| | Avoiding complications of laparoscopic surgery☆Abstract No matter how skilled the surgeon, the risk of complications always exists. Complications of laparoscopic surgery include anesthesia difficulties, positioning and nerve injuries, injuries due to insertion of needles and trocars, and intraoperative vascular, bowel, and urinary tract injuries. Injuries from electrosurgical equipment may also result. This article focuses on preventing such complications.
In typical laparoscopic procedures complications can arise in many areas, from initial induction to anesthesia to the removal of trocars and closing of the incisions. In addition, patients at high risks of bowel or urological injuries need to be addressed preoperatively. Anticipation and appropriate preparedness for surgery are crucial to limiting complications. Knowing how to manage complications is of course important, but knowing how to avoid them is prudent and intelligent, and will prevent heartache for both patient and surgeon.
Anesthesia  The surgeon should carefully observe the induction, ventilation, and intubation of the patient. Prolonged ventilation with difficult intubation may fill the stomach with air, increasing the risk of viscus injury. Ask the anesthesiologist to decompress the stomach with a small nasogastric tube just prior to inserting the Veress needle when a left upper quadrant incision is needed in anticipation of periumbilical adhesions. Positioning and nerve injuries With the patient asleep, the next step is to position her properly, with specific attention to potential nerve injuries that result from compression or stretching. Long nerves and those that course superficially are especially vulnerable to injury under general anesthesia. These include the brachial plexus, ulnar, femoral, and common peroneal nerves. Long laparoscopic procedures under general anesthesia, with complete paralysis, place these nerves under special risk of injury. The union of anterior rami, C5–C8, and T1 forms the brachial plexus. It courses from the inferior lateral aspect of the neck toward the axillae. The plexus then breaks into terminal branches supplying the upper extremities. Any significant abduction, extension, or external rotation of the arm can stretch the brachial plexus and cause a nerve injury. If improperly placed, the use of shoulder restraints, to prevent slippage in steep Trendelenburg position, may also cause significant compression of brachial plexus nerves between the shoulder braces and the first rib. To avoid this, the shoulder braces should be placed laterally on the acromioclavicular joint. Avoid any medial deviation toward the neck. Alternatively, one can attach Velcro between the mattress and the actual table to reduce the amount of slippage that occurs with steep Trendelenburg position and avoid the use of shoulder braces altogether. Placing both arms by the side with the arms pronated and with gel pads placed near the ulna, beneath the elbow and tucked loosely by the side, can prevent both ulnar and brachial plexus injuries (Fig. 1). This also gives the surgeon access and mobility to operate by the patient's side. The patient's legs are then placed in the stirrups, with attention to the common peroneal nerve and the femoral nerve. The common peroneal nerve is a branch of the sciatic nerve that passes very close to the head of the fibula on its lateral aspect. Make sure that when the legs are placed in the stirrups and abducted there is good cushion support to the common peroneal nerve (Fig. 2). The femoral nerve is also at risk of injury when the legs are placed at extreme flexion, external rotation, and abduction (Fig. 3). The femoral nerve can be stretched or compressed by the inguinal ligament especially when the legs are elevated for a laparoscopic-assisted vaginal hysterectomy. Before draping, it is important to deflex the knee so that when the legs are elevated, the femoral nerve is not stretched significantly. Patients should be informed that postoperative numbness or tingling usually resolves by the fifth day. But symptoms that persist beyond 5 days require neurological consultation. Motor deficits, too, should have neurological consults. Prognosis will depend on the amount of stretching and the duration of compression. Bladder decompression and insertion of uterine manipulator The patient should then be prepped and draped and a Foley catheter placed to decompress the bladder. Failure to do so increases the risk of trocar injury to the bladder. Injecting betadine into the urethra before Foley catheter insertion may reduce the risk of postoperative urinary tract infection. A uterine manipulator is then typically placed into the uterine cavity. As simple as this procedure