Hypercarbia
 (b) Pressure Specific Effects- Excessive Pressure on IVC & Hypercarbia
Reduced VR Reduced CO Rapid stretch of peritoneal membrane &
Vasovagal response Bradycardia, occasionally hypotension
 Management –
 1.Desufflation of abdomen
 2.Vagolytic (Atropine)
 3.Adequate volume replacement

34. DVT AND PULMONARY EMBOLISM
Increased intra-abdominal pressure
Reduced VR (Along with reverse Trendlenburg position)
Venous engorgement
Deep vein thrombosis
Pulmonary Embolism
 Management :
 1.Sequential compression stockings
 2.Subcutaneous heparin or low molecular weight heparin

35. VASCULAR INJURIES
 ABDOMINAL WALL –
1. INFERIOR EPIGASTRIC ARTERY
 INTRAPERITONEAL-
1. OMENTAL VESSEL
2. MESENTRIC VESSELS
 RETROPERITONEAL –
1. ILIAC VESSELS
2. AORTA
3. IVC

36. HOW TO AVOID ABDOMINAL VESSEL WALL
INJURY ?

37. MEASURES TO AVOID VESSEL INJURY
 Avoid Trendlenberg procedure
 The angle of insertion should be 45% at the umbilicus in thin patient and more
vertical in obese patients
 Use of disposable trocars and sharp instruments to avoid use of unneccesary
force during primary entry

38. SUPERFICIAL EPIGASTRIC ARTERY
 Superficial epigastric artery
 It arises from the femoral artery and runs medially over the rectus muscle.
 Prevention:
 Identified By transillumination of the abdominal wall
 Injury: subcutaneous haematoma
 Management: suture around the 5mm cannula

39. Injury causes –
Retroperitoneal
hematoma
Management-
1. Suture around 5 mm
cannula or coagulation .
2.Open surgery

40. MANAGEMENT
 The needle should be left in place
 Inserting 5mm suprapubic laproscope
 Minimal bleeding- controlled by bipolarcoagulation and laproscope suture
 Severe bleeding- laprotomy and compress aorta
 CALL VASCULAR SURGERY TEAM

41. INJURY TO STOMACH
 CAUSE -Hyperventilation by Mask lead to distended stomach
 May be injured with trochar or needle
 DIAGNOSIS - Laparoscopic view of inside of stomach
 MANAGEMENT -
 1.Extend trocar incision into a minilap for a two layer closure.
 2.Laparosocpically – Purse string suture or a figure of 8 suture in the seromuscular layer
surround the defect.
 Nasogastric tube drainage for two days.

42.  BOWEL –
 CAUSE-May be injured due to trocar or veress needle.
 If due to veress needle it is managed conservatively
 DIAGNOSIS - Emanation of foul smelling gas through pneumo-peritoneal needle is a helpful
diagnostic sign.
 There may be GI contents at the tip of needle.
 MANAGEMENT –
 Mini laprotomy and repair of perforation.
 Laparoscopically it may be sutured of laparoscopic stapler (ENDO-GIA) can be used.
 Colostomy

43.  SMALL BOWEL –
 CAUSE-Most often during insertion of umbilical or lower quadrant trocars
 Usually recognized later in the procedure
 If adhesions are not freed from anterior abdominal wall, perforation may not be recognized .
 MANAGEMENT –
 1.One should consider higher primary site if adhesions are found through umblical port.
 2.Perforation repaired transversally .
 If it is free of adhesions bowel can be withdrawn through 10 mm trocar tract and repaired.

44. BLADDER INJURY
 Caused by second puncture trocar usually .
 DIAGNOSIS - Appearance of gas and blood in Foley’s catheter bag.
 MANAGEMENT - Early detection is important.
 1. Place an indwelling catheter for 7-10 days and prophylactic antibiotics .
 2 If defect is larger- Repaired by a figure of 8 suture through muscularis of
bladder & second suture to close peritoneum
 A water tight seal should be documented by filling bladder with indigo
carmine dye solution

45. URETER INJURY
 CAUSE-May be injured in adenexal surgeries , pelvic adhesions , congenital
anomalies.
 Thermal injury will result in ureteral narrowing and hydroureter.
 Management –

46. COMPLICATIONS DUE TO DISTENSION
MEDIUM
 CARBON DIOXIDE –
 GAS EMBOLISM
 CARDIAC ARRYTHMIA
 CHEST PAIN
 NITROUS OXIDE-
 SUPPORT COMBUSTION
 METHANE GAS + ELECTROCAUTERY
= EXPLOSION
 Helium and argon are inert gases that are compromised by low
solubility.
 An increased rate of subcutaneous emphysema and venous gas
embolism after helium insufflation is seen .

