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Laparoscopycomplications.1saudia (1)
This document discusses potential complications of laparoscopic procedures and how to avoid or manage them. It covers issues that can arise during different stages of laparoscopy like insufflation, port placement, and visceral injury. Key points include choosing appropriate cases and having the right equipment, team, and surgical plan. Complications must be promptly recognized and remedied. Being prepared is essential to avoiding complications that may otherwise be preventable.
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Laparoscopycomplications.1saudia (1)
- 1. COMPLICATIONS OF LAPAROSCOPIC PROCEDURES DANIEL H. SMITH, MD DIRECTOR, GYNECOLOGIC ONCOLOGY AND MINIMALLY INVASIVE GYNECOLOGY HOLY NAME MEDICAL CENTER TEANECK, NEW JERSEY, USA MAY 13, 2013
- 2. AVOIDABLE AND UNAVOIDABLE …THEREARE NO UNAVOIDABLE
- 3. • PATIENT SELECTION • PROCEDURE SELECTION • LACKOF PROPER EQUIPMENT FOR PROCEDURE • LACK OF PROPER EQUIPMENT FOR EMERGENCY • ISSUES OF SKILLS OF PARTICIPANTS STANDARD ISSUES
- 4. COMPLICATIONS AT ANESTHESIAINDUCTION • ENDOTRACHEAL TUBE NOT IN CORRECTLY • ENDOTRACHEAL TUBE UNSECURED • NASO-GASTRIC TUBE NOT PASSED • IDIOSYNCRATIC DRUG REACTION
- 5. ACHIEVING PNEUMO-PERITONEUM • DIRECT PUNCTURE • VERRESS • HANGINGDROP • HIGH GAS FLOW • AM I IN? • IF THIS IS TRULY A QUESTION? “NO!” • ? SECOND TRY • SAME SITE • LEFT UPPER QUADRANT • OPEN TECHNIQUE – HASSAN • PLACE CAMERA TROCHAR WITHOUT PNEUMO • NOT ADVISED
- 6. INITIAL PORT PLACEMENTNOT INTRA-PERITONEAL • JUST PUSH HARDER!?!?!?! • TRY ANOTHER LOCATION • USE OPEN TECHNIQUE
- 7. PLACEMENT OF SECONDARYPORTS UNDER DIRECT VISION • SHOULD BE ABLE TO BE DONE WITHOUT INJURY • BLEEDING • INFERIOR EPIGASTRIC ARTERY/VEIN • SECURE ENDOSCOPICALLY • SECURE USING A PERCUTANEOUS CLOSURE • OTHER CAUSE • OBSERVE • MANY NEED TO EXPLORE PORT SITE FROM SKIN LEVEL
- 8. PROBLEMS DUE TOINCORRECT PORT POSITION • SWORDING-TELESCOPE OR ASSISTANT BLOCK OPERATOR • REPOSITION ASSISTANT • ROTATE ANGLED TELESCOPE • TRANSPOSITION OF INSTRUMENTS • ADDITIONAL PORT • VISCERAL INJURY
- 9. VISCERAL INJURY • HOLLOW VISCUS • STOMACH0.02% • SMALL BOWEL 2.7% • LARGE BOWEL 0.15% • BLADDER 0.5% • SOLID ORGANS • LIVER • SPLEEN
- 11. VISCERAL INJURY • VESSEL INJURY • INFERIOREPIGASTRIC • OMENTAL • MESENTERIC VESSELS • AORTA • INFERIOR VENA CAVA • ILIAC VESSELS • COMMON • EXTERNAL • INTERNAL