may seem, there have been reports of air embolism from air being sucked in through the channel for hydrotubation, when the patients are placed in steep Trendelenburg position. Capping this channel will remove that risk. Insertion of trocars Usually, a Veress needle is inserted in the umbilicus where the peritoneum, fascia, and skin fuse. We use an intraumbilical small vertical incision and then carefully dissect the subcutaneous tissue until we see the shiny white fascia. That fascia is elevated with a Kocker clamp. The assistant is then able to lift the anterior abdominal wall away from the aorta and vital structures (Fig. 4). This technique (Fig. 5) allows the surgeon to use two-handed controlled insertion to enter the abdomen. It also allows a more direct 90-degree insertion when entering the abdomen. The lift obtained with the fascia is superior to the lift obtained manually or by using towel clips on the skin. Once the Veress needle is inserted, a filled syringe is used to first aspirate and check for a vascular or bowel injury; failure to do so may result in air or carbon dioxide being insufflated into a vascular bed or a viscus. The flow of gas at a pressure gradient of 4 mm Hg through a Swan-Ganz catheter is sufficient to induce a fatal air embolism (1). Although carbon dioxide is approximately five times more soluble than air, the injection of large volumes rapidly into the vascular system can result in a carbon dioxide embolism. This causes mechanical obstruction of the right ventricle outflow track with resultant pulmonary obstruction, right ventricular dilation, and failure. A rapid drop in the end-tidal carbon dioxide and the oxygen saturation is followed by a drop in blood pressure, and coronary circulation is compromised. Survival depends on immediate recognition, stopping the insufflation, and if necessary, placing the patient in left lateral decubitus with head down. This, hopefully, moves the large air bubble away from the right outflow tract. After the umbilical trocar is placed appropriately, the pelvis and abdomen should be examined thoroughly for any needle or trocar injuries. This includes inspection of omentum and bowel in pelvis and the retroperitoneal spaces. The secondary trocars are placed under direct vision. We prefer radically expanding trocars vs cutting trocars. Radically expanding trocars result in less postoperative pain and reduce both vascular abdominal wall injuries and postoperative trocar site hernia (2). Usually, secondary trocars are placed lateral to the rectus muscle (Fig. 6). In doing so, one can avoid the inferior epigastric vessels. These can usually be visualized from inside by laparoscopy as they leave the inguinal ring and course beneath the rectus muscles. When inserting the secondary trocars laterally to the rectus muscles, the external iliac vessels become susceptible to injury. The proximity of these vessels to the lateral trocars is a matter of a few centimeters and a slight lateral deviation may nick these vessels. Intraoperative complications The three major areas of intraoperative complication include vascular injuries, bowel injuries, and urological injuries. All intraoperative injuries can be life-threatening, especially if they go unrecognized. Therefore, any suspicion should be followed through to ensure the integrity of internal organs. Intraoperative vascular injuries Vascular injuries can occur from abdominal wall bleeding, intraperitoneal injury, or retroperitoneal vessel injury. Inferior epigastric vessel injury is usually prevented by direct visualization of these vessels. In obese patients, difficulty in properly visualizing these vessels and deviating medially from the initial skin incision may result in vessel injury. If the inferior epigastric vessel is nicked, tamponade is usually the easiest way to achieve hemostasis. If the vessel is directly visible, then bipolar cautery may be used. But this is not usual; more typically a Foley bulb is placed through the port, inflated, and placed on tension. The Foley may be deflated at the end of the procedure and if hemostasis is achieved, it may be removed; otherwise the Foley is reinflated and removed 24 hours later. Alternatively, a large needle absorbable stitch may be placed in figure-eight fashion and tied over gauze or a sponge, and left in place for 24–48 hours. Intraperitoneal injury is usually a result of instrumentation. Remaining in vascular planes will usually prevent vascular bleeding and oozing. The surgeon must dissect along the white lines that demarcate the planes of dissection. Bipolar current is the preferred method of achieving hemostasis, although hemostatic intracorporeal suturing may also be needed for large venous