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
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%
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
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.