- 13. UNRECOGNIZED INJURIES WITHCOMPLICATIONS • SEVERE HYPOTENSION • PRESUME RETRO-PERITONEAL INJURY • PROCEED TO IMMEDIATE MID-LINE LAPAROTOMY • LEAVE INSTRUMENTS IN PLACE • TAMPONADE BLEEDING SITE • OBTAIN ASSISTANCE OF VASCULAR SURGEON
- 14. UNRECOGNIZED INJURIES WITHCOMPLICATIONS • MILD TO MODERATE HYPOTENSION - ADVISED • DISCONTINUE GAS INSUFFLATION • REDUCE INTRA-ABDOMINAL PRESSURE TO 8.0mm Hg • QUICKLY PERFORM 360o SCAN OF ABDOMEN • IF BLEEDING OR EPANDING HEMATOMA SEEN • MID-LINE LAPAROTOMY • TAMPONADE • EITHER/OR • EXPOSE BLEEDING VESSEL / APPLY VASCULAR CLAMPS • OBTAIN ASSISTANCE OF VASCULAR SURGEON
- 15. PLACEMENT OF SECONDARYPORTS UNDER DIRECT VISION SHOULD BE WITHOUT ANY INJURY TO INTRA-ABDOMINAL ORGANS BLEEDING INFERIOR EPIGASTRIC ARTERY/VEIN SECURE ENDOSCOPICALLY SECURE USING A PER-CUTANEOUS CLOSURE DEVICE OTHER OBSERVE MAY NEED TO EXPLORE PORT SITE FROM SKIN ENERGY SOURCE INJURY TO UNINTENDED TISSUES KNOW THE SPECIFICS OF THE SOURCE – BOVIE, HARMONIC, LIGASURE IF YOU ‘THINK’ YOU DID IT, YOU DID IT ASSESS THE AREA OF INJURY RECOGNIZE SPEAD MAY NOT BE VISIBLE REPAIR AREA SITE OF INJURY MAY BE AT THE TIP OR AT AN INTERMEDIATE POINT ALWAYS KEEP THE INSTRUMENT IN VIEW RECOGNIZED VISCUS INJURY BLADDER URETER RECTUM SMALL BOWEL STOMACH LARGE BOWEL MAJOR VESSEL
- 16. INSUFFLATION USING VERESSNEEDLE -IS IT INTRA-PERITONEAL? • IS IT INTRA-PERITONEAL? • DROP TEST • CO2 ON HIGH FLOW • INJECTION • HIGH FILLING PRESSURE/NOT CONFIRMABLE • TRY ANOTHER LOCATION • USE OPEN TECHNIQUE
- 17. UNRECOGNIZED INJURIES WITHCOMPLICATIONS • CARDIAC ARRHYTHMIA FOUND • STOP INSUFFLATION • WITHDRAW INSTRUMENT AND REMOVE CO2 WITH PORT IN PLACE • TURN THE PATIENT TO THE LEFT • CORRECT HYPOXIA AND RESUSCITATE • POSTPONE SURGERY
- 18. ENERGY SOURCE INJURYTO OTHER TISSUES • KNOW THE SPECIFICS OF THE SOURCE • BOVIE • HARMONIC • LIGASURE • IF YOU ‘THINK’ YOU DID IT, YOU DID IT • ASSESS THE AREA OF INJURY • RECOGNIZE THAT ENERGY SPREAD MAY NOT BE VISIBLE • REPAIR AREA • BEWARE • INJURIES MAY OCCUR ALON THE SHAFT OF THE INSTRUMENT • ALWAYS KEEP THE INSTRUMENT IN VIEW
- 19. BLADDER DOME OVERSEW – TWOLAYERS, MONOFILAMENT ABSORBABLE FOLEY CATHETER TRIGONE PERFORM CYSTOTOMY IDENTIFY URETERIC ORIFICES DETERMINE PATENCY ?PLACE STENTS REPAIR FOLEY/STENT DRAINAGE
- 21. URETER ABOVE PELVIC BRIM ENDTO END ANASTAMOSIS STENT DRAIN BELOW THE PELVIC BRIM RE-IMPLANTATION STENT DRAIN ?BOARI FLAP
- 22. SHOULD I PLACESTENTS? WHAT’S THE IMPORTANCE OF THE COLOR OF THE URINE WHEN SHOULD I USE EXCRETABLE DYE (e.g., METHYLENE BLUE)?