oozing. Major retroperitoneal vessel injury may result from Veress needle or trocar insertion. Placing the patient in steep Trendelenburg position before Veress needle insertion will rotate the sacrum and vessels anteriorly, making them more prone to injury if the surgeon does not adjust to the new angle of insertion (3). When working with an extremely thin patient, it is crucial to elevate the abdominal wall, by the fascia, in the umbilicus. The bifurcation of the aorta and the left common iliac vein may course above the promontory of the sacrum, and both are especially susceptible to injury. With a controlled two-handed technique, the surgeon can carefully slip the Veress needle in a 90-degree fashion, advancing the needle just 2 or 3 cm to enter the peritoneal cavity. These steps are especially important in the thin patient. Any type of retroperitoneal large vessel injury needs to be addressed immediately. Control can be accomplished with tamponade or pressure, until a vascular surgeon is available for repair. Intraoperative gastrointestinal injuries The management of bowel complications varies according to the type and size of the injury, the segment of bowel involved, and the general status of the patient. Although unintentional, operative injury to the bowel can occur within the standard of care, and its occurrence can lead to significant consequences. Recognition and immediate attention to this problem is imperative. Gastrointestinal injury may be thermal or mechanical. The mechanical injury is usually caused by trocar insertion or operative trauma. The prevention of trocar-related injuries related to the bowel include decompressing the stomach, as mentioned previously, and having a high index of suspicion for bowel abdominal wall adhesions. An enema will empty the bowel and make it easier to notice adhesions (Table 1). . This preparation will also reduce spillage and contamination if the bowel is injured. If bowel adhesions to the anterior abdominal wall are suspected, a left upper quadrant incision is preferred to an open technique because the risk of bowel injury by open technique is similar to those with closed insertion of a Veress needle (4).  | BOWEL PREPARATION -  | |
| 1.  | |
| Purchase Fleet enema. | |
| Purchase 3 ounces Fleet Phospho-soda  (1) bottle of magnesium citrate. | |
| 2.  - Follow **clear liquids** only all day. In A.M., mix 1 1/2 oz. (3 measuring tablespoons - NOT tableware) of Fleet Phospho-soda with at least 4 oz. of cold clear liquid (ginger ale, apple juice, Sprite or 7-Up helps improve the taste) and drink. Then follow with a glass of (8 oz.) of Clear Liquid. Repeat in P.M.,  drink 1/2 bottle of magnesium citrate in A.M. and 1/2 bottle in P.M. | |
| 3. Administer a Fleet enema to yourself 1 hour before bedtime.  | |
| BOWEL PREPARATION -  | |
| 1.  | |
| Purchase 4 1/2 ounces of Fleet phospho-soda  (2) bottles of magnesium citrate | |
| Purchase (1) 8-ounce can of Ensure. | |
| Purchase Fleet enema. | |
| 2.  - Follow **light breakfast** below and **clear liquids** after noon. | |
| In A.M., mix 1 1/2 oz. (3 measuring tablespoons - NOT tableware) of Fleet Phospho-soda with at least 4 oz. of cold clear liquid (ginger ale, apple juice, Sprite or 7-Up helps improve the taste) and drink. Then follow with a glass of (8 oz.) of clear liquid,  drink 1/2 bottle of magnesium citrate in A.M. | |
| 3.  - **Clear liquids** only all day. | |
| In A.M., mix 1 1/2 oz. Fleet Phospho-soda again, like yesterday. Repeat in P.M.,  drink 1/2 bottle of magnesium citrate in A.M. and 1/2 bottle in P.M. | |
| 4. Drink plenty of clear liquids to avoid dehydration. | |
| 5. Administer a Fleet enema to yourself 1 hour before bedtime.  | |
| **Light Breakfast** | **Clear Liquids** | |
| Any item from clear liquids list |  | |
| One boiled or poached egg | Soft drinks, Gatorade, Kool-Aid | |
| Cream of wheat | Strained fruit juices without pulp | |
| White toast (no butter) | Water, tea, or coffee (no milk or non-dairy creamer) | |
| One 8 oz. can Ensure | Low sodium chicken or beef bouillon/broth | |
| | Hard candies | |
| | Jell-O (no fruit or toppings) | |
| | Popsicles (no sherbets or fruit bars). | | | | |
