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 Complications of laparoscopy
Dr .Ashraf Fouda Damietta General Hospital E.
mail ashraffoda_at_hotmail.com
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(No Transcript)
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INTRODUCTION

• As
• Operative laparoscopy becomes more widely
  accepted,
• New techniques are being developed and
• More surgeons are adopting this form of
  management,
• The complication rate can be expected to rise.

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INTRODUCTION

• The incidence of laparoscopic complications is
• 1.1 to 5.2 in minor procedures
  and
• 2.5 to 6 in major ones

(Kane Krejs, 1984).
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INTRODUCTION

• To reduce the prevalence of complications
• Training programmes must include supervision at
  all levels of development and
• There must be a high degree of awareness of the
  potential risks of laparoscopic surgery.

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Complications may be associated with

• The anesthetic
• The induction of pneumoperitoneum
• Insertion of primary and secondary trocars
• Thermal Instruments
• Mechanical Instruments
• Other associated conditions

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A. THE ANESTHETIC

• Local anesthesia may be used for tubal
  sterilization and some other minor procedures.

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A. THE ANESTHETIC

• May produce specific problems and complications
• Complications directly attributable to the
  general anesthetic are no different from those
  which may occur when any other type of surgery is
  performed.
• Some features of laparoscopic surgery predispose
  to specific anesthetic complications.

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A. THE ANESTHETIC

• The use of a steep Trendelenburg position and the
  distension of the abdomen may both reduce
  excursion of the diaphragm.
• Carbon dioxide (CO2) can be absorbed particularly
  during prolonged operations.

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A. THE ANESTHETIC

• Monitoring by
• Pulse oximetry,
• The use of endotracheal intubation and
• Positive pressure assisted ventilation
• Reduce the risk of hypercarbia to a
  minimum.

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A. THE ANESTHETIC

• If arrhythmia occurs
  the anesthetist will be responsible for its
  management and
• The surgeon should
• Return the patient to the supine position,
• Evacuate the pneumoperitoneum and
• Discontinue the surgery.

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A. THE ANESTHETIC

• Vasovagal reflex may produce shock and collapse
  especially if the anesthetic is not deep enough.
• It may be prevented by efficient anesthesia and
  should only be diagnosed when other causes of
  shock have been excluded.

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1. Anxiety

• May be prevented by administration of
  Diazepam 20 mg orally about one
  hour pre-operatively.

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2. Vasovagal reaction

• This may be associated with bradycardia and,
  in more severe cases, cardiac arrest,
  convulsion and shock.

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2. Vasovagal reaction

• The treatment should include
• Atropine 0.5 mg given intravenously (IV)
• Oxygen given by endotracheal tube at a rate of
  4-6 litres/minute
• Adrenaline 0.5-1.0 ml of 1100,000 solution given
  slowly IV
• Respiratory and cardiac resuscitation.

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3. Pain

• Pain may be prevented to some extent by the
  administration of non-steroidal
  anti-inflammatory drugs such as
  mefanimic acid,
  naprosene or
  fentanyl.

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4. Allergic reactions and anaphylaxis

• Any local anaesthetic should be given initially
  as a small test dose to determine if an
  unsuspected hypersensitivity exists.
• If it does, no more medication should be
  administered.
• If it occurs it will be characterized by
  agitation, flushing, palpitations, bronchospasm,
  pruritus and urticaria.

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4. Allergic reactions and anaphylaxis

• The treatment will depend on the severity of the
  reaction and may include
• Adrenaline 0.5 mg (1100,000 solution IVI or IMI)
  
• Prednisolone 25 mg IVI
• Theophylline 250 mg (10ml) given slowly IV.
• Intravenous fluids
• Oxygen

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B. INDUCTION OF PNEUMOPERITONEUM
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1. Extra-peritoneal gas insufflation

• Failure to introduce the Veress' needle into the
  peritoneal cavity may produce extra-peritoneal
  emphysema.
• This occurs in about 2 of cases.

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1. Extra-peritoneal gas insufflation

• The diagnosis is made by palpation of crepitus
  caused by bubbles of CÓ2 under the skin..
• If this is recognized early, the gas may be
  allowed to escape and the needle re-introduced
  through the same or another site.

