Correct Trocar Placement

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    BASIC LAPAROSCOPY

    DR UTPAL DE

    Department of Surgery

    CMCH

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    Access Techniques

    Open, Hasson technique Small incision through skin and fascia and direct view of

    peritoneum

    Closed, Veress needle technique Needle with safety shield placed through a small skinincision

    Optiview Technique

    Direct visualization of abdominal wall layers with insertion

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    Veress Technique

    Closed, Veress needletechnique Needle with safety

    shield placed through a

    small skin incision Insufflate abdomen

    with CO2

    Exchange needle for

    trocar

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    Trocars

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    Orientation

    Positioning Trocars, camera and

    surgeon

    Triangulation of

    InstrumentsCamera behind and in

    center of workSpatial Orientation

    Pitch Roll Yaw

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    Triangulation of Instruments

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    Camera-Target- Monitor Axis

    Align Field of View and

    Direction of View with

    Target and Monitor

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    Eyes cannot see what the mind does not know

    Visual cues from known anatomyOrientation changes with camera position

    Know where you are in the box

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    COMPLICATIONS OF

    LAPAROSCOPY

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    The incidence of laparoscopic

    complications is:1. 1.1% to 5.2% in minor proceduresand

    2. 2.5% to 6% in major ones

    INTRODUCTION

    (Kane & Krejs, 1984).

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    To reduce the prevalence ofcomplications:

    1. Training programmes must include

    supervision at all levels of developmentand

    2. There must be a high degree of

    awareness of the potential risks oflaparoscopic surgery.

    INTRODUCTION

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    Complications may be associated with:

    1. The anesthesia2. The induction of pneumoperitoneum

    3. Insertion of primary and secondarytrocars

    4. Thermal Instruments5. Mechanical Instruments

    6. Other associated conditions

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    A. ANESTHETIC complication

    Local anesthesia may be used

    fortubal sterilization andsome other minor procedures.

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    May produce specific problems andcomplications:

    1.Complications directly attributable to the

    general anesthesia are no different from thosewhich may occur when any other type ofsurgery is performed.

    2.Some features of laparoscopic surgerypredispose to specific anestheticcomplications.

    A. THE ANESTHETIC complication

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    The use of a steep Trendelenburgposition and the distension of the

    abdomen may both reduce excursionof the diaphragm.

    Carbon dioxide (CO2) can be absorbed

    particularly during prolonged operations.

    A. THE ANESTHETIC

    complication

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    Monitoring by :1. Pulse oximetry,

    2. The use of endotracheal intubationand3. Positive pressure assisted ventilation

    Reduce the risk of hypercarbiato a minimum.

    A. THE ANESTHETIC

    complication

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    Ifarrhythmia occursthe anesthetist will be responsiblefor its management and

    The surgeon should :

    1. Return the patient to the supine

    position,2. Evacuate the pneumoperitoneum and

    3 Discontinue the surgery.

    A. THE ANESTHETICcomplication

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    Vasovagal reflex may produceshockand collapse especially if the

    anesthetic is not deep enough.It may beprevented by efficient

    anesthesia and should only bediagnosed when other causes of shockhave been excluded.

    A. THE ANESTHETIC complication

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    1. Anxiety

    May be prevented byadministration of

    Diazepam 20 mgorally about one hour

    pre-operatively.

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    2. Vasovagal reaction

    This may be associated

    withbradycardia and,in more severe cases,cardiac arrest, convulsion

    and shock.

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    The treatment should include:

    1.Atropine 0.5 mg given intravenously (IV)

    2.Oxygen given by endotracheal tube at a rate of4-6 litres/minute

    3.Adrenaline 0.5-1.0 ml of 1:100,000 solution

    given slowly IV4.Respiratory and cardiac resuscitation.

    2. Vasovagal reaction

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    3. Pain

    Pain may be prevented to some extentby the administration ofnon-steroidal

    anti-inflammatory drugs such asmefanimic acid, naprosene or fentanyl.

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    4. Allergic reactions and anaphylaxis

    Any local anaesthetic should be given

    initially as asmall test dose to determine

    if an unsuspectedhypersensitivity exists.If it does, no more medication should be

    administered.

    If it occurs it will be characterized by

    agitation, flushing, palpitations,

    bronchospasm, pruritus and urticaria.

