Complications of laparoscopic surgeries

COMPLICATIONS OF LAPAROSCOPIC SURGERIES Dr.Anil Haripriya

INTRODUCTION Laparoscopic surgeries are currently being increasingly used for wider and wider application. It is necessary to have a knowledge of its equipments, basic procedures, limitations and indications & complications.

HISTORY Celioscopy Peritoneoscopy Laparoscopy

HISTORY 1901 Kelling 1st laparoscopic examination of abdominal cavity in rats called it celioscopy 1911 Jacobeus 1 st human laproscopy 1938 Veress Spring loaded obturator needle for pneumoperitoneum 1960 Hopkins Developed Rod Lens Optical System 1960- Semm Developed automatic insufflators and 70 instruments 1 st lap appendisectomy. Father of modern laproscopic surgery 1987 Philip 1 st L.C. Mouret

EQUIPMENT & INSTRUMENTATION OPTICAL INSTRUMENTS ABDOMINAL ACCESS INSTRUMENTS LAPAROSCOPIC INSTRUMENTS

OPTICAL INSTRUMENTS I - ROD LENS SYSTEM II - FIBER OPTIC CABLES III - LIGHT SOURCES

LAPAROSCOPIC INSTRUMENTS These are miniature transformation of the instruments used in open surgeries. Aspirator Dissecting forceps Grasping instruments Scissors Clip applicator s Staples Sutures / needles Needle holder Cautery (mono & bi polar)

ABDOMINAL ACCESS INSTRUMENTS Open Technique Closed Technique Hasson Cannula Veress Needle Trocar Sheath assemblies

COMPLICATIONS OF LAPAROSCOPICA SURGERIES Anaesthetics Complications Complications due to pneumoperitonium Surgical complications Diathermy related injuries Patients factors related complications Post operative complications

COMPLICATIONS Anaesthetic Complications : Inadequate Muscle Relaxation – Contraction of muscle during procedure Difficulty in Causes pain during port Pneumoperitoneum insertion Management – Endotracheal intubation Pharmacological neuromuscular blockade Positive pressure ventilation

Anaesthetic Complications : 2. Mask hyper ventilation Prior to induction 100% oxygen is given by mask ventilation Hyperventilation Distended stomach Respiratory Dysfunction Liable to injury during port inser. Or veress needle inser. Management – Nasogastric tube prior to surgery.

Anaesthetic Complications : 3. Air Embolism CO 2 used for pneumoperitonium Gets absorbed into circulation Embolus may form and block pulmonary circulation Loud and clear murmur heard in (R) atrium and (R) ventricle (Mill-Wheel murmur) Management – Direct intracardiac insertion of needle Central venous catheter.

Management Continuous I/V assess Emergency cart with all resuscitative drugs and defibrillator. One should be prepared with – Oxygen Suction Bag and mask ventilation Oral and nasal pharyngeal airway, ET tubes of various sizes. Sphygmomanometer Electrocardiograph Pulse oxymeter

COMPLICATIONS DUE TO PNEUMOPERITONIUM CO 2 pneumoperitonium Gas specific effects (b) Pressure Specific Effects Respiratory Acidosis Excessive Pressure on IVC Hypercarbia Reduced VR Reduced CO Rapid stretch of peritoneal membrane Vasovagal response Bradycardia, occasionally hypotension Management - Desufflation of abd. Vagolytic (Atropine) Adequate volume replacement

Respiratory Dysfunction Increased pressure pneumoperitonium Transmitted directly across paralysed diaphragm to thoracic cavity Increase Central venous pressure & inc. filling pressure of (Rt) and (Lt) sides of heart Management : Keep intraabdominal pressure under 15 mm Hg

DVT, Pulmonary Embolism Increased intraabdominal pressure Reduced VR (Along with reverse Trendlenburg position) Venous engorgement Deep vein thrombosis Pulmonary Embolism Management : Sequential compression stockings Subcutaneous heparin or low molecular weight heparin

Effects on renal system Increased intraabdominal pressure Reduced RBF, Reduced GFR Inc. ADH activity Reduced Urine output Inc. free water absor. Inc. plasma renin activity Inc. Na+ retention Management : Adequate volume replacement at maintenance rate.

Pneumothorax Due to true diaphragmatic hernia. Without any apparent cause. Diagnosis - Presence of rapidly falling Oxygen saturation or PO2 together with difficult ventilation and decreased breath sounds. Management – Immediate needle thoracostomy. Aspiration Chest radiograph Placement of chest tube

Subcutaneous and Subfascial Emphysema and Edema Improper insertion of veress needle Manipulation of instruments often loosens the parietal perotoneum surrounding the instruments portal of exit into the peritoneal cavity. CO 2 then infiltrates the loose areolar tissue of the body Subsutaneous and subfascial emphysema * It rapidly resolves within 2 – 4 hours postoperatively.