47. COMPLICATIONS DURING ENTRY
AND EXIT OF TROCAR

48. AVOID THESE MISTAKES BEFORE
VERES NEEDLE INSERTION –
1. LONG NEEDLE
2. PREMATURE TRENDLENBERG
3. DISTENSION – STOMACH ,
COLON ,BLADDER
4. ADHESIONS
GUIDELINES FOR SAFE VERES NEEDLE -
 Aim to sacral hollow.
 Aim at right angle to the skin, then readjust.
 Aim away from pelvic vessels.
 Test for peritoneal entry (IPP ≤ 10 mm Hg).
 Advance only 2-3 cm after piercing
peritoneum.
 Avoid over-insufflation

49. Primary port insertion
 The primary incision should be vertical from the base of the umbilicus.
 Aim at right angle to the skin, then readjust 45-90 degree
 Aim to sacral hollow,aim away from pelvic vessels
 Extend index on the trocar to prevent sudden thrust of trocar.
 Rotate in a semi-circular fashion.
 Advance not more than 2-3cm beyond peritoneum

50. Secondary trocar insertions
 The structures most frequently injured are: Inferior epigastric vessels.
 Golden safety rules: Transillumination and under endoscopic direct vision
at 20- 25 mm Hg pressure. And once it has entered peritoneum it should be
directed toward anterior pelvis.
 When laparoscopic landmarks are not visible, secondary trocars should be
placed 5 cm superior to the mid pubic-symphysis and 8 cm lateral to the
midline to avoid injury to the vessels of the anterior abdominal wall.

51. BLEEDING FROM TROCAR SITE
•CAUSE –
•1.Occurs if falciform ligament is pierced with substernal trocar or epigastric vessels are
injured
MGT –
1. Controlled by applying upwards and lateral pressure with trocar
2. Monofilament suture attached to specialized needle passed into abdominal cavity and
exited at other side of ligament using grasper
 Loop suspended and compression achieved during procedure & remove loop after
procedure under direct vision ensure hemostasis
3.Pressure applied with foleys catheter entered into the trocar site & inflate balloon
maintain in traction keep for 24 hours and remove.

52. VISUAL ACCESS CANNULA INTRODUCED BY
CLOCKWISE ROTATION AND ALL LAYERS ARE
INDIVIDUALLY VISUALISED .

53. REMOVAL OF PRIMARY TROCAR
PRIMARY TROCAR TO BE REMOVED UNDER DIRECT VISION TO PREVENT
ANY BOWEL ENTRAPMENT

54. DIATHERMY
 During electrocautery, current does not enter the
patient's body. Only the heated wire comes in
contact with tissue.
 In electrosurgery, the patient is included in the
circuit and current enters the patient's body.
 In the operating room, the circuit is composed of the
1.Patient
2.the electrosurgical generator,
3. the active electrode and
4. the return electrodes.

55. DIATHERMY RELATED COMPLICATIONS
 1.Inadvertent activation of the diathermy pedal
 2. Faulty insulation
 3.Direct coupling
 4.Capacitative coupling

56. FAULTY INSULATION
 Main cause of laparoscopic electrosurgical injuries.
 Distal third of laparoscopic instruments is mc site
 Break or defect in the insulation that coats the instrument.
 Insulation failure is caused by
 1. excessive use of reusable instruments
 2. repetitive passage through trocars and
 3. frequent mechanized sterilization.