- 23. STENTS FOR IDENTIFICATION OFTHE URETER TO RELIEVE AN OBSTRUCTION ‘FOR EVERY PATIENT’ COLOR OF THE URINE CLEAR, BLOOD-TINGED, BLOODY WITH CLOTS URETERIC LIGATION = CLEAR SEVERING ONE URETER = CLEAR URETERIC KINKING = CLEAR BLADDER INJURY OR IRRITATION BY FOLEY = BLOOD TINGED WHEN TO USE DYE TO CONFIRM URETERIC PATENCY MUST VISUALIZE TRIGONE + COLOR IN FOLEY BAG = AT LEAST ONE URETER OPEN
- 24. INTESTINAL RECTUM USUALLY PRIMARY CLOSURE MIS– EEA DIVERSION MAY NOT BE REQUIRED COLON PRIMARY CLOSURE DIVERSION MAY NOT BE REQUIRED SMALL BOWEL PRIMARY CLOSURE/RESECTION DIVERSION RARELY REQUIRED OTHER ABDOMINAL ORGANS REPAIR RESECTION REMOVAL
- 25. VASCULAR INJURIES IN THETRUE PELVIS USUALLY CAN BE LIGATED/CAUTERIZED IN THE MAJOR VESSELS ASSESS SEVERITY OF INJURY AND VESSEL INJURED INSTANCES OF PRIMARY CLOSURE SUTURES CLIPS TAMPONADE TERMINATE MIS PROCEDURE ADEQUATE LAPAROTOMY MAINTAIN TAMPONADE WHILE… VASCULAR TEAM ASSEMBLED VASCULAR INSTRUMENTS READIED
- 26. INSUFFLATION BEGINS PATIENT ARRESTS NGTUBE SHOWS BLOOD TROCARS PLACED BILE SEEN IN ABDOMEN BLOOD PLENTIFUL IN ABDOMEN STOOL OR SMALL BOWEL CONTENTS SEEN END OF CASE/RECOVERY ROOM SHOCK INTENSE PAIN ACUTE ABDOMINAL SWELLING (NOT CO2) ONE WEEK LATER FEVER INTENSE PAIN NAUSEA AND VOMITTING CHANGE IN BOWEL HABITS
- 27. BE PREPARED KNOW THEPROCEDURE HAVE ADEQUATE STAFF AND INSTRUMENTATION RECOGNIZE A POTENTIAL PROBLEM GAS PRESSURE TOO HIGH ON INSUFFLATION ABNORMAL FLUID IN THE ABDOMEN PROMPTLY DETERMINE THE EXTENT IF A PROBLEM SEEN REMEDY THE PROBLEM BE PREPARED THE UNAVOIDABLE COMPLICATION IS OFTEN AVOIDABLE
- 28. POST-OPERATIVE ATTENTIVENESS • IMMEDIATE • UNEXPLAINED TACHYCARDIAOR HYPOTENSION • SUSTAINED PAIN IN EXCESS OF EXPECTATIONS • DRUG REACTIONS/ALLERGIES • LATER • CONTINUED OR INCREASED ABDOMINAL PAIN • CHANGE IN BOWEL HABITS • FEVERS IN ALL CASES, IMMEDIATE INVESTIGATION MANDATORY
- 30. DEFINE ‘MINIMALLY INVASIVE’ OFTENPROBLEM OF OVARIAN CANCER REQUIRES MAXIMUM PROCEDURE WHEN CAN MIS BE UTILIZED DIAGNOSTIC TREATMENT OF EARLY DISEASE TREATMENT OF LIMITED DISEASE DIAGNOSIS AND TREATMENT OF ADVANCED DISEASE DIAGNOSIS AND TREATMENT OF RECURRENT DISEASE DIAGNOSTIC IDENTIFY PROBLEM PREPARED TO HANDLE IT? TREATMENT OF EARLY/LIMITED DISEASE PREPARED TO DO THE BEST SURGERY FOR THE PATIENT? LYMPH NODES OMENTECTOMY RESECTION OF DISEASE IN THE UPPER ABDOMEN LIVER, STOMACH, SPLEEN, DIAPHRAGMS TREATMENT OF ADVANCE DISEASE IS MODALITY EFFECT IN DEBULKING SEE ABOVE TREATMENT OF RECURRENCE BEST IF LIMITED DISEASE (RARE) FUTURE – IMAGE GUIDED SURGERY/BETTER INSTRUMENTS
- 32. SCREENING FOR OVARIANCANCER
- 33. SEEMS TO BEA WILL’O THE WISP HISTORICALLY – CALLED STOMACH CANCER – FEW LIVED FOR VERY LONG SURGERY – DIDN’T DIE OF THE OPERATION CHEMOTHERAPY – LIFE COULD BE SUSTAINED… WITH COSTS WHAT TO DO? CURE CANCER/PREVENT CANCER CURE OF ADVANCED DISEASE CURRENTLY DAUNTING – NEW DRUGS, TRIALS THUS, SCREENING FOR EARLY DISEASE HAS BEEN A RECENT GOAL TOOLS – SYMPTOMS = ADVANCED PE – UNABLE TO DETECT EARLY DISEASE IMAGING – U/S, CT, MRI, PET, TAGGED NUCLEOTIDES – SOME COSTLY, ALL INEFFECTIVE BLOOD TESTING – NOT SPECIFIC, NOT SENSITIVE COMBINATIONS – RARELY CAN SHOW EFFICACY, BUT PRICEY GENETICS – CURRENTLY FOR CERTAIN IDENTIFIED GENES FUTURE – PAP SMEARS CAN DETECT/?MAKES A DIFFERENCE PREVENTION – GENETIC TESTING INCREASED SURVEILLANCE RISK REDUCTION – SURGERY, MEDICATIONS
- 34. MINIMALLY INVASIVE SURGERY FOROVARIAN CANCER
- 35.