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    The treatment will depend on the severity ofthe reaction and may include:

    1.Adrenaline0.5 mg (1:100,000 solution IVI or IMI)2.Prednisolone25 mg IVI

    3.Theophylline250 mg (10ml) given slowly IV.

    4.Intravenous fluids5.Oxygen

    4. Allergic reactions and anaphylaxis

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    B. INDUCTION OF

    PNEUMOPERITONEUM

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    1. Extra-peritoneal gas

    insufflation

    the Veress' needle into the

    peritoneal cavity may produce extra-peritoneal emphysema.This occurs in about 2% of cases.

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    The diagnosis is made by palpation

    ofcrepitus caused by bubbles of C2under the skin..

    If this is recognized early, the gas

    may be allowed to escape and theneedle re-introduced through the

    same or another site

    1. Extra-peritoneal gas

    insufflation

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    If the complication is not recognizedduring the introduction of gas, the typical

    appearance of extra-peritoneal gas may berecognized when an attempt is made tointroduce the telescope.

    It is always essential to view through thetelescope during its insertion through its

    cannula

    1. Extra-peritoneal gas insufflation

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    The typicalspider-web

    appearance caused by pre-

    peritoneal insufflation will be seenwhen the telescope reaches the end

    of the cannula andfurtherstripping of the peritoneum by the

    tip of the telescope avoided.

    1. Extra-peritoneal gas insufflation

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    The laparoscope should be withdrawn and

    attempts made to express the gas.

    The needle may then be re-introduced

    through the same or another site.

    Alternatively the trocar and cannula may be

    introduced by 'open laparoscopy'.

    1. Extra-peritoneal gas insufflation

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    The aspiration test and the

    high insufflation pressure

    will make it obvious that

    the needle is sited incorrectly

    in which case it should be

    withdrawn and re-sited.

    1. Extra-peritoneal gas insufflation

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    Complications from the

    distension medium

    Carbon dioxide (CO2)

    is the distension medium mostcommonly used for operative

    laparoscopy.

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    Carbon dioxide (CO2)Gas embolism is possible but uncommon

    because the gas is highly soluble and isreabsorbed so quickly that, even if there hasbeen a moderate embolus, the circulatorychanges return to normal within a fewminutes and the patient recovers.

    Up to 400ml of gas may be intravasatedwithout producing changes in the ECG.

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    Cardiac arrythmia may be due to excessiveabsorption of CO2.

    Monitor the intra-abdominal pressure throughout

    the operation and use an automatic pneumoflatorfor all but the simplest forms of surgery.

    This will cut out if the intra-abdominal pressure

    rises.Endotracheal intubation and positive pressure

    respiration will help to prevent complications from

    CO2 insufflation.

    Carbon dioxide (CO2)

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    Post-operative pain is common with CO2insufflation due to peritoneal irritation

    which is a result of conversion of CO2 tocarbonic acid.

    The chest pain may be confused with

    coronary heart disease and be treated

    inappropriately with anti-coagulants.

    Carbon dioxide (CO2)

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    Nitrous oxide (N2O) has becomepopular with some laparoscopists because

    there are less side effects than with CO2.Anesthetists can dispense with

    intubation and allow the patient to breaththrough a laryngeal mask.

    Complications from the distension

    medium

    C li i f h di i

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    However, a diagnostic laparoscopy maydevelop into a complicated operativeprocedure.

    N2O supports combustion.

    Methane gas may be released into the

    peritoneal cavity following bowel injury.A high frequency monopolar current used

    during laparoscopic surgery may cause an

    explosion.

    Complications from the distension

    medium

    C li i f h di i

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    The main place forN2O is whenlaparoscopy is being performed under

    local anesthesia in which case the painfactor becomes important.

    This is applicable to tubal sterilization

    with clips, rings, or bipolar coagulation,but not to more advanced laparoscopic

    procedures

    Complications from the distension

    medium

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    2. Mediastinal emphysema

    Gas may extend from a correctlyinduced pneumoperitoneum into the

    mediastinum and create mediastinalemphysema.

    Extensive emphysema may causecardiac embarrassment which will bediagnosed by the anaesthetist.

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    There will be loss of dullness topercussion over the precordium.

    The laparoscopy must be abandoned andas much gas as possible evacuated.

    The patient must be kept under closeobservation until the gas has beenabsorbed.

    2. Mediastinal emphysema

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    3. Pneumothorax

    May result from insertion of the Veress'needle into the pleural cavity.

