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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.