The key to treating bowel injury is immediate recognition. Gastric injury from a Veress needle can be managed by decompression for 24 hours. Injury from a trocar should be repaired immediately by laparoscopy or laparotomy, depending on the surgeon's level of skill. When a small bowel injury is recognized, primary repair should be done immediately. If immediate repair is not possible, than either a staple or a small suture should mark the area so that one can find the defect later in the procedure. Trocar injuries through the small bowel should be left in place and the loop of bowel brought out through an extended incision and repaired. Or, the loop can be repaired intracorporally, carefully avoiding any stricture of the small bowel. Repair of large bowel injuries will depend on the spillage and contamination of the peritoneal cavity by large bowel contents. Small traumatic lacerations can usually be managed by primary closure, but larger injuries with contamination may require diverting colostomy and repair at a later date. Unrecognized injuries typically present within 48 to 72 hours with increasing abdominal pain and fever. Postoperative intestinal blockage following laparoscopy rarely occurs; when it does, it warrants immediate evaluation. Thermal injuries with monopolar or bipolar energy may be difficult to see at the time they occur. If recognized they generally require resection of a 1- to 2-cm border to ensure that only viable tissue is used for repair. Recognizing ways that thermal injury may occur will be covered later in the section on electrical energy. Intraoperative urological injuries Serious urinary complications are increasing as more major operative laparoscopy procedures are performed. Urological complications can be classified, as with bowel injuries, into thermal and mechanical injuries. The course of the ureter places it at extreme risk during major laparoscopic pelvic dissection. The ureter is best identified at the pelvic brim and may be followed down as it enters beneath the uterine vessels. Thermal injuries and ischemic injuries that occur because of direct thermal application or loss of blood supply to the ureter may result in fistula formation that is unrecognized and present 3–14 days postoperatively. Endometriosis is a major factor for increasing the risk of serious urinary complications after operative laparoscopy (5). Many ureter injuries now occur with laparoscopically assisted vaginal hysterectomies (6). Most occur in the distal portion of the ureter where coagulation or stapling is used to divide the cardinal ligament. The close proximity with the ureter places it at risk for lateral thermal spread and delayed necrosis. To reduce that risk, the hysterectomy may be completed vaginally. Alternatively, a supracervical hysterectomy may be performed, avoiding altogether dissection of the cardinal uterosacral ligament complex. Exposure, identification of anatomic landmarks, and careful dissection will reduce the risk of injury. In cases where suspected injury is noted, the integrity may be checked with indigo dye injected intravascularly. The ureters are observed for any spillage and cystoscopy will confirm bilateral spillage into the bladder. If there is any suspicion of ischemia, whether from thermal drainage or extensive devascularization of a segment, a stent should be placed and a urological consult obtained. Most injuries to the bladder can be managed with a primary repair and drainage for approximately 7–10 days (7). Electrical energy Electrosurgery has been an important tool for use in surgery for the purpose of cutting and coagulation. Electrical and thermal burns to patient are usually predictable and usually preventable. Electrosurgical instruments generate high-frequency electric current, between 400,000 and 1,000,000 Hz. The pathway of the current is from the active output connection, along a cable to the active electrode. Two pathways of current are used (Fig 7, Fig 8). In monopolar mode, the pathway of the current is from the active output connection, along a cable to the active electrode tip. The current then returns through the patient to a return pad (large dispersive electrode). From the return pad, the current returns to the generator to complete the circuit. In bipolar mode, the current flows from one paddle of the forceps through the tissue, grasped between the paddles, and back to the generator to complete the circuit. Bipolar current is used mainly for controlled coagulation, whereas monopolar current may be used for cutting or coagulation. A high-voltage monopolar current will seek pathways to ground. If there is any interruption in the normal return pathway from the active output to the return unit, the current will seek an alternate pathway (stray current) resulting in unwanted effects. The newer generators and grounding pads are equipped with a system that will detect any interruption in current and automatically will deactivate the generator. This technology has significantly reduced pad site burns. Nevertheless, thermal burns still occur, now mostly from insulation failures of the active electrode, direct coupling of the active electrode to another conducting instrument, or capacitive coupling of current. Insulation failures Any break or breach in the