    Whenever a high site of insertion is

    chosen the needle should be directedaway from the diaphragm and, as always,

    the standard protocol of aspiration andsounding tests employed.

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    Should be suspected if there is difficulty inventilating the patient.

    There may be a contra-lateral mediastinal shift andincreased tympanism over the affected area.

    The procedure should be abandoned and the gasallowed to escape.

    The patient should be kept under observation.

    Occasionally assisted ventilation and insertion of apleural tube may be required.

    3. Pneumothorax

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    4. Pneumo-omentum

    The omentum is penetrated by the Veress' needle inabout 2 % of cases.

    The misplacement should be recognized by theaspiration test and the position of the tip altered tofree the needle.

    There will also be a raised insufflation pressurewhich should lead the surgeon to suspect an error inthe position of the needle.

    The condition is usually innocuous unless omentalblood vessel is punctured.

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    5. Injury to gastro-intestinal tract

    Certain conditions may predispose toinjury by the Veress' needle.

    These include :1. Distension of the gastro-intestinal tractor

    2. Adhesions of bowel to the abdominalwall.

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    Penetration of the

    stomach may occur whenan upper abdominal site ofinsertion is chosen or the

    stomach is distended duringinduction of anesthesia.

    5. Injury to gastro-intestinal tract

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    Gastric distension may also occur if

    anesthesia is maintained with a mask

    and should be suspected if there isupper abdominal distension or

    increased tympanism.

    In this case thestomach should be

    aspirated with a naso -gastric tube.

    5. Injury to gastro-intestinal tract

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    The diagnosis ofgastric

    perforation by the Veress' needle

    may be made when the patientbelches gas.

    The laparoscope should beintroduced and the stomach

    inspected carefully.

    5. Injury to gastro-intestinal tract

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    Provided the stomach wall has not beentorn, no surgical treatment is necessary

    but a broad spectrum antibiotic should begiven.

    If the stomach has been torn, surgicalrepaireither by laparotomy orlaparoscopy is mandatory.

    5. Injury to gastro-intestinal tract

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    Aspiration following initial

    insertion of the needle

    should permit early

    recognition of perforation

    of the bowel but it is notfool-proof.

    5. Injury to gastro-intestinal tract

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    Bowel penetration should be

    suspected if there is

    1.Asymmetric abdominaldistension,

    2.Belching,3.Passing of flatus or a fecal

    odour.

    5. Injury to gastro-intestinal tract

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    The induction ofpneumoperitoneum should be

    stopped and the needle re-sitedto introduce thepneumoperitoneum correctly.

    The gastro-intestinal tractshould be examined carefully forperforation.

    5. Injury to gastro-intestinal tract

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    It is important that bothsides of the bowel be examined

    as the exit wound may belarger than the entry wound.

    Fecal soiling demandsimmediate laparotomy and

    repair of the bowel.

    5. Injury to gastro-intestinal tract

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    It is important to ensure that

    there has not been a

    through-and-through injury

    of a loop of bowel

    which is adherent to theperitoneum at the site of

    insertion.

    5. Injury to gastro-intestinal tract

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    A simple needle

    penetration requires notreatment but the patient

    should be kept under

    observation and given

    broad spectrum antibiotics.

    5. Injury to gastro-intestinal tract

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    6. Bladder injury

    Routine catheterization of

    the bladder and propersitting of the needle should

    prevent bladder penetration.

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    Ifpneumaturia is noted

    the needle should be

    partially withdrawn and thecreation of

    pneumoperitoneumcontinued.

    6. Bladder injury

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    The bladder peritoneum should

    be carefully inspected to ensure

    that no significant injury has beencaused.

    The treatment of a simplepuncture is conservative with

    postoperative bladder drainage.

    6. Bladder injury

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    7. Blood vessel injury

    The Veress' needle maypenetrate:

    1. omental or2. mesenteric vessels or

    3. any of the major abdominal orpelvic arteries or veins.

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    Minor vascular injuries involving

    the omental or mesenteric vessels

    are difficult to prevent asit is impossible to ensure that

    the omentum is not close to the

    abdominal wall during blindinsertion of the insufflating

    needle.

    7. Blood vessel injury

    7 Bl d l i j

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    Injury may be suspected if:

    1. blood returns up the open needle

    or if :2. free blood is seen in the peritoneal

    cavity after insertion of thelaparoscope.