SURGICAL COMPLICATIONS Injury to Viscus : Stomach -Hyperventilation by Mask Distended stomach May be injured with trochar or needle Diagnosis - Laparoscopic view of inside of stomach Management – Extend trocar incision into a minilap. for a two layer closure. Laparosocpically - Pursestring suture or a figure of 8 suture in the seromuscular layer surround the defect. - Nasogastric tube drainage for two days.

Injury to Viscus : Bowel - May be injured due to trocar or veress needle If due to veress needle it is managed conservatively Diagnosis - The emanation of foul smelling gas through pneumo-peritoneal needle is a helpful diagnostic sign. There may be GI contents at the tip of needle. Management – Mini laprotomy and repair of perforation. Laparoscopically it may be sutured of laparoscopic stapler (ENDO-GIA) can be used. Colostomy

Injury to Viscus : Small Bowel Perforation - Most often during insertion of umblical or lower quadrant trocars Usually recognized later in the procedure If adhesions are not freed from anterior abdominal wall perforation may not be recognized Management – One should consider higher primary site if adhesions are found through umblical port. Perforation repaired transversally If injury is free of adhesions bowel can be withdrawn through 10 mm trocar tract and repaired.

Injury to Viscus : Bladder - Injury caused by second puncture trocar usually . Diagnosis : Appearance of gas and blood in Foley’s catheter bag. Management – Early detection is important. Place an indwelling catheter for 7-10 days and prophylactic antibiotics - If defect is larger. Repaired by a figure of 8 suture through muscularis of bladder & second suture to close peritonium * A water tight seal should be documented by filling bladder with indigo carmine dye solution.

Injury to Viscus : Ureter - May be injured in adenexal surgeries. Thermal injury will result in ureteral narrowing and hydroureter. Management – Placement of ureteric stent for 3 – 6 weeks. Incision Hernia : Failure to close facial defects from incisions for secondary trocars. Incised fascia should be located with help of skin hooks and repaired.

Vessel Injury : Larger vessels may be injured by trocar or veress needle. CO 2 peritoneum may tamponade a large vessel injury. When pressure normalizes it starts bleeding. Management – Examine the course of large vessels. Overlying peritoneum is opened with laproscopic scissors or a CO 2 laser. Hematoma evacuated by alternate suction and irrigation. * Laprotomy is required if hematoma is expanding or persistent bleeding.

Vessel Injury : Epigastric Vessels – Deep epigastric vessels most frequently injured in laproscopic hysterectomy. Management – By Tamponade – Rotate second puncture sleave by 360 0 . By Foley’s catheter Bipolar coutery Needle suturing Small haemostate (Mosquito clamp) Ovarian or uterine vessels – Injured during laproscopic hysterectomy Management – Bipolar desiccation Ureter must be identified before desiccation.

DIATHERMY RELATED INJURIES Due to – Inadvertent activation of the diathermy pedal. Faulty insulation Direct coupling Capacitative coupling Cautery should be used under vision Injuries – Thermal necrosis of organs. Inadvertent organ ligation. Unrecognized haemorrhage.

PATIENT’S FACTORS RELATED COMPLICATIONS Obesity Ascites Organomegaly – organ damage Clotting problems – haemorrhage POST OPERATIVE COMPLICATIONS Concealed injury to organs Delayed fecal fistula Port site metastasis Recidual air (Referred chest or shoulder pain)

CONTRAINDICATIONS Absolute : Generalized peritonitis Intestinal obstruction Clotting abnormalities Liver cirrhosis Failure to tolerate general anesthesia Uncontrolled shock Relative : Multiple abdominal adhesions Organomegaly Abdominal aortic aneurysm

COMPLICATIONS OF LAPROSCOPIC APPENDICECTOMY Bleeding : - Inferior epigastric artery - Appendicular artery - Retroperitoneal vessels Perforation of the bowel - By trocar - Inadvertent electrosurgical injury - slippage of appendix base loops Injury to bladder Postoperative intraabdominal and pelvic abscess. Wound infections Incomplete appendecectomy Incisional hernia DVT and pulmonary embolism

COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY Bile Leak : - Recognized by presence of bile in the drain bottle. - Patient returns after 3-5 days with pain and tenderness in the right upper quadrant of the abdomen and jaundice - May arise from cystic duct stump divided cystohepatic duct of Luschka, injury to a major bile duct. Diagnosis – by USG or CT by early ERCP Management - Temporary biliary stent inserted endoscopically decompresses the biliary system

2. Major Bile Duct Injury : - Incidence is 1 in 300-500 laproscopies. - It includes complete transaction and clipping of common duct. Diagnosis – by early ERCP Management - * Management of major bile duct injuries is complex and best dealt with in a unite specializing in their treatment.

COMPLICATIONS OF LAPAROSCOPIC COLECTOMY Bowel Injuries : - The viscra and small bowel including the duodenum, may be damaged by grasping or cauterizing instruments. - Spleenic injury - Minimize this by using open insertion of first cannula and subsequent cannula insertion under vision. Vessel Injuries : - Mesenteric vessels, iliac vessels, epigastric vessels and innominate vessels. Injury to Ureter Post operative bleeding Port site metastasis

Complications of laparoscopic surgeries

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