- 36.
- 37. CHOOSE THE APPROPRIATECASE • PATIENT • PROBLEM • EQUIPMENT • SURGEON’S SKILLS
- 38. BE MINDFUL OFPOTENTIAL CONFOUNDING FACTORS • PATIENT HABITUS AND HEALTH • PRIOR SURGERIES (INCLUDING CAESARIAN SECTIONS) • UNIQUE PATIENT PROBLEMS • DERMATITIS • ANTI-‐COAGULATION
- 39. HAVE PROPER TEAMASSEMBLED • ANESTHESIOLOGY • NURSING – SCRUB AND CIRCULATING • ADEQUATE SURGICAL ASSISTANT • PATHOLOGY SERVICES READY FOR POSSIBLE FROZEN SECTION • A TELEPHONE!
- 40. HAVE PROPER/NECESSARY INSTRUMENTS • UTERINE MANIPULATORS – SPONGE STICK OR DEVICE • INSUFFLATOR – VERRESS OR HASSAN • TROCHARS – BLADED OR BLADELESS ? CAMERA ASSIST • APPROPRIATE SELECTION OF SCISSORS, GRASPERS, RETRACTORS • ENERGY APPLICATIONS – BOVIE, HARMONIC, LIGASURE • AVAILABILITY OF SPECIALIZED INSTRUMENTS – CLIP, SEW, STAPLE • AVAILABILITY OF SPECIALIZED MEDICATIONS – INTERCEED, FLO-‐SEAL, BLOOD
- 41. HAVE DEFINITE PLANFOR SURGERY • BE VERY FAMILIAR - PROPOSED SURGICAL PROCEDURE • ANTICIPATE EXPECTED FINDINGS • ANATOMY • PATHOLOGY • ANTICIPATE POSSIBLE DIFFICULTIES • ACCESS • ADHESIONS • HAVE APPROPRIATE INSTRUMENTS • FOR EXPECTED • ACCESS TO THOSE FOR UNEXPECTED • HAVE PREVIOUSLY DISCUSSED PORT PLACEMENT • “I ALWAYS” = POTENTIAL PROBLEM • REMEMBER – “CAMERA FIRST!”
- 42. ANESTHESIA INDUCTION ISSUES • ENDOTRACHEALTUBE IN PROPER PLACE • ENDO TRACHEAL TUBE ADEQUATELY SECURED • EYE/FACE PROTECTION • ORO-GASTRIC TUBE PLACED
- 43. MINIMALLY INVASIVE SURGERY FOROVARIAN CANCER
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- 46. CHOOSE THE APPROPRIATECASE • PATIENT • PROBLEM • EQUIPMENT • SURGEON’S SKILLS
- 47. BE MINDFUL OFPOTENTIAL CONFOUNDING FACTORS • PATIENT HABITUS AND HEALTH • PRIOR SURGERIES (INCLUDING CAESARIAN SECTIONS) • UNIQUE PATIENT PROBLEMS • DERMATITIS • ANTI-‐COAGULATION
- 48. HAVE PROPER TEAMASSEMBLED • ANESTHESIOLOGY • NURSING – SCRUB AND CIRCULATING • ADEQUATE SURGICAL ASSISTANT • PATHOLOGY SERVICES READY FOR POSSIBLE FROZEN SECTION • A TELEPHONE!
