2. Laparoscopic
Complications
§ Often
considered
as
minimally
invasive
surgery
but
risk
is
not.
§ Has
specific
risks
and
complications
§ Most
complications
occur
during
the
setup
phase
(60-‐75%)
§ Complications
8.9%
laparoscopy
vs.
15.2%
laparotomy
(metaanalysis)
3. Complications
§ Generally
safe
but
does
have
mortality
(0.03%-‐0.49%)
§ In
gynecology
LAVH
most
commonly
associated
with
complications
§ Adnexal
surgery
next
§ Generally
more
complex
surgery/
earlier
on
a
learning
curve
will
lead
to
more
complications
4. Complications
§ Injury
to
adjacent
organs
§ Bleeding
from
solid
organs
(liver
and
spleen)
§ Vascular
injuries
§ Puncture/perforation/cauterization
of
the
bowel
§ Transection/perforation
of
bile
ducts
§ Perforation
of
the
bladder
§ Puncture/perforation
of
the
uterus
§ Complications
of
abdominal
access
§ Port
site
hernia
§ Wound
infection
§ Also
see
Injury
to
adjacent
organs
§ Complications
of
specimen
removal
§ Port
site
recurrence
of
cancer
§ Splenosis
§ Endometriosis
§ Complications
of
the
pneumoperitoneum
§ Pneumothorax
§ Pneumomediastinum
§ Gas
embolus
§ Subcutaneous
emphysema
5. Patient
risk
factors
§ Previous
abdominal
or
pelvic
surgery
§ Previous
intra-‐abdominal
or
pelvic
disease
process(infection,
neoplasia,
inflammation)
§ Obesity
§ Thinness
§ Anticoagulation
8. SOGC
Guideline
§ LUQ
entry
considered
with
adhesions/
surgery
§ Veress
needle
tests
don’t
work;
do
not
waggle
§ Attach
the
CO2
as
pressure
<
10
mm
Hg
is
indicative
of
being
in
cavity
§ Elevation
is
not
helpful
§ Vary
angle
according
to
BMI
§ Use
pressure
and
not
volume
to
determine
adequacy
of
insufflation;
high
pressures
do
not
effect
healthy
women
§ May
use
Hassan
technique
but
not
done
by
Gyn;
Open=veress
§ Direct
insertion
OK
§ Shielded
trocars
OK
§ Radially
expanding
trocars
not
recommended
§ Visual
entry
OK
but
not
superior
9. Positioning
§ Patient
safety
§ Comfort
for
surgeon
and
assistants
§ Provide
access
for
surgery
§ Use
moveable
stirrups
§ Arms
at
side
(wrapped)
§ Bed
that
can
be
lowered
(45
cm
of
floor)
10. Peripheral
nerve
injury
ú Poor
patient
position
ú Pressure
from
surgeon/
assistants
ú Rarely
from
disection
(
exception
is
obturator
and
genitofemoral
nerve)
§ Perineal
nerve
injury
ú Nerve
compression
against
stirrups
ú Loss
in
sensation
lat
aspect
of
foot
and
leg
with
a
foot
drop
ú Take
care
with
appropriate
stirrups
and
position
11. Peripheral
nerve
injury
§ Brachial
Plexus
injury
ú Arms
abducted
>
90o
ú Deep
trendelenburg
position
ú Surgeon
leaning
against
arms
ú Diagnosed:
damage
to
C5-‐C6
roots
with
loss
of
flexion
of
elbow
and
aduction
of
shoulder
ú Prevention:
Place
arms
at
side
Tuck
arms
with
padding
Large
patients
use
arm
boards
18. Trocar
Site
Hernias
§ Hernias
are
well
reported
§ Ports
greater
than
10
mm
ú 21
per
100000
cases
ú 17.9%
despite
fascial
closure
ú 86.3%
with
trocars
greater
than
10
mm
ú Close
port
sites
20. Vascular
Injuries
§ Trauma
to
a
large
vessel
§ Risk
of
major
vessel
injury
1/1000
§ Large
vessels
need
a
laparotomy
and
appropriate
consultation
§ Smaller
vessels
can
be
controlled
with
bipolar
cautery,
clips,
pressure
25. Gastro-‐Intestinal
Injury
§ risk1.8/1000
§ Mechanical
or
thermal
§ Mechanical
commonest
during
set
up
with
the
veress
needle
or
trocar
26. Risk
factors
for
GI
injury
ú Previous
laparotomy
(midline>pfannensteil)
ú Previous
generalized
peritonitis(
inc.
