Upload
rajarshi-kumar
View
227
Download
0
Embed Size (px)
Citation preview
7/30/2019 Correct Trocar Placement
1/132
BASIC LAPAROSCOPY
DR UTPAL DE
Department of Surgery
CMCH
7/30/2019 Correct Trocar Placement
2/132
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
7/30/2019 Correct Trocar Placement
3/132
Veress Technique
Closed, Veress needletechnique Needle with safety
shield placed through a
small skin incision Insufflate abdomen
with CO2
Exchange needle for
trocar
7/30/2019 Correct Trocar Placement
4/132
Trocars
7/30/2019 Correct Trocar Placement
5/132
7/30/2019 Correct Trocar Placement
6/132
Orientation
Positioning Trocars, camera and
surgeon
Triangulation of
InstrumentsCamera behind and in
center of workSpatial Orientation
Pitch Roll Yaw
7/30/2019 Correct Trocar Placement
7/132
Triangulation of Instruments
7/30/2019 Correct Trocar Placement
8/132
Camera-Target- Monitor Axis
Align Field of View and
Direction of View with
Target and Monitor
7/30/2019 Correct Trocar Placement
9/132
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
7/30/2019 Correct Trocar Placement
10/132
COMPLICATIONS OF
LAPAROSCOPY
7/30/2019 Correct Trocar Placement
11/132
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).
7/30/2019 Correct Trocar Placement
12/132
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
7/30/2019 Correct Trocar Placement
13/132
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
7/30/2019 Correct Trocar Placement
14/132
A. ANESTHETIC complication
Local anesthesia may be used
fortubal sterilization andsome other minor procedures.
7/30/2019 Correct Trocar Placement
15/132
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
7/30/2019 Correct Trocar Placement
16/132
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
7/30/2019 Correct Trocar Placement
17/132
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
7/30/2019 Correct Trocar Placement
18/132
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
7/30/2019 Correct Trocar Placement
19/132
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
7/30/2019 Correct Trocar Placement
20/132
1. Anxiety
May be prevented byadministration of
Diazepam 20 mgorally about one hour
pre-operatively.
7/30/2019 Correct Trocar Placement
21/132
2. Vasovagal reaction
This may be associated
withbradycardia and,in more severe cases,cardiac arrest, convulsion
and shock.
7/30/2019 Correct Trocar Placement
22/132
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
7/30/2019 Correct Trocar Placement
23/132
3. Pain
Pain may be prevented to some extentby the administration ofnon-steroidal
anti-inflammatory drugs such asmefanimic acid, naprosene or fentanyl.
7/30/2019 Correct Trocar Placement
24/132
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.
7/30/2019 Correct Trocar Placement
25/132
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
7/30/2019 Correct Trocar Placement
26/132
B. INDUCTION OF
PNEUMOPERITONEUM
7/30/2019 Correct Trocar Placement
27/132
1. Extra-peritoneal gas
insufflation
the Veress' needle into the
peritoneal cavity may produce extra-peritoneal emphysema.This occurs in about 2% of cases.
7/30/2019 Correct Trocar Placement
28/132
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
7/30/2019 Correct Trocar Placement
29/132
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
7/30/2019 Correct Trocar Placement
30/132
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
7/30/2019 Correct Trocar Placement
31/132
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
7/30/2019 Correct Trocar Placement
32/132
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
7/30/2019 Correct Trocar Placement
33/132
Complications from the
distension medium
Carbon dioxide (CO2)
is the distension medium mostcommonly used for operative
laparoscopy.
7/30/2019 Correct Trocar Placement
34/132
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.
7/30/2019 Correct Trocar Placement
35/132
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)
7/30/2019 Correct Trocar Placement
36/132
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)
7/30/2019 Correct Trocar Placement
37/132
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
7/30/2019 Correct Trocar Placement
38/132
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
7/30/2019 Correct Trocar Placement
39/132
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
7/30/2019 Correct Trocar Placement
40/132
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.
7/30/2019 Correct Trocar Placement
41/132
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
7/30/2019 Correct Trocar Placement
42/132
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.
7/30/2019 Correct Trocar Placement
43/132
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
7/30/2019 Correct Trocar Placement
44/132
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.
7/30/2019 Correct Trocar Placement
45/132
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.
7/30/2019 Correct Trocar Placement
46/132
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
7/30/2019 Correct Trocar Placement
47/132
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
7/30/2019 Correct Trocar Placement
48/132
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
7/30/2019 Correct Trocar Placement
49/132
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
7/30/2019 Correct Trocar Placement
50/132
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
7/30/2019 Correct Trocar Placement
51/132
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
7/30/2019 Correct Trocar Placement
52/132
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
7/30/2019 Correct Trocar Placement
53/132
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
7/30/2019 Correct Trocar Placement
54/132
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
7/30/2019 Correct Trocar Placement
55/132
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
7/30/2019 Correct Trocar Placement
56/132
6. Bladder injury
Routine catheterization of
the bladder and propersitting of the needle should
prevent bladder penetration.
7/30/2019 Correct Trocar Placement
57/132
Ifpneumaturia is noted
the needle should be
partially withdrawn and thecreation of
pneumoperitoneumcontinued.
6. Bladder injury
7/30/2019 Correct Trocar Placement
58/132
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
7/30/2019 Correct Trocar Placement
59/132
7. Blood vessel injury
The Veress' needle maypenetrate:
1. omental or2. mesenteric vessels or
3. any of the major abdominal orpelvic arteries or veins.
