BAYLOR COLLEGE OF MEDICINEBAYLOR COLLEGE OF MEDICINEBAYLOR COLLEGE OF MEDICINE

SCOTT DEPARTMENT OF UROLOGY

Laparoscopy:Complications

Lars J Cisek MD PhD

Ooops!

Complications

The problem is not that there are problems. The problem is expecting otherwise.

Theodore Rubin

Judgement comes from experience.Experience comes from living through the results of bad judgement.

Patrick Walsh

There is a snake under every bush.

Edmond Gonzales

The Snakes

• Access/ports

• Visceral injury

• Inadvertent energy transfer

• Procedure based

• Closure

• Surgery in general

NOTE

Conversion is not on this list!

Fix’n Trouble

Convert for

• Problem you are not able to address

• Surgical Dystocia

• Have predetermined indications and benchmarks for the case

• Inadvertent laceration or perforation of intraabdominal structure or vascular structure.

• Usually initial access.

• Occurs with all access methods

• Most common injury - epigastric laceration

Access/Ports

• 5 per 10,000 to 3 per 1000

• Bowel or vascular injury comprises 76% of access injuries

• 13% mortality

Access/Ports

Access/Ports

• “Safety shields” are not safe

• Based on review of FDA device reporting database the term was removed from port advertising.

Anatomy

• Umbilicus at level of bifurcation

• A-P distance is ~1-3 cms

Access/Ports

Methods• Open or Hasson

• Closed or Veress

• Direct

Access/Ports

Hasson Veress Direct

?slow/fast Fast Faster

Bigger incision Minimal incision Minimal incision

Direct vision Blind Can beDirect vision

Novice Experience required

Experience required

Access/Ports

• A reliable and efficient method to pierce the body wall to gain access to the surgical site and establish the space is critical

• There are a number of options

• Find one which works quickly and reliably for you

Direct Access

Optical Trocar

Strategies to Limit Access/Ports Problems• Avoid scared areas

• Disposable initial trocar

• less entry force

• Lift abdominal wall

• increase distance to retroperitoneum

• Angle of entry 45-60o (umbilical)

• Adjust method to fit the patient senerio

Fix’n TroubleAccess/Ports

Epigastric Vessels

• Box stitch

Fix’n TroubleAccess/Ports

Epigastric Vessels

• Box stitch

Fix’n TroubleAccess/Ports

Epigastric Vessels

• Box stitch

Fix’n TroubleAccess/Ports

Epigastric Vessels

• Box stitch

Fix’n TroubleAccess/Ports

Epigastric Vessels

• Box stitch

Fix’n TroubleAccess/Ports

Epigastric vessels

• Cautery

• Harmonic

• Tie with figure of eight internally

Fix’n TroubleAccess/Ports

Mysenteric vessels

• Tamponade

• Harmonic

• Endo loop

• Tie with figure of eight internally

Fix’n TroubleAccess/Ports

Major vessels

• Tamponade

• Get blood

• Open

Fix’n TroubleAccess/Ports

Major vessels

• Tamponade

• Confirm all ready to convert

• Add extra port(s)

• Lap Sitinsky or Bulldog, suturing equipment

• Expose area cautiously, ordered release of tamponade

Fix’n TroubleAccess/Ports

Hollow Viscera

• These injuries may be harder to detect

• Veress needles may simply be removed, strongly consider a simple serosal stitch

• Larger injuries can also be closed primarily

• Look for second wall injury

Fix’n TroubleAccess/Ports

Hollow Viscera

• A surgical stapler can be used if lumen diameter for bowel is not compromised.

• A discrete injury in bowel can be exteriorized through an enlarged port site, and repaired

• Bladder injuries should prompt foley drainage, absorbable suture repair if needed

Fix’n TroubleAccess/Ports

Solid Viscera - liver, spleen, kidney

• Tamponade

• Argon, harmonic, true fulguration

• Surgical coagulant (FloSeal)

• Open

Gas embolism

• Sudden decrease in ET CO2 & BP

• Typically with initial insuflation/vascular injury

• Mill wheel murmur

• Advantage of Trendelenburg/left side down vs supine unclear

Injury to Viscera

• Usually occur with manipulation

• Tears or trauma from “rough handling”

• Energy

Electrosurgery

• Alternating current @ 5-20 x105 Hz

• Reversing polarity prevents cell depolarization

• Current heats the tissue

Electrosurgery

• Current flow follows least resistive path

• In body tissue resistance is in inverse proportion to water content

• Preferential flow:

blood>nerve>muscle>adipose>bone

• Heat generation is proportional to current density (at any point along the path)

Electrosurgery

• Monopolar

• 2 electrodes at a distance

• Small active electrode at site

• Large indifferent electrode at remote site

• Bipolar

• Active and indifferent electrode at the site of action

Electrosurgery• Cutting

• Sparks

• Continuous current duty cycle

• Tissue heats and cell explodes

• Fulguration

• Short current duty cycle (10%)

• Tissue heats then cools

• Desiccation

• Dry tissue by “boiling” water

Electrosurgery in laparoscopy

• Less cooling capacity in closed space

• High water content of gas which increases conductive capacity

• Potential for contained combustible gas (NO2, methane)

• Limited field of view

Electrosurgery in laparoscopy

• Current concentration

• Arcing

• Direct coupling

• Capacitive coupling

• Insulation failure

Insulation failure

Capacitive coupling

Ultrasonic energy• Electricity induces a vibration in a crystal

• Vibration propagates down a extending rod to a “balde” (standing wave)

• Mechanical vibration transfered to tissue with heating by friction within the tissue

• Local effect

• Instrument gets hot

• Good to about 5mm vessel size

Energy Sources

• There is less field effect with harmonic energy sources (thermal conduction but not heat production at a distance)

• The use of electrosurgical methods for bowel reflection and adhesiolysis is currently in less favor than ultrasonic

Energy

• The most dangerous injury is the conduction injury to bowel

• Delayed perforation

• Use harmonic to take down bowel adhesions, reflect colon

Fix’n TroubleEnergy

If a portion of bowel appears “blanched”

• Small - treat as a puncture

• Place a reinforcing suture

• Large - treat as a tear

• Oversew, exteriorize, open

• Think of electrocautery injury like high velocity GSW; harmonic - low velocity

Post Operative

Bowel injury

• Failure to thrive

• Ileus

• Obstipation

• Low grade fever

• Pain or drainage at a port site

Herniation

• Port sites

• More likely with:

• Larger port size

• Cutting greater than dilating trocars

• Midline greater than lateral

• Good data defends closure 10mm or greater in adults

• Peds 5mm (?3mm in infants)

Take time to deliberate, but when the time for action has arrived, stop thinking and go in.

- Napoleon Bonaparte

Fix’n Trouble

General considerations

• Have a plan, and a back up

• Addition of a second port to better visualize address problem

• Communicate with the surgical team

• Get help

• Open

Fix’n Trouble

Rehearse and review your plan

Build skills to address problems

Fix’n Trouble

Convert for

• Problem you are not able to address

• Surgical Dystocia

• Have predetermined indications and benchmarks for the case

Fix’n Trouble

Factors to consider for an advanced repair

• Equipment available

• Your skill level

• Your assistant’s skill level, teamwork

- Boy Scout Motto

Be prepared

Be prepared

• Easier to stay out of trouble than fix it

• Have a plan

• Know your limits

• Know the limits of your team

• Get help