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1. Extra-peritoneal gas insufflation

• If the complication is not recognized during the
  introduction of gas, the typical appearance of
  extra-peritoneal gas may be recognized when an
  attempt is made to introduce the telescope.
• It is always essential to view through the
  telescope during its insertion through its
  cannula.

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1. Extra-peritoneal gas insufflation

• The typical spider-web appearance caused by
  pre-peritoneal insufflation will be seen when the
  telescope reaches the end of the cannula and
  further stripping of the peritoneum by the tip of
  the telescope avoided.

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1. Extra-peritoneal gas insufflation

• The laparoscope should be withdrawn and attempts
  made to express the gas.
• The needle may then be re-introduced through the
  same or another site.
• Alternatively the trocar and cannula may be
  introduced by 'open
  laparoscopy'.

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1. Extra-peritoneal gas insufflation

• The aspiration test and the high insufflation
  pressure will make it obvious that
  the needle is sited incorrectly in which case it
  should be withdrawn and re-sited.

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Complications from the
distension medium

• Carbon dioxide (CO2) is the distension
  medium most commonly used for operative
  laparoscopy.

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Carbon dioxide (CO2)

• Gas embolism is possible but uncommon because the
  gas is highly soluble and is reabsorbed so
  quickly that, even if there has been a moderate
  embolus, the circulatory changes return to normal
  within a few minutes and the patient recovers.
• Up to 400ml of gas may be intravasated without
  producing changes in the ECG.

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Carbon dioxide (CO2)

• Cardiac arrythmia may be due to excessive
  absorption of CO2.
• Monitor the intra-abdominal pressure throughout
  the operation and use an automatic pneumoflator
  for all but the simplest forms of surgery.
• This will cut out if the intra-abdominal pressure
  rises.
• Endotracheal intubation and positive pressure
  respiration will help to prevent complications
  from CO2 insufflation.

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Carbon dioxide (CO2)

• Post-operative pain is common with CO2
  insufflation due to peritoneal irritation which
  is a result of conversion of CO2 to carbonic
  acid.
• The chest pain may be confused with coronary
  heart disease and be treated inappropriately with
  anti-coagulants.

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Complications from the distension
medium

• Nitrous oxide (N2O) has become popular with some
  laparoscopists because there are less side
  effects than with CO2.
• Anesthetists can dispense with intubation and
  allow the patient to breath through a laryngeal
  mask.

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Complications from the distension
medium

• However, a diagnostic laparoscopy may develop
  into a complicated operative procedure.
• N2O supports combustion.
• Methane gas may be released into the peritoneal
  cavity following bowel injury.
• A high frequency monopolar current used during
  laparoscopic surgery may cause an explosion.

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Complications from the distension medium

• The main place for N2O is when laparoscopy is
  being performed under local anesthesia in which
  case the pain factor becomes important.
• This is applicable to tubal sterilization with
  clips, rings, or bipolar coagulation, but not to
  more advanced laparoscopic procedures.

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2. Mediastinal emphysema

• Gas may extend from a correctly induced
  pneumoperitoneum into the mediastinum and create
  mediastinal emphysema.
• Extensive emphysema may cause cardiac
  embarrassment which will be diagnosed by the
  anaesthetist.

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2. Mediastinal emphysema

• There will be loss of dullness to percussion over
  the precordium.
• The laparoscopy must be abandoned and as much gas
  as possible evacuated.
• The patient must be kept under close observation
  until the gas has been absorbed.

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3. Pneumothorax

• May result from insertion of the Veress' needle
  into the pleural cavity.
• Whenever a high site of insertion is chosen the
  needle should be directed away from the diaphragm
  and, as always, the standard protocol of
  aspiration and sounding tests employed.

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3. Pneumothorax

• Should be suspected if there is difficulty in
  ventilating the patient.
• There may be a contra-lateral mediastinal shift
  and increased tympanism over the affected area.
• The procedure should be abandoned and the gas
  allowed to escape.
• The patient should be kept under observation.
• Occasionally assisted ventilation and insertion
  of a pleural tube may be required.

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4. Pneumo-omentum

• The omentum is penetrated by the Veress' needle
  in about 2 of cases.
• The misplacement should be recognized by the
  aspiration test and the position of the tip
  altered to free the needle.
• There will also be a raised insufflation pressure
  which should lead the surgeon to suspect an error
  in the position of the needle.
• The condition is usually innocuous unless omental
  blood vessel is punctured.

