How to Deal with Access Injury: Digestive and Vascular

How to deal with ACCESS INJURY: digestive and vascular George S. Ferzli MD, FACS Professor of Surgery SUNY HSC, Brooklyn, NY

PREVENTION is the best way to deal with access injury. Laparoscopic access varies on an individual patient basis.

Entry into abdomen Patient considerations: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Abdominal wall ,[object Object],[object Object],[object Object]

Epigastric vessels - Injury ,[object Object],[object Object],[object Object],[object Object],[object Object]

Epigastric vessels – Prevention ,[object Object],[object Object],Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

Epigastric vessels- Management ,[object Object],[object Object],[object Object]

Anatomic distribution of nerves across anterior abdominal wall ,[object Object],Iliohypogastric nerve (adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)

Incision line/trocar sites vs. nerve distribution Iliohypogastric n. Ilioinguinal n. Epigastric a. Trocar site Pfannenstiel incision (adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)

Bladder injury- ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Nehzat C et al. Laparoscopic management of intentional and unintentional cystostomy. Jnl Urol 1996; 156:1400 Armenakas N et al. Iatrogenic bladder perforations. JACS 2004; 198:78

Bladder injury- Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Tools: Laparoscopic entry systems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Hassan Veress Ternamian, Artin, MD, FRCSC. Laparoscopic Entry Safety.

Tools: Laparoscopic entry systems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Optiview Ternamian, Artin, MD, FRCSC. Laparoscopic Entry Safety.

Veress needle ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Veress needle ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Palmer’s entry point Bifurcation variability. 45° 90° * Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47

Open laparoscopy Hasson ,[object Object],[object Object],[object Object],[object Object],[object Object],Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47

Guidelines ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],*Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47

Vascular injury ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Harkki-Sirren P et al. Major Complications of laparoscopy: Follow-up Finnish study. Obst Gyned 1999; 94:95 Deziel DJ et cl. Complications of laproscopic cholecystectomy. Am J Surg 1993; 165:9 Saville L et al. Laparoscopy and major retroperitoneal vascular injuries. Surg Endosc 1995; 9:1096 Chapron et al. Major vascular injuries during gynecologic laparoscopy. JACS 1997

Vascular injury- Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Bowel injury ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Schrenk P et al. Mechanism, management and prevention of laparoscopic bowel injuries. Gastroin Endosc 1996; 43:572 Bishoff J et al. Laparoscopic bowel injury: Incidence and clinical presentation. J Urol 1999; 161:887

Management of injuries detected at initial access ,[object Object],[object Object],[object Object],[object Object],Veress injury Fecal odor / aspiration test Find another entry and excise site of injury Sharp trocar injuries Serosa (superficial) No further treatment Deep (through and through) Close transversely (if <1/2 direction of bowel Small bowel Brownish fluid Careful inspection Segmental resection if >1/2 mesenteric supply interrupted

Second trocar insertion ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

After second trocar insertion ,[object Object],[object Object],[object Object]

Conclusion Cautious Careful Preventive

How to Deal with Access Injury: Digestive and Vascular

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How to Deal with Access Injury: Digestive and Vascular