- 49. HAVE PROPER/NECESSARY INSTRUMENTS • UTERINE MANIPULATORS – SPONGE STICK OR DEVICE • INSUFFLATOR – VERRESS OR HASSAN • TROCHARS – BLADED OR BLADELESS ? CAMERA ASSIST • APPROPRIATE SELECTION OF SCISSORS, GRASPERS, RETRACTORS • ENERGY APPLICATIONS – BOVIE, HARMONIC, LIGASURE • AVAILABILITY OF SPECIALIZED INSTRUMENTS – CLIP, SEW, STAPLE • AVAILABILITY OF SPECIALIZED MEDICATIONS – INTERCEED, FLO-‐SEAL, BLOOD
- 50. HAVE DEFINITE PLANFOR SURGERY • BE VERY FAMILIAR - PROPOSED SURGICAL PROCEDURE • ANTICIPATE EXPECTED FINDINGS • ANATOMY • PATHOLOGY • ANTICIPATE POSSIBLE DIFFICULTIES • ACCESS • ADHESIONS • HAVE APPROPRIATE INSTRUMENTS • FOR EXPECTED • ACCESS TO THOSE FOR UNEXPECTED • HAVE PREVIOUSLY DISCUSSED PORT PLACEMENT • “I ALWAYS” = POTENTIAL PROBLEM • REMEMBER – “CAMERA FIRST!”
- 51. PRE-OPERATIVE PREPARATION • MEDICAL OPTIMIZATION • BOWELPREP • CONTROVERSIAL • OFTEN NOT NEEDED • PRE-OPERATIVE ANTIBIOTICS • ANTI-EMBOLISM PROTECTION • PNEUMATIC BOOTS • HEPARIN/LOVENOX
- 52. ANESTHESIA INDUCTION ISSUES • ENDOTRACHEALTUBE IN PROPER PLACE • ENDO TRACHEAL TUBE ADEQUATELY SECURED • EYE/FACE PROTECTION • ORO-GASTRIC TUBE PLACED
- 53. PRE-OPERATIVE PREPARATION • MEDICAL OPTIMIZATION • BOWELPREP • CONTROVERSIAL • OFTEN NOT NEEDED • PRE-OPERATIVE ANTIBIOTICS • ANTI-EMBOLISM PROTECTION • PNEUMATIC BOOTS • HEPARIN/LOVENOX
- 54. OPERATING ROOM TABLE • CANACHIEVE NECESSARY TRENDELENBURG POSITION • PROPER MATTRESS TO PREVENT SLIDING • CAN SUPPORT A HEAVY PATIENT • AVAILABLE PROTECTIVE PADDING
- 55. PATIENT POSITIONING AFTERINDUCTION • STIRRUPS – ALLEN, YELLOW-FIN • FACE PROTECTION – EYES, HEAD • PADDING OF POINTS OF PRESSURE • HAND PROTECTION • COMPRESSION BOOTS • LEGS PROPERLY ALLIGNED • ARMS TUCKED/OUT • OPERATIVE SPACE IN ANESTHESIA AREA FOR SILS
- 56. DIRECT PUNCTURE –VERRESS NEEDLE • WHERE? • MID-LINE • UMBILICUS • LEFT UPPER QUADRANT • WHAT IF THERE ARE SCARS?
- 57. DIRECT PUNCTURE –VERRESS NEEDLE
- 58. DIRECT PUNCTURE –VERRESS NEEDLE
- 59. DIRECT PUNCTURE –VERRESS NEEDLE
- 60. PORT PLACEMENT • LOCALE • OPTIMIZE ACCESSTO OPERATIVE AREA • CAMERA FIRST • FIRST PORT BLIND – CAMERA IN TROCHAR • ALL OTHERS UNDER DIRECT VISION • ADHESIONS • AT INITIAL PORT SITE • CHOOSE SECOND SITE – CAMERA • LYSIS • WHEN TO CONVERT TO OPEN
- 64. ADEQUATE DISTANCES • CAMERA TO TARGET >= 18cm • CAMERA TO OPERATIVE ARMS >5CM (OPT ~10cm) • OPERATIVE ARM TO OPERATIVE ARM >5cm • ANGLE OF OPERATIVE ARMS RELATIVE TO CAMERA THIS IS NOT BASEBALL!