    7. Blood vessel injury

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    If blood returns up the needle and

    the patient's condition is stable,

    the site of injury may beinvestigated laparoscopically.

    The needle should be left in place

    and a 5 mm laparoscope introduced

    through a suprapubic cannula.

    7. Blood vessel injury

    7 Blood vessel injury

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    Minimal bleeding may usually becontrolled by bipolar coagulation or a

    laparoscopic suture.

    Laparotomy is not usually necessaryexcept in the case of injury to the

    superior mesenteric artery.

    Such injury requires repair by avascular surgeon

    7. Blood vessel injury

    (Bassil et al, 1993)

    7 Blood vessel injury

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    Injury to the major vessels may beprevented by:1.Liftingthe abdominal wall,

    2.Anglingthe needle towards the pelvisonce the initial thrust through the

    fascia has been made and by3.Insertingonly as much of the needle

    as necessary.

    7. Blood vessel injury

    7 Bl d l i j

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    Thin patients and children areat particular risk of this injury.

    Withdrawalof blood onaspiration following insertion of

    the needle shouldallow earlydetection of blood vessel injury.

    7. Blood vessel injury

    7 Blood vessel injury

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    If injury to a vessel such asthe aorta, inferior vena cava

    or common iliac vessel

    is suspected,the needle should be left place

    to mark the site of the injuryand laparotomy performed

    through a mid-line incision.

    7. Blood vessel injury

    7 Bl d l i j

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    There is usually a largehaematoma which obscures the

    site of the injury.

    The aorta should be compressed

    with a clamp or hand until a

    vascular surgeon arrives toperform definitive surgery.

    7. Blood vessel injury

    7 Blood vessel injury

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    Dramatic collapse may result frompenetration of a major vessel but the

    bleeding may not be immediately

    evident if it is retro-peritoneal.The loose areolar tissue anterior to

    the aorta can allow accumulation of a

    considerable amount of blood before

    frank intra-abdominal bleeding is

    seen.

    7. Blood vessel injury

    7 Blood vessel injury

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    A thorough search must bemade to determine the extentof vessel damage.

    This includes retraction ofbowel to expose the aorta

    above the pelvic brim which isthe most common site ofperforation.

    7. Blood vessel injury

    7 Bl d l i j

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    Failure to do search may

    result in continued bleeding

    and formation of a largehaematoma leading to a

    second episode of shock somehours later

    7. Blood vessel injury

    8 G b li

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    8. Gas embolism

    Intravascular insufflation ofgas may lead to gas embolism

    or even death.This can only happen if the

    penetration by the Veress'

    needle goes unrecognized and

    insufflation commences.

    8 G b li

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    It should be prevented byroutine use of the aspiration

    test.The patient should be turned on

    to the left lateral position and,

    If immediate recovery does nottake place, cardiac punctureperformed to release the gas.

    8. Gas embolism

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    9. Puncture of liver or spleen

    The liver or spleen may be

    punctured by the Veress

    C O C O O OC S

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    C. INTRODUCTION OF TROCARS AND

    CANNULAE

    Some of the most serious injuries

    that occur during laparoscopy are

    caused by the insertion of thetrocars and cannulae.

    Insertion of the primary trocarand cannula is, of necessity, blind.

    INTRODUCTION OF TROCARS AND

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    The causation of injuries

    by the primary trocar aresimilar to those caused by

    the Veress' needle but the

    magnitude of the injury

    is greater.

    INTRODUCTION OF TROCARS AND

    CANNULAE

    INTRODUCTION OF TROCARS AND

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    The sites of the secondary

    portals of entry must be

    selected carefully and theinsertion must always be

    made under visual control.

    INTRODUCTION OF TROCARS AND

    CANNULAE

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    1. Injury to vessels in the abdominal wall

    Superficial bleeding from theincision rarely gives rise to

    concern and always stops withapplication of pressure.

    Bleeding from puncture ofthe deep inferior epigastricartery is more serious.

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    The artery is at risk

    during the insertion ofsecondary trocars and

    cannulae.

    Inferior epigastric artery

    Inferior epigastric artery

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    Injury may be prevented bytransilluminating the abdominal

    wall before insertion in a thin

    patient or by visualizing the

    artery laparoscopically as it runs

    lateral to the obliteratedumbilical artery.

