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Misadventures in endoscopic surgery dr rabi
This document discusses complications that can occur during endoscopic and hysteroscopic surgeries. It notes that reported complication rates for endoscopic surgery are around 3-5 cases per 1000, and have decreased by around 50% since the 1970s. Common complications include injuries from trocars or the Veress needle, organ perforation, and hemorrhage. The document provides tips for minimizing complications, such as using cauterization and identifying tissue planes before dissection. It also discusses specific complications for hysteroscopic procedures like trauma, hemorrhage, and thermal damage. Overall, the document outlines various complications and best practices for reducing risks during minimally invasive gynecological surgeries.
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Misadventures in endoscopic surgery dr rabi
- 1. MISADVENTURES INMISADVENTURES IN ENDOSCOPICSURGERYENDOSCOPIC SURGERY Dr. Rabinarayan SatapathyDr. Rabinarayan Satapathy Asst. ProfessorAsst. Professor Dept. of Obst.& GynaeDept. of Obst.& Gynae S.C.B. Medical College,CuttackS.C.B. Medical College,Cuttack
- 2. Complications :Complications : **Related to endoscopy itselfRelated to endoscopy itself ** Related to anaesthesiaRelated to anaesthesia
- 3. • Reported complicationrate of 3.2/1000( FrenchReported complication rate of 3.2/1000( French multicentric, collaborative study of 15,521cases)multicentric, collaborative study of 15,521cases) • Nezhat et al reported complication rate of 3.08% ofNezhat et al reported complication rate of 3.08% of 6949 advanced endoscopic surgeries6949 advanced endoscopic surgeries • Complication rate ↑ to 5 .2/1000 for advancedComplication rate ↑ to 5 .2/1000 for advanced interventionsinterventions • Complication rateComplication rate↓↓ by almost 50 % since 1972 (6.8 vsby almost 50 % since 1972 (6.8 vs 3.2/1000)3.2/1000)
- 4. ANAESTHETIC COMPLICATIONSANAESTHETIC COMPLICATIONS RareRare HypoventilationHypoventilation Inadvertent endobronchial intubation (as hilumInadvertent endobronchial intubation (as hilum of lung displaced upwards in deep Trendelenburgof lung displaced upwards in deep Trendelenburg position)position) ↑↑ risk of regurgitation of gastric contentsrisk of regurgitation of gastric contents Adverse cardiorespiratory effectsAdverse cardiorespiratory effects
- 5. Minimizing ComplicationsMinimizing Complications Use cuffed endotracheal tubeUse cuffed endotracheal tube Use nasogastric drainageUse nasogastric drainage Avoid overforceful mask ventilationAvoid overforceful mask ventilation Use complete muscle paralysisUse complete muscle paralysis
- 6. Complications of PneumoperitoneumComplicationsof Pneumoperitoneum Associated with Veress needleAssociated with Veress needle :: ** Preperitoneal & omental emphysemaPreperitoneal & omental emphysema ** Injury to blood vesselInjury to blood vessel **Injury to intestinal tractInjury to intestinal tract **Injury to bladderInjury to bladder **Gas embolismGas embolism
- 7. Minimizing complications ofMinimizingcomplications of PneumoperitoneumPneumoperitoneum • Percuss left upper quadrant to detect gastricPercuss left upper quadrant to detect gastric distensiondistension • Test spring mechanism before insertionTest spring mechanism before insertion • Leave valve openLeave valve open • Direct towards hollow of sacrumDirect towards hollow of sacrum • Advance only 2-3mm after piercing parietalAdvance only 2-3mm after piercing parietal peritoneumperitoneum
- 8. ……contdcontd • Perform safetytestsPerform safety tests :: **hissing phenomenonhissing phenomenon **aspiration testaspiration test **hanging drop methodhanging drop method **monitoring intra-abd pressuremonitoring intra-abd pressure • Do not insufflate at more than 1L/min initiallyDo not insufflate at more than 1L/min initially • If no obliteration of liver dullness, suspectIf no obliteration of liver dullness, suspect extravasationextravasation • Avoid over-insufflation of peritoneal cavityAvoid over-insufflation of peritoneal cavity
- 9. Extraperitoneal InsufflationExtraperitoneal Insufflation •Usually pre-peritoneal • Recognized by abnormal high insufflation pressure & palpation of abdomen • Remove needle, allow gas to escape, then re- introduce • Complications include mediastinal emphysema & compromised cardiac function • Pneumo-omentum harmless & rare (2%)