57. COMPLICATIONS – DIRECT COUPLING

58. COMPLICATIONS – CAPACITIVE COUPLING

59. PRECAUTIONS TO AVOID BURNS AT PAD
SITE
 Place the long edge of the dispersive pad closest to the surgical site and on
the same side of the body as the incision.
 Choose a well vascularized muscle mass .
 Avoid areas of vascular insufficiency, irregular body contours, bony
prominences .
 Remove excessive hair .
 Check equipment before each use

60. OTHER ELECTROSURGICAL
COMPLICATIONS

61. DIATHERMY RELATED COMPLICATIONS
 The small bowel, especially the ileum, is most frequently involved.
 Features of electrical injuries –
1. an area of Coagulative necrosis,
2. Absence of Capillary ingrowth in fibroblastic muscle coat reconstruction,
3. and Absence of white cell infiltration, except in focal areas at the viable
borders of injury.

62. AVOIDING ELECTROSURGICAL COMPLICATIONS
 Inspect insulation carefully
 Use the lowest possible power setting
 Use a low-voltage waveform (cut)
 Brief intermittent activation
 Do not activate in open circuit
 Do not activate in close proximity or direct contact with another instrument
 Use bipolar electrosurgery when appropriate
 Select an all metal cannula system as the safest choice
 Utilize available technology (tissue response generator, active electrode monitoring) to
eliminate concerns about insulation failure and capacitive coupling.

63. INJURY DUE TO POSITION / NERVE
ENTRAPMENT
1. BRACHIAL PLEXUS
2. ULNAR NERVE
3. FEMORAL NERVE
4. COMMON PERONEAL NERVE

64. BRACHIAL PLEXUS INJURY

65. ULNAR NEUROPATHY

66. PERONEAL NERVE INJURY

67. HEAD UP /REVERSE
TRENDLENBERG
HEAD DOWN /
TRENDLENBERG

68. SURGERY - RELATED
COMPLICATIONS

69. LAP. CHOLECYSTECTOMY
 Hemorrhage
 Bile duct injury/leak
 Retained stones
 Pancreatitis
 Wound infection
 Incisional hernia
 Pneumoperitoneum related:
 CO2 embolism ; Vaso-vagal reflex ; arrhythmias ; Hypercarbic acidosis
 Trocar related: Bleeding: vascular injury/abdominal wall injury & Visceral injury

70. LAP . APPENDICECTOMY
 Intrabdominal abscess
 Bleeding :
- Inferior epigastric artery
- Appendicular artery
- Retroperitoneal vessels
 Perforation of the bowel
- By trocar
- Inadvertent electrosurgical injury
- slippage of appendix base loops
 Injury to bladder
 Wound infections

71. TRANS – ABDOMINAL PREPERITONEAL
HERNIA SURGERY
 Port site infection
 Major bleeding during inguinal hernia repair - inferior epigastric vessels . Iliac vessel can
be severe and because of staples placed in the region of the so-called “Triangle of
Doom.”
 Ischemic orchitis
 Inguinal seromas
 Hydrocele formation
 Nerve injuries - the iliopubic tract is an important anatomic point. Lateral to the
spermatic vessels, and immediately below the fibers of the IPT, are the genital and
femoral branches of the GFN, the femoral nerve and the LFC nerve of thigh.
 Urinary bladder injury

72. PATIENT RELATED FACTORS-
 Select appropriate patients for laproscopy .
 Cases that may pose greater risk than usual for laproscopy –
 1.weight >100 kgs
 2. >2 previous subumbilical vertical incisons
 3. previous bowel obstruction, peritonitis or inflammatory bowel diseases .
 4. clotting disorders
 5. ascites / organomegaly

73. CONTRAINDICATIONS
 ABSOLUTE-
1. Generalized peritonitis
2. Intestinal obstruction
3. Clotting abnormalities
4. Liver cirrhosis
5. Failure to tolerate general anesthesia
6. Uncontrolled shock
 RELATIVE –
1. Multiple abdominal adhesions
2. Organomegaly
3. Abdominal aortic aneurysm

74. COMPLICATIONS POST SURGERY
 RESIDUAL AIR (REFERRED CHEST OR SHOULDER PAIN)
 WOUND HEMATOMA
 PORT SITE SEPSIS-
MYCOBACTERIUM CHELONAE
 PORT SITE HERNIA -
SUTURE ALL PORT OF 10 MM AND >
 PORT SITE RECUURENCE -
GB CANCER
 DELAYED FECAL FISTULA
 ADHESIONS

75. THANK- YOU