    Inferior epigastric artery

    I f i i i

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    The site of insertion can then bechosen by depressing the wall skin

    with the handle of the scalpel andnoting its relationship to the vessels.The diagnosis may be made by the

    sight ofblood dripping into the pelvisfrom the trocar wound.

    Inferior epigastric artery

    I f i i t i t

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    Occasionally blood may actually beseen spurting across the abdominal

    cavity.Alternatively the immediate or

    delayed appearance of a large

    abdominal wall haematoma indicatesinjury to the deep inferior epigastric

    artery

    Inferior epigastric artery

    Inferior epigastric artery

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    The treatment is usually simple.The trocar and cannula should be

    left in situ to act as a marker and also

    prevent the artery slipping away.

    A Foley catheter passed down the

    cannula and inflated may act as acompress and control the bleeding.

    Inferior epigastric artery

    Inferior epigastric artery

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    Alternatively the incision should beenlarged to about 2 cm in length to

    expose the anterior rectus sheath.

    A round bodied needle should be

    inserted through the full thickness of

    the abdominal wall from the sheathto the peritoneum under

    laparoscopic control.

    Inferior epigastric artery

    Inferior epigastric artery

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    The needle point should be broughtout again to the surface of the rectus

    sheath and a knot tiedfirmly on the

    sheath.This is preferable to tying the knot on

    the skin which is painful and leaves an

    unsightly scar although it is acceptableto tie the knot over a gauze swab to

    prevent skin injury.

    Inferior epigastric artery

    I f i ig t i t

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    It may be necessary

    to insert two sutures,one above and

    one belowthe site of bleeding.

    Inferior epigastric artery

    Inferior epigastric artery

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    Occasionally it may benecessary to open the wound

    wider to locate the bleeding

    artery.

    This should be reserved for

    those cases where there isprofuse bleeding or primary

    laparoscopic suturing is

    Inferior epigastric artery

    2. Injury to an intra-

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    j y

    abdominal vessel

    Injury to minor blood vessels is usuallyself-limiting or can be controlled by

    bipolar electro-coagulation.

    Damage to major vessels is more seriousthan with a Verres' needle because of the

    size of the trocar tip and may result inprofuse bleeding.

    2. Injury to an intra-abdominal vessel

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    Injury to omental vessels may compromise the

    vitality of a segment of bowel.Treatment of these injuries is by:

    1. Resuscitation,

    2. Laparotomy,

    3. Vascular repair or ligation and, where necessary,

    4. Bowel resection and anastomosis with theassistance of the appropriate surgical colleague.

    j y

    2. Injury to an intra-abdominal vessel

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    A small leak from the a major vein may not beimmediately apparent.

    The intra-abdominal pressure of the

    pneumoperitoneum and the decreased venouspressure induced by the Trendelenburg position maytemporarily control it.

    However, as soon as the intra-abdominal andvenous pressures return to normal, the bleeding may

    recommence and produce a retro-peritonealhaematoma and shock.

    2. Injury to an intra abdominal vessel

    2. Injury to an intra-abdominal vessel

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    It is essential therefore, at thecompletion of any laparoscopic

    procedure, but especially those involving

    the pelvic side wall, toinspect the course of the major vessels

    and look for a haematoma.

    This applies particularly to the

    treatment of endometriosis at this site.

    2. Injury to an intra abdominal vessel

    2 Injury to an intra abdominal vessel

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    A small haematoma may be the

    only evidence of injury to a vein

    at the pelvic brim.Occasionally there may be a

    defect in the overlyingperitoneum which indicates the

    site of entry of the trocar.

    2. Injury to an intra-abdominal vessel

    2 Injury to an

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    It is essential to proceed to

    laparotomy to repair the vessel.A vascular surgeon should beconsulted and the vesselcompressed until the arrival ofspecialized assistance.

    2. Injury to an

    intra-abdominal vessel

    3 Injury to a hollow viscus

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    3. Injury to a hollow viscus

    Injury to a hollow viscus may vary fromsuperficial damage of the serosa tocomplete penetration into the lumen.If penetration has occurred:1. The viscus may slip off the trocar,2. The trocar may remain within the lumen

    or, rarely:3. The trocar may pass right through the a loopof bowel which becomes impaled upon it.

    3 I j t h ll i

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    It is always important to

    inspect the bowel at the axis

    of insertion of the primarytrocar and cannula to ensure

    that it has not beendamaged.