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5. Injury to gastro-intestinal tract

• Certain conditions may predispose to injury by
  the Veress' needle.
• These include
• Distension of the gastro-intestinal tract or
• Adhesions of bowel to the abdominal wall.

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5. Injury to gastro-intestinal tract

• Penetration of the stomach may occur when an
  upper abdominal site of insertion is chosen or
  the stomach is distended during induction of
  anesthesia.

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5. Injury to gastro-intestinal tract

• Gastric distension may also occur if anesthesia
  is maintained with a mask and should be suspected
  if there is upper abdominal distension or
  increased tympanism.
• In this case the stomach should be aspirated with
  a naso -gastric tube.

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5. Injury to gastro-intestinal tract

• The diagnosis of gastric perforation by the
  Veress' needle may be made when the patient
  belches gas.
• The laparoscope should be introduced and the
  stomach inspected carefully.

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5. Injury to gastro-intestinal tract

• Provided the stomach wall has not been torn, no
  surgical treatment is necessary but a broad
  spectrum antibiotic should be given.
• If the stomach has been torn, surgical repair
  either by laparotomy or laparoscopy is mandatory.

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5. Injury to gastro-intestinal tract

• Aspiration following initial insertion of the
  needle should permit early recognition of
  perforation of the bowel but it is not
  fool-proof.

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5. Injury to gastro-intestinal tract

• Bowel penetration should be suspected if there is
  
• Asymmetric abdominal distension,
• Belching,
• Passing of flatus or a fecal odour.

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5. Injury to gastro-intestinal tract

• The induction of pneumoperitoneum should be
  stopped and the needle re-sited to introduce the
  pneumoperitoneum correctly.
• The gastro-intestinal tract should be examined
  carefully for perforation.

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5. Injury to gastro-intestinal tract

• It is important that both sides of the
  bowel be examined as the exit wound may
  be larger than the entry wound.
• Fecal soiling demands immediate laparotomy and
  repair of the bowel.

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5. Injury to gastro-intestinal tract

• It is important to ensure that there has not been
  a through-and-through injury of a
  loop of bowel which is adherent to
  the peritoneum at the site of insertion.

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5. Injury to gastro-intestinal tract

• A simple needle penetration requires no treatment
  but the patient should be kept under observation
  and given broad spectrum antibiotics.

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6. Bladder injury

• Routine catheterization of the bladder and proper
  sitting of the needle should prevent bladder
  penetration.

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6. Bladder injury

• If pneumaturia is noted the needle should be
  partially withdrawn and the creation of
  pneumoperitoneum continued.

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6. Bladder injury

• The bladder peritoneum should be carefully
  inspected to ensure that no significant injury
  has been caused.
• The treatment of a simple puncture is
  conservative with postoperative bladder drainage.

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7. Blood vessel injury

• The Veress' needle may penetrate
• omental or
• mesenteric vessels or
• any of the major abdominal or pelvic arteries or
  veins.

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7. Blood vessel injury

• Minor vascular injuries involving the omental or
  mesenteric vessels are difficult to prevent as
  it is impossible to ensure that the
  omentum is not close to the abdominal wall during
  blind insertion of the insufflating needle.

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7. Blood vessel injury

• Injury may be suspected if
• blood returns up the open needle or if
• free blood is seen in the peritoneal cavity after
  insertion of the laparoscope.

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7. Blood vessel injury

• If blood returns up the needle and the patient's
  condition is stable, the site of injury may be
  investigated laparoscopically.
• The needle should be left in place and a 5 mm
  laparoscope introduced through a suprapubic
  cannula.

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7. Blood vessel injury

• Minimal bleeding may usually be controlled by
  bipolar coagulation or a laparoscopic suture.
• Laparotomy is not usually necessary except in the
  case of injury to the superior mesenteric artery.
  
• Such injury requires repair by a vascular surgeon

(Bassil et al, 1993)
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7. Blood vessel injury

• Injury to the major vessels may be prevented by
• Lifting the abdominal wall,
• Angling the needle towards the pelvis once the
  initial thrust through the fascia has been made
  and by
• Inserting only as much of the needle as
  necessary.