- 10. Complications due toTrocarsComplications due to Trocars ♦♦ Major injuries due to adherent bowel or lowMajor injuries due to adherent bowel or low intraperitoneal pressure at time of introductionintraperitoneal pressure at time of introduction ( wait for intraperitoneal pressure of 15 mm Hg)( wait for intraperitoneal pressure of 15 mm Hg) ♦♦ Injury to hollow viscera or blood vesselsInjury to hollow viscera or blood vessels → due to→ due to uncontrolled entry or improper directionuncontrolled entry or improper direction ↓↓ Laparotomy and vascular repair
- 11. Injury to epigastricvessels:Injury to epigastric vessels: Transillumination of abdominal wall isTransillumination of abdominal wall is preventivepreventive Transparietal suturesTransparietal sutures BBipolar laparoscopic coagulationipolar laparoscopic coagulation Compression by Foley’s catheter at involvedCompression by Foley’s catheter at involved site by introduction through 5 mm trocarsite by introduction through 5 mm trocar sleevesleeve
- 12. Minimizing complications withTrocarMinimizing complications with Trocar ** Place finger guard to within 3cm of trocar tipPlace finger guard to within 3cm of trocar tip ** Use controlled twisting motionUse controlled twisting motion ** Direct trocar tip towards sacral hollowDirect trocar tip towards sacral hollow ** Advance no more than 2cm beyond parietalAdvance no more than 2cm beyond parietal peritoneumperitoneum ** Replace laparoscope into trocar sheath firstReplace laparoscope into trocar sheath first during withdrawalduring withdrawal
- 13. Minimizing complicationsMinimizing complications **Transilluminate for epigastric vesselsTransilluminate for epigastric vessels ** Place trocars as high above symphysis pubisPlace trocars as high above symphysis pubis as cosmetically possible ( never less than 3cm)as cosmetically possible ( never less than 3cm) ** Insert ancillary trocar under direct lap visionInsert ancillary trocar under direct lap vision ** Direct downward, not laterallyDirect downward, not laterally
- 14. Injuries during OperativeProcedureInjuries during Operative Procedure Injury to bladder Due to: * dissection * electrocoagulation * laser use Predisposing factors include previous CS, endometriosis Detection by noting presence of blood & gas in urobag. Confirmation by infusion of methylene blue dye into bladder Small injury – heals spontaneously with indwelling catheter Large injury – suture by laparotomy or laparoscopy
- 15. Injuries during OperativeInjuriesduring Operative Procedure…Procedure… contd.contd. Injury to ureterInjury to ureter **Due to:Due to: -- sharp dissectionsharp dissection -- electrosurgeryelectrosurgery -- laserlaser -- during isolation of uterosacral ligamentduring isolation of uterosacral ligament -- improper evaluation of anatomyimproper evaluation of anatomy -- adhesions, myomas, endometriosisadhesions, myomas, endometriosis ** Diagnosis madeDiagnosis made 48-72 hrs after surgery48-72 hrs after surgery ** Confirm by IVPConfirm by IVP ** Treatment is reanastomosisTreatment is reanastomosis
- 16. Injuries during OperativeInjuriesduring Operative Procedure…Procedure… contd.contd. Injury to small bowelInjury to small bowel * Occurs during surgery for adhesions * Electro or laser surgery causes occult thermal lesions- apparent after 48-72 hrs. * Frank bowel perforation warrants laparotomy for transverse suture or resection-anastomosis
- 17. Injuries during OperativeInjuriesduring Operative Procedure…Procedure… contd.contd. Vascular injuryVascular injury * Occurs mainly during lap hysterectomy * Careful isolation and coagulation of uterine arteries by bipolar electrosurgery is the key * Beware of improper haemostasis * Other sites are tubal, ovarian or vaginal vessels * Should be managed laparoscopically * Ensure haemostasis before withdrawing scope
- 18. Other ComplicationsOther Complications Haemorrhage & shockHaemorrhage & shock InfectionInfection Incisional herniaIncisional hernia Peritoneal fistula formationPeritoneal fistula formation Accidental burnsAccidental burns