    3. Injury to a hollow viscus

    3. Injury to a hollow viscus

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    If the cannula remains within the bowel

    the injury will be obvious by the

    recognition ofmucosal folds.

    A through and through injury may bemissed and only become apparent by the

    sight offaecal soiling, a faecal smell

    when the pneumoperitoneum is releasedor the subsequent development of

    peritonitis.

    3. Injury to a hollow viscus

    3. Injury to a hollow viscus

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    Injury to the stomach or bowel arealways serious.

    The management depends on the

    skill of the surgeon.The classical treatment is to perform

    laparotomy and suture the bowel in two

    layers.

    A skilled surgeon may perform the

    repair by laparoscopic suturing

    j y

    3. Injury to a hollow viscus

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    The defect should be closed in twolayers in such a way as to avoid

    stricture formation, there should be

    copious peritoneal irrigation and a

    drain should be inserted into the

    abdomen.

    Appropriate antibiotic therapy

    should be instituted.

    3. Injury to a hollow viscus

    3. Injury to a hollow viscus

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    It may not be possible to identifythe site of bowel injury by

    laparoscopy.

    In this case it is essential to performlaparotomy to find and treat the

    bowel injury.Failure to do this will result in the

    patient developing faecal peritonitis

    j y

    3. Injury to a hollow viscus

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    Bladder laceration may occurduring mobilization of the bladder

    in advanced pelvic surgery.It should be sutured in two

    layers using laparoscopic suturing

    technique and a Foley catheterinserted into the bladder.

    3. Injury to a hollow viscus

    4. Damage to other organs

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    g g

    Minor injuries to other organs areusually self-limiting.

    They should be inspected at the

    completion of the procedure.

    Peritoneal lavage must be

    carried out to remove blood andclot and ensure that the bleeding

    has stopped.

    4. Damage to other organs

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    A small puncture on thesurface of the uterus may

    be treated with bipolarelectro-coagulation if

    bleeding does not stopspontaneously.

    4. Damage to other organs

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    D THERMAL DAMAGE

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    D. THERMAL DAMAGE

    Burns from electric current were one of themajor causes of complications whenmonopolar tubal coagulation was the principle

    method offemale sterilization.The incidence of burns was dramatically

    reduced by the introduction ofbipolarandthermal coagulation and mechanical devices toocclude the tubes.

    THERMAL DAMAGE

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    Monopolar electric current passes intothe patient's body from the electrode

    which may be forceps or a needle.

    The current passes into the patient'stissues at the point of contact and then

    must return to the generator via the

    return plate.

    This is usually placed on the patient's

    leg.

    THERMAL DAMAGE

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    The effect of the electric

    current will depend its

    power and the powerdensity which, in turn

    depends on the area andduration of application.

    THERMAL DAMAGE

    THERMAL DAMAGE

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    To obtain maximum tissue effect

    the area of application at the target organis small.

    The current passes from that small areaalong the path of least resistance towardsthe return plate.

    In gynecological surgery this pathway isusually over the surface of loops of

    bowel THERMAL DAMAGE

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    The area of the return plate islarge so the power density at its

    site of application to the skin is

    low.However on its return pathway

    the current may pass over a small

    area of contact between twoorgans.

    The power density at that point

    THERMAL DAMAGE

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    In this way a burn may occur

    outside the surgeon's visual field.

    Normally this does not happen

    and the current passes

    harmlessly to the dispersiveplate.

    THERMAL DAMAGE

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    Thermal injury to organs such asbowel mayalso result from leakage of current from theshaft of the instrument.

    This may result from :1. Insufficient or faulty insulation or from

    2. Capacitative coupling in which there is a

    build up of current in the shaft of theinstrument because the normal escape routehas been shut off.

    THERMAL DAMAGE

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    Current normally escapes from the metalcannula through the patient's anteriorabdominal wall to the return plate.

    If aplastic cannula has been used this route isclosed and the current may escape to bowel.

    If the contact point between instrument and

    bowel is small, thepower density may be highand thermal injury will result.

    THERMAL DAMAGE

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    Occasionally the monitoring system

    may not be properly earthed.

    If the current passes via an ECG

    electrode instead of to the returnplate, the patient may suffer a skin

    burn because the ECG electrode is

    small and so the power density is

    high at this site.

    THERMAL DAMAGE

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    Alternatively, the current maypass along one of the

    ancillary instruments which,if not properly insulated, may

    produce a skin burn at the portal

    of entry or the surgeon maysuffer a burn on the hands or

    face.