insulation may provide an alternate pathway for the flow of current (Fig. 9). This can be minimized by periodically checking the insulation covering of all the electrodes. Testing may be achieved cheaply by placing a raw chicken breast on a grounded pad and passing the activated insulated instrument along the breast, looking for any visible blanching. Direct coupling Direct coupling occurs when an active electrode makes an unintended contact with another electrode or conductive instrument. The surgeon must always know what instruments are in every port. When pressing on a monopolar pedal, all instrument tips must be in view. Avoid close proximity to prevent sparking or direct coupling (Fig. 10). Capacitive coupling In monopolar mode, an alternate current flowing through an active monopolar electrode and back to the electrosurgical generator through the patient and the return pad, induces an unintended current in any conductors in close proximity (8). This process is referred to as capacitive coupling (Fig. 11). The degree of current induced from one conductor to another will depend on the proximity of the two, the voltage, and the insulation. Any conductor in the operating room is at risk of inheriting a stray current by becoming capacitively coupled to the current coming from the active electrode. Potential conductors include jewelry, the operating room table, an idle electrode, other electrical devices, surgical instruments, wires, and scopes. Capacitively coupled currents are eliminated in bipolar cords since they travel in opposite directions and cancel each other. Bowel thermal injuries are prone to stray currents that are not apparent initially, as the injury is usually not in the field of view (Fig. 12). Which current to use Electrosurgical generators produce an alternating current with a variety of waveforms (Fig. 13). A cutting current will produce a constant waveform with rapid rise in heat at tissue level, allowing the surgeon to vaporize or cut tissue. The generator will dampen the waveform so that the interrupted waveform will produce less heat, creating a coagulum effect on the tissue. For a constant power setting, changing the cutting to coagulation will result in higher peak-to-peak voltage with longer interruptions in waveform. The higher voltage also increases the risks of stray currents. The effect on the tissues depends on the power setting and the shape of the tip of the active electrode instrument. The smaller the tip, the higher the power density at that tip, and the lower the amount of energy needed to achieve the effect; the lower the power setting on the generator, the lower the risk of stray currents. For cutting tissue one should use an unmodulated pure sinusoidal waveform (with low peak-to-peak voltage), a small tip electrode (higher power density), and a rapid pass of the active electrode. This should minimize the amount of thermal spread and stray currents. For coagulation of vessels we recommend bipolar current, which will use lower voltage with minimal thermal spread and stray currents. For fulguration, a high peak-to-peak voltage should be used without touching the tissues. The higher voltage will allow sparking and only the surface will be coagulated without deep tissue penetration of thermal spread. If tissue area is touched by the higher voltage current, the effect would result in deeper tissue necrosis. Having an understanding of electric energy will enable a surgeon to be watchful of potential hazards. Whenever energy is used, the surgeon must quickly evaluate the field for potential unintended currents from breaks in insulation, direct coupling, or capacitive coupling. Conclusion Advanced laparoscopy has evolved tremendously in the past decade. More and more intricate procedures are being performed in this fashion. Surgeons are now crossing new boundaries and must be vigilant about potential complications in every aspect of the surgical case. A basic understanding of electric energy used is paramount in preventing unwanted tissue effects. With more experience and growing skill, surgeons can learn to reduce potential complications and avoid scenarios that may predispose them to these complications. By reviewing complications one encounters and by learning and reading about others' mishaps, we will enhance the care that we provide to our patients. References 1.
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☆ Vigilance in anesthesia, positioning, bladder decompression, trocar placement, electrosurgery, and post-op care can prevent most injuries PII: S1546-2501(04)00023-4 doi:10.1016/j.sram.2004.02.022 © 2003 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved. | |
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