7/30/2019 Correct Trocar Placement
60/132
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
7/30/2019 Correct Trocar Placement
61/132
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
7/30/2019 Correct Trocar Placement
62/132
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
7/30/2019 Correct Trocar Placement
63/132
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
7/30/2019 Correct Trocar Placement
64/132
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
7/30/2019 Correct Trocar Placement
65/132
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
7/30/2019 Correct Trocar Placement
66/132
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
7/30/2019 Correct Trocar Placement
67/132
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
7/30/2019 Correct Trocar Placement
68/132
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
7/30/2019 Correct Trocar Placement
69/132
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
7/30/2019 Correct Trocar Placement
70/132
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
7/30/2019 Correct Trocar Placement
71/132
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
7/30/2019 Correct Trocar Placement
72/132
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
7/30/2019 Correct Trocar Placement
73/132
9. Puncture of liver or spleen
The liver or spleen may be
punctured by the Veress
C O C O O OC S
7/30/2019 Correct Trocar Placement
74/132
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
7/30/2019 Correct Trocar Placement
75/132
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
7/30/2019 Correct Trocar Placement
76/132
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
7/30/2019 Correct Trocar Placement
77/132
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.
7/30/2019 Correct Trocar Placement
78/132
The artery is at risk
during the insertion ofsecondary trocars and
cannulae.
Inferior epigastric artery
Inferior epigastric artery
7/30/2019 Correct Trocar Placement
79/132
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
7/30/2019 Correct Trocar Placement
80/132
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
7/30/2019 Correct Trocar Placement
81/132
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
7/30/2019 Correct Trocar Placement
82/132
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
7/30/2019 Correct Trocar Placement
83/132
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
7/30/2019 Correct Trocar Placement
84/132
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
7/30/2019 Correct Trocar Placement
85/132
It may be necessary
to insert two sutures,one above and
one belowthe site of bleeding.
Inferior epigastric artery
Inferior epigastric artery
7/30/2019 Correct Trocar Placement
86/132
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-
7/30/2019 Correct Trocar Placement
87/132
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
7/30/2019 Correct Trocar Placement
88/132
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
7/30/2019 Correct Trocar Placement
89/132
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
7/30/2019 Correct Trocar Placement
90/132
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
7/30/2019 Correct Trocar Placement
91/132
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
7/30/2019 Correct Trocar Placement
92/132
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
7/30/2019 Correct Trocar Placement
93/132
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
7/30/2019 Correct Trocar Placement
94/132
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
7/30/2019 Correct Trocar Placement
95/132
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
7/30/2019 Correct Trocar Placement
96/132
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
7/30/2019 Correct Trocar Placement
97/132
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
7/30/2019 Correct Trocar Placement
98/132
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
7/30/2019 Correct Trocar Placement
99/132
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
7/30/2019 Correct Trocar Placement
100/132
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
7/30/2019 Correct Trocar Placement
101/132
A small puncture on thesurface of the uterus may
be treated with bipolarelectro-coagulation if
bleeding does not stopspontaneously.
4. Damage to other organs
7/30/2019 Correct Trocar Placement
102/132
D THERMAL DAMAGE
7/30/2019 Correct Trocar Placement
103/132
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
7/30/2019 Correct Trocar Placement
104/132
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
7/30/2019 Correct Trocar Placement
105/132
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
7/30/2019 Correct Trocar Placement
106/132
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
7/30/2019 Correct Trocar Placement
107/132
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
7/30/2019 Correct Trocar Placement
108/132
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
7/30/2019 Correct Trocar Placement
109/132
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
7/30/2019 Correct Trocar Placement
110/132
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
7/30/2019 Correct Trocar Placement
111/132
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
7/30/2019 Correct Trocar Placement
112/132
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
7/30/2019 Correct Trocar Placement
113/132
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
7/30/2019 Correct Trocar Placement
114/132
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
7/30/2019 Correct Trocar Placement
115/132
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
7/30/2019 Correct Trocar Placement
116/132
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
7/30/2019 Correct Trocar Placement
117/132
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
7/30/2019 Correct Trocar Placement
118/132
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
7/30/2019 Correct Trocar Placement
119/132
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
7/30/2019 Correct Trocar Placement
120/132
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
7/30/2019 Correct Trocar Placement
121/132
Laparotomy is followed byrepair of the bowel or, more
often, colostomy and drainage ofthe peritoneum.
A prolonged period of seriousillness may follow.
THERMAL DAMAGE
7/30/2019 Correct Trocar Placement
122/132
It must always beremembered that
electric current is potentiallydangerous and all the safety
rules for its use must be strictlyobeyed.
INJURY FROM MECHANICAL INSTRUMENTS
7/30/2019 Correct Trocar Placement
123/132
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
7/30/2019 Correct Trocar Placement
124/132
A number of othercomplications may result
from laparoscopy.
3. Shoulder pain
7/30/2019 Correct Trocar Placement
125/132
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
7/30/2019 Correct Trocar Placement
126/132
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
7/30/2019 Correct Trocar Placement
127/132
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
7/30/2019 Correct Trocar Placement
128/132
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
7/30/2019 Correct Trocar Placement
129/132
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
7/30/2019 Correct Trocar Placement
130/132
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
7/30/2019 Correct Trocar Placement
131/132
Questions
7/30/2019 Correct Trocar Placement
132/132