    THERMAL DAMAGE

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    There is a danger oflateralheat spread with monopolar

    or bipolar current.

    It is important to ensure that

    no other organ is in contact

    with or near an organ to which

    electricity is being applied.

    THERMAL DAMAGE

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    Lateral spread may also beminimized by keeping the forceps

    blades close together.Build-up of thermal energy

    may be prevented by intermittent

    application of energy which,in effect, produces a pulsed current

    THERMAL DAMAGE

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    The bowel is the most commonlyinjured organ.

    The injury may range from

    minor blanching of the serosa tofrank perforation.

    Perforation requires laparotomy,excision of the surroundingdevitalized bowel and repair ofthe defect.

    THERMAL DAMAGE

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    If blanching is significant,laparotomy excision of thedamaged tissue and surgical

    repair should be performedimmediately.

    Failure to do so may result indelayed ischemic necrosisat the site of the burn.

    THERMAL DAMAGE

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    Initially there may be few

    symptoms but commonly

    the patient will complain offeeling unwell and this

    feeling may not improve asquickly as usual.

    THERMAL DAMAGE

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    It should be realized that anypatient who feels unwell on the day

    after surgery and whose condition

    does not improve over the next fewhours, may have an unsuspected

    injury to the bowel.

    The unwary physician may allow the

    patient to return home.

    THERMAL DAMAGE

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    The insidious development ofvague abdominal symptoms,

    discomfort, anorexia and possibly

    pyrexia may not be recognized by

    her medical attendants.

    A faecal fistula may not form for48-72 hours.

    THERMAL DAMAGE

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    Fecal peritonitis slowly develops

    and the patient may become

    seriously ill over a period of daysbefore re-admission is requested.

    Radiology followed by

    laparotomy reveals the desperatesituation.

    THERMAL DAMAGE

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    Laparotomy is followed byrepair of the bowel or, more

    often, colostomy and drainage ofthe peritoneum.

    A prolonged period of seriousillness may follow.

    THERMAL DAMAGE

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    It must always beremembered that

    electric current is potentiallydangerous and all the safety

    rules for its use must be strictlyobeyed.

    INJURY FROM MECHANICAL INSTRUMENTS

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    INJURY FROM MECHANICAL INSTRUMENTS

    The main injuries caused by scissors orforceps are to ablood vessels.

    Bleeding will be immediately obvious andshould be controlled bybipolarorthermocoagulation or by suturing.

    Direct inadvertent injury to other organs bymechanical instruments may result fromcareless or clumsy use.

    OTHER COMPLICATIONS

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    A number of othercomplications may result

    from laparoscopy.

    3. Shoulder pain

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    Carbon dioxide is converted to carbonic acidwhen it is in solution with body fluids.

    This is irritant to the peritoneum.

    Diaphragmatic peritoneal irritation producespain which is referred to the shoulder by thephrenic nerve.

    This pain may be confused with cardiac painby the unwary physician and treatedinappropriately.

    5 Omental and Richter's herniation

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    5. Omental and Richter's herniation

    If the primary cannula is withdrawn withits valve closed, it is possible to draw a

    piece of omentum into the umbilicalwound by the negative pressure soproduced.

    This is usually recognized immediatelyand the omentum is easily replaced.

    5. Omental and Richter's herniation

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    Herniation may occur some hours after theoperation.

    It is usually easy to replace it under local

    anesthesia and resuture the wound.Herniation does not occurcommonly with 5

    mm skin incisions.

    Incisions greater than 7 mm should besutured in layers to prevent formation of a

    Richter's hernia

    6. Injuries from the operating table

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    j g

    Care must always be taken inpositioning the patient on the operating

    table.

    Injury can be caused to the nerves of theleg and to the hip and sacro-iliac joints.

    Compression of the leg veins maypredispose to venous thrombosis.

    6. Injuries from the operating table

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    Thebrachial plexus may be injuredif the arm is abducted.

    The hands may be caught in movingparts of the table.

    It is important that the patient touches no

    metallic parts of the table if electricenergy is being used.

    7. Foreign bodies

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    g

    Occasionally tubal clips or rings orparts of instruments such as saphire

    laser tips may be inadvertently

    dropped and lost in the peritonealcavity.

    They should be removed if they are

    easily found but there have been noreports of long term complications

    from such foreign bodies

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    Questions

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