- 67. OMEGA INCISION SKIN INCISION FASCIAL INCISION
- 68. PORT CLOSURE • NECESSARY? • YES, IFTROCHAR >10cm • FROM OUTSIDE • ENDOSCOPICALLY • MANY DEVICES • BLEEDING • CLOSURE MUST SECURE HEMOSTASIS • or OTHER MEASURES
- 70. PAIN MANAGEMENT POST-OPERATIVELY • LOCALANESTHETIC INJECTIONS OF PORT SITES • BEFORE PLACEMENT • ABDOMINAL WALL BLOCK • ORAL ANALGESICS
- 71. POST-OPERATIVE ‘GAS PAIN’ • ATTENTIONTO CO2 REMOVAL • BEFORE REMOVING PORTS • INSTILL 1-2 L NORMAL SALINE • PERFORM VALSALVA • REMOVE LAST PORT
- 72. POST-OPERATIVE ATTENTIVENESS • IMMEDIATE • UNEXPLAINED TACHYCARDIAOR HYPOTENSION • SUSTAINED PAIN IN EXCESS OF EXPECTATIONS • DRUG REACTIONS/ALLERGIES • LATER • CONTINUED OR INCREASED ABDOMINAL PAIN • CHANGE IN BOWEL HABITS • FEVERS IN ALL CASES, IMMEDIATE INVESTIGATION MANDATORY
- 73. BE PREPARED! CHOOSE THEAPPROPRIATE CASE PATIENT PROBLEM EQUIPMENT SURGEON’S SKILL BE MINDFUL OF POTENTIAL CONFOUNDING FACTORS PATIENT HABITUS AND HEALTH PRIOR SURGERIES (INCLUDING CESARIAN SECTIONS) PATIENT MEDICAL PROBLEMS - DERMATITIS HAVE PROPER TEAM ASSEMBLED ANESTHESIOLOGY NURSING – SCRUB AND CIRCULATING ADEQUATE SURGICAL ASSISTANT PATHOLOGY SERVICES AVAILABLE A TELEPHONE HAVE PROPER/NECESSARY INSTRUMENTS UTERINE MANIPULATOR – HULKA,HUMI,V-CARE,SPONGE STICK, ETC. INSUFFLATION – VERESS/HASSAN TROCHARS – BLADED/BLADELESS/VERSI-STEP/DISPOSIBLE/NOT APPROPRIATE SELECTION OF SCISSORS, GRASPERS, ETC. ENERGY APPLICATIONS – BOVEY, HARMONIC, LIGASURE, ETC. AVAILABILITY OF SPECIAL INSTRUMENTS – ENDO-CLIP,SEW,STAPLE AVAILABILITY OF SPECIAL MEDICATIONS – INTERCEED, FLO-SEAL
- 74. HAVE DEFINITE PLANFOR SURGERY ANTICIPATE EXPECTED FINDINGS HAVE AVAILABLE APPROPRIATE INSTRUMENTATION HAVE PREVIOUSLY DISCUSSED PORT PLACEMENT SITES BE PREPARED! PRE-OPERATIVE PREPARATION – BOWEL PREP GENERALLY UNNECESSARY OPERATING ROOM TABLE – CAN ACHIEVE PROPER TRENDELENBERG, PADDING PATIENT POSITIONING AFTER INDUCTION- STIRRUPS – ALLEN FACE PROTECTION – EYES, HEAD PADDING OF POINTS OF PRESSURE COMPRESSION BOOTS LEGS PROPERLY ALIGNED ARMS TUCKED/OUT OPERATIVE SPACE IN ANESTHESIA AREA FOR SILS ACHIEVING PNEUMO-PERITONEUM DIRECT PUNCTURE OPEN TECHNIQUE PLACE TROCHARS FIRST FIRST PORT PLACEMENT BLIND WITH SCOPE IN TROCHAR SUBSEQUENT PORT PLACEMENT ALL DONE UNDER DIRECT VISION
- 75. PORT CLOSURE NECESSARY? FROM OUTSIDE ENDOSCOPICALLY BLEEDING PAINMANAGEMENT POST-OPERATIVELY LOCAL ANESTHETIC INJECTION OF PORT SITES BEFORE PLACING ABDOMINAL WALL BLOCK PO MEDS POST-OPERATIVE ‘GAS PAIN’ ATTENTION TO CO2 REMOVAL AT END OF CASE PRIOR TO REMOVING/CLOSING PORTS, PERFORM A VALSAVA INSTIL 1-2 LITERS OF NS POST-OPERATIVE ATTENTIVENESS IMMEDIATE UNEXPLAINED TACHYCARDIA OR HYPOTENSION SUSTAINED PAIN IN EXCESS OF EXPECTATIONS DRUG REACTIONS/ALLERGIES LATER CONTINUED OR INCREASED ABDOMINAL PAIN CHANGE IN BOWEL HABITS FEVERS IN ALL CASES, IMMEDIATE INVESTIGATION MANDATORY