- 19. Minimizing complications ofMinimizingcomplications of Endoscopic SurgeryEndoscopic Surgery ** Minimize use of unipolar electrocauteryMinimize use of unipolar electrocautery ** Disconnect all electrosurgical units when not in useDisconnect all electrosurgical units when not in use ** Identify ureters before ant surgery of pelvic side wallIdentify ureters before ant surgery of pelvic side wall ** Use traction/countertraction to identify tissue planesUse traction/countertraction to identify tissue planes ** Minimize forceful blunt dissectionMinimize forceful blunt dissection ** Spread jaw of scissors to develop tissue planesSpread jaw of scissors to develop tissue planes ** Cauterize vessels before transectionCauterize vessels before transection ** Avoid scissor action between instruments to avoidAvoid scissor action between instruments to avoid pinching of bowel or omentumpinching of bowel or omentum ** Do not cut any tissue before identifying its anatomyDo not cut any tissue before identifying its anatomy
- 20. Complications of HysteroscopyComplicationsof Hysteroscopy ** TraumaTrauma ** HaemorrhageHaemorrhage ** Complications related to distension mediaComplications related to distension media ** InfectionInfection ** Thermal damageThermal damage ** CO2 & air embolismCO2 & air embolism
- 21. TraumaTrauma * Cervical &Uterine perforationCervical & Uterine perforation ** Occurs during insertion of manipulators,Occurs during insertion of manipulators, dilators, hysteroscope or during surgerydilators, hysteroscope or during surgery ** Hysteroscopic surgery suspended due to gasHysteroscopic surgery suspended due to gas or fluid leakageor fluid leakage ** Small, mechanical perforations – observationSmall, mechanical perforations – observation onlyonly
- 22. Trauma…Trauma…contdcontd.. ** Lateral wallinjury or broad ligamentLateral wall injury or broad ligament haematoma- concurrent use of laparoscopehaematoma- concurrent use of laparoscope usefuluseful ** Perforation due to electrosurgical electrode –Perforation due to electrosurgical electrode – laparotomy warrantedlaparotomy warranted ** Uterine perforations avoided by gentleUterine perforations avoided by gentle insertion of hysteroscope under direct visioninsertion of hysteroscope under direct vision ** In difficult cases, do concomitant laparoscopyIn difficult cases, do concomitant laparoscopy
- 23. HaemorrhageHaemorrhage ** Occurs duringsurgery for submucusOccurs during surgery for submucus myoma/TCREmyoma/TCRE ** Usually possible to control withUsually possible to control with electrocauteryelectrocautery ** Post opereative tamponade with Foley’sPost opereative tamponade with Foley’s catheter usefulcatheter useful ** If field of vision obscured, stop operationIf field of vision obscured, stop operation
- 24. Complications related todistension mediaComplications related to distension media ** Distension media used:Distension media used: CO2CO2 Dextran-70Dextran-70 5% dextrose5% dextrose Glycine, Sorbitol, MannitolGlycine, Sorbitol, Mannitol ** Should be non-conductive in hysteroscopic surgeryShould be non-conductive in hysteroscopic surgery ** Dangers:Dangers: Dextran - anaphylaxis, DIC, ARDS, non-cardiogenicDextran - anaphylaxis, DIC, ARDS, non-cardiogenic pulmonary oedemapulmonary oedema 5% dext - hyperglycaemia, hyponatraemia5% dext - hyperglycaemia, hyponatraemia CO2 – Fatal gas embolismCO2 – Fatal gas embolism
- 25. FLUID OVERLOADFLUID OVERLOAD ~Monitor fluid intake & output carefully. Look out for +ve fluid balance ~ Length of hysteroscopic procedure and the amount of raw uterine surface created are important factors. ~ Dilutional hyponatraemia causes cerebral oedema , convulsions and even death
- 26. + ve fluidbalance+ ve fluid balance RemarksRemarks 1000ml1000ml AlertAlert 1500m1500m Finish surgeryFinish surgery quicklyquickly 2000ml2000ml STOP SURGERY!!STOP SURGERY!! Give diureticsGive diuretics
- 27. CONCLUSIONCONCLUSION ** Complications ofendoscopic surgery areComplications of endoscopic surgery are directly related to the skill of the surgeondirectly related to the skill of the surgeon ** Availability of appropriate instruments is anAvailability of appropriate instruments is an important factorimportant factor ** Prevention of complications should be thePrevention of complications should be the aimaim ** Early detection of complications is essentialEarly detection of complications is essential
- 28. FOREWARNED IS FOREARMEDFOREWARNEDIS FOREARMED MISADVENTUREMISADVENTURE ↓↓ ADVENTUREADVENTURE ENDOSCOPIC SURGERY IS SAFE!!ENDOSCOPIC SURGERY IS SAFE!!