Complications of laparoscopy

Dr. S. Easwaramoorthy

Lotus hospital

Erode

Position related injuries Access related Injuries Due to Pneumoperitoneum During Surgery Post operative complications

Brachial plexusUlnar nerveFemoral nerveCommon peroneal nerve

Position related injuries Access related Injuries Due to Pneumoperitoneum During Surgery Post operative complications

Entry to free peritoneal cavity

No Injury to Major vessels

Aorta/IVC/Iliac vessels

Bowel

Bladder

Other viscera

Anaesthetised patient

Relaxed abdomen

Empty stomach

Empty bladder

Prepared bowel

Experienced team

Excellent equipments

Injury to

Vessel

Bladder

Bowel

During the insertion of Veress needle and Trocars

Pop test and Drop test

Abdominal wall

Inferior epigastric artery

Intra peritoneal

Omentum

Mesenteric vessels

Retroperitoneal

Aorta

IVC

Iliac vessels

Control of Bleeding•Diathermy•Figure of 8 suture•Foley’s balloon

Shock

Hemorrhage

Retro peritoneal hematoma

Co2 embolism

Incidence of major vascular injuries occurred in34 patients (0.05%) with 3 deaths after 77,604 lap cholecystectomy

•Aorta : 12•IVC : 4•Aorta/IVC : 1•Iliac vessels : 17

Deziel et alAm. J. Surg 1993: 165: 9-14

Don’t panic

Trocar in situ

Seek help/Arrange for blood

Immediate laparotomy

Vascular control

Harrith Hasson, Chicago

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

When it can happen? Needle in side a vessel/ liver Exposed vascular area Argon plasma coagulationHow to recognize? Hypotension and hypoxia Sudden drop in ETco2 Mill wheel murmurHow to manage? Stop pneumoperitoneum and vent it out Head down and left lateral position Aspiration of air through central line

During Access During Veress needle insertion Primary trocar insertion Secondary trocar insertion

Dissection/Retraction Release of adhesions

Diathermy use Pilot error Insulation failure Coupling

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

No Previous surgery 0-0.6%

Previous laparoscopy 0-15%

Laparotomy through Pfannensteil incision 20-28%

Laparotomy though midline incision 50-60%

Alternative sites

LUQ RLQ

With or without pneumoperitoneum

Under vision

Layer by layer controlled entry

During Access During Veress needle insertion Primary trocar insertion Secondary trocar insertion

Dissection/Retraction Diathermy use

Pilot error Insulation failure Coupling current

Position related injuries Access related Injuries Due to Pneumoperitoneum During Surgery Post operative complications

Cardiac HR Decrease in COIncrease in SVRDecrease in Venous return

Respiratory Increase in Air way pressureDecrease in FRCDecrease in ComplianceAcidosis

Vascular Decrease in Venous returnCompression of splanchnic bed

Neurohormonal Catecholamine releaseReninCortisolVasopressin

Trouble Prevention•IAP < 12mm•Pre op volume loading•Hyperventillation•PEEP•Monitor

•End tidal Co2•PCWP•Trans eso Echo

Hypercapnia and acid base disturbance

Abdominal pain (H2CO3)

Position related injuries Access related Injuries Due to Pneumoperitoneum During Surgery Post operative complications

Injury During

1 Bile duct injury Lap cholecystectomy

2 Bladder injury Lap hysterectomy

3 Ureteric injury Lap colectomy , hysterectomy

4 Bowel injury Adhesiolysis

5 Pneumothorax Lap fundoplication

•Inadvertent division•Dissection & traction injury•Diathermy induced•Staples

Classical BDI during Lap Chole

You see What U want to See

Position related injuries Access related Injuries Due to Pneumoperitoneum During Surgery Post operative complications

Port Site sepsis Mycobacterium Chelonae

Port site hernia Suture all ports 10mm & >

Port site recurrence GB cancer

Adequate training reduces laparoscopy related complications

Trouble shooting guidelines are mandatory

Conversion to open should not be seen as failure.