ruptured
appendix)
ú Previous
bowel
obstruction
or
resection
ú Previous
intraabdominal
cancer,
rads,
chemo
ú Inflammatory
bowel
disease
ú PID
ú Endometriosis
27. GI
Injury
§ If
at
risk
need
bowel
prep
(fleet
enema)
§ NG
to
decompress
the
stomach
§ Veress
needle
aspiration
ú If
in
can
remove
and
reinsert
checking
site
§ Trocar
Injuries
ú If
in
put
a
foley
down
the
sheath
and
then
laparotomy
with
appropriate
consultation
ú Can
repair
small
lesions
in
small
and
large
bowel
28. GI
thermal
Injury
§ Three
main
causes
ú Defective
insulation
ú Lateral
thermal
spread
with
a
source
too
close
to
the
bowel
ú Contact
with
the
bowel
during
activation
§ Suspect
with
persistently
blanched
bowel
ú Need
to
resect
with
5
cm
margin
Classical
recommendation,
not
always
necessary.
33. Other
electrosurgical
complications
§ Alternate
site
burns
at
the
dispersive
site
ú Partial
detachment
ú Manufacturing/quality
defect
ú Placement
over
moist
skin,
bony
prominence
§ Caution
with
pacemakers
ú Monopolar
currents
may
override/
reset
pacemakers
34. GI
Injury
§ Biggest
problem
is
delay
in
diagnosis
§ 34-‐62%
of
injuries
noted
at
time
of
surgery
§ Average
time
to
small
bowel
perf
3.3
days
§ Average
time
with
large
bowel
perf
2-‐10
days
35. GI
Injury
§ Usually
Present
<
48
hrs
with
peritonitis
§ CO2
Gas
reabsorbed
within
48
hrs
§ Explore
early
as
delay
may
be
catastrophic
37. Risk
Factors:
Urinary
Tract
Injuries
Endo
PID
acute
or
chronic
Pelvic
malignancy
Previous
pelvic
surgery
Previous
pelvic
radiation
Bladder
wall
diverticula
Adhesions
Distended
bladder
wall
Surgery
during
pp
or
lactation
age
38. Urinary
Tract
Injury
§ Use
foley
or
empty
bladder
§ Risk
at
LAVH
with
bladder
dissection
§ Ureteric
injury
with
adnexal
surgery
ú Identify
and
retract
40. Urinary
Tract
Injury
§ Bladder/
small
ureteric
injuries
can
be
repaired
primarily
with
stents
§ Thermal
injury
requires
resection
41. Urinary
Tract
Injury
§ Bladder
injury
noted
at
1.1
days
§ Ureteric
injury
at
29.4
days
ú Be
aware
of
low
urine
output
ú Ascites
/
peritonitis
ú Investigate
with
IVP
cysto
and
retrograde
42. Other
Complications
§ Anaesthetic
ú Increased
CO2
ú Problems
with
ventilation
pressures
ú Arrhythmias
ú Pain
§ Subcutaneous
emphysema/
pneumomediastinum
§ Wound
infection
43. Specimen
Retrieval
§ Failure
to
use
appropriate
bags/
devices
§ Mechanical
difficulty
§ Spillage
of
irritant
material,
e.g.
Ovarian
Dermoid
§ Infectious
material
leak
44. Port
site
mets
§ Well
recognised
ú Increased
with
CO2
pneumoperitoneum
ú Increased
intra
abdominal
pressures
ú Excessive
manipulation
ú Failure
to
use
bags
§ May
occur
in
similar
rates
to
open
cases?
45. TABLE 18-4 -- Colon Cancer Recurrences: Laparoscopy Versus Open
Authors Year No. of Patients No. of Port Site Metastases Percentage of Port Site
Metastases
Guillou et al 1993 59 1 1.7
Franklin et al 1996 191 0 0
Gellman et al 1996 58 1 1.7
Kwok et al1996 83 1 1.2
Vukasin et al 1996 451 5 1.1
Fleshman et al 1996 372 4 1.1
Lacy et al 1997 106 0 0
Fielding et al 1997 149 2 1.3
Larach et al 1997 108 0 0
Croce et al 1997 134 1 0.9
Khalili et al 1998 80 0 0
Bouvet et al 1998 91 0 0
Kawamura et al 1999 67 (gasless) 0 0
Leung et al1999 217 1 0.65
Poulin et al 1999 172 0 0
Schiedeck et al 2000 399 1 0.25
Total 1737 17 1
From Zmora O, Gervaz P, Wexner SD: Trocar site recurrence in laparoscopic surgery for colorectal cancer.
Surg Endosc 15:790, 2001.
48. Conclusion
§ Laparoscopic
surgery
does
have
considerable
advantages
§ Need
to
be
aware
of
all
potential
complications
and
have
methods
available
to
fix!