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7. Blood vessel injury

• Thin patients and children are at
  particular risk of this injury.
• Withdrawal of blood on aspiration following
  insertion of the needle should allow early
  detection of blood vessel injury.

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7. Blood vessel injury

• If injury to a vessel such as the aorta, inferior
  vena cava or common iliac vessel
  is suspected, the
  needle should be left place to mark the site of
  the injury and laparotomy performed through a
  mid-line incision.

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7. Blood vessel injury

• There is usually a large haematoma which obscures
  the site of the injury.
• The aorta should be compressed with a clamp or
  hand until a vascular surgeon arrives to perform
  definitive surgery.

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7. Blood vessel injury

• Dramatic collapse may result from penetration of
  a major vessel but the bleeding may not be
  immediately evident if it is retro-peritoneal.
• The loose areolar tissue anterior to the aorta
  can allow accumulation of a considerable amount
  of blood before frank intra-abdominal bleeding is
  seen.

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7. Blood vessel injury

• A thorough search must be made to determine the
  extent of vessel damage.
• This includes retraction of bowel to expose the
  aorta above the pelvic brim which is the most
  common site of perforation.

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7. Blood vessel injury

• Failure to do search may result in continued
  bleeding and formation of a large haematoma
  leading to a second episode
  of shock some hours later

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8. Gas embolism

• Intravascular insufflation of gas may lead to gas
  embolism or even death.
• This can only happen if the penetration by the
  Veress' needle goes unrecognized and insufflation
  commences.

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8. Gas embolism

• It should be prevented by routine use of the
  aspiration test.
• The patient should be turned on to the left
  lateral position and,
• If immediate recovery does not take place,
  cardiac puncture performed to release the gas.

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9. Puncture of liver or spleen

• The liver or spleen may be punctured by the
  Veress

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C. INTRODUCTION OF TROCARS AND CANNULAE

• Some of the most serious injuries that occur
  during laparoscopy are caused by the insertion of
  the trocars and cannulae.
• Insertion of the primary trocar and cannula is,
  of necessity, blind.

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INTRODUCTION OF TROCARS AND CANNULAE

• The causation of injuries by the primary trocar
  are similar to those caused by the Veress' needle
  but the magnitude of the injury is
  greater.

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INTRODUCTION OF TROCARS AND CANNULAE

• The sites of the secondary portals of entry must
  be selected carefully and the insertion must
  always be made under visual control.

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1. Injury to vessels in the abdominal wall

• Superficial bleeding from the incision rarely
  gives rise to concern and always stops with
  application of pressure.
• Bleeding from puncture of the deep inferior
  epigastric artery is more serious.

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Inferior epigastric artery

• The artery is at risk during the insertion of
  secondary trocars and cannulae.

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Inferior epigastric artery

• Injury may be prevented by transilluminating the
  abdominal wall before insertion in a thin patient
  or by visualizing the artery laparoscopically as
  it runs lateral to the obliterated umbilical
  artery.

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Inferior epigastric artery

• The site of insertion can then be chosen by
  depressing the wall skin with the handle of the
  scalpel and noting its relationship to the
  vessels.
• The diagnosis may be made by the sight of blood
  dripping into the pelvis from the trocar wound.

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Inferior epigastric artery

• Occasionally blood may actually be seen spurting
  across the abdominal cavity.
• Alternatively the immediate or delayed appearance
  of a large abdominal wall haematoma indicates
  injury to the deep inferior epigastric artery.

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Inferior epigastric artery

• The treatment is usually simple.
• The trocar and cannula should be left in
  situ to act as a marker and also prevent the
  artery slipping away.
• A Foley catheter passed down the cannula and
  inflated may act as a compress and control the
  bleeding.

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Inferior epigastric artery

• Alternatively the incision should be enlarged to
  about 2 cm in length to expose the anterior
  rectus sheath.
• A round bodied needle should be inserted through
  the full thickness of the abdominal wall from the
  sheath to the peritoneum under laparoscopic
  control.

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Inferior epigastric artery

• The needle point should be brought out again to
  the surface of the rectus sheath and a knot tied
  firmly on the sheath.
• This is preferable to tying the knot on the skin
  which is painful and leaves an unsightly scar
  although it is acceptable to tie the knot over a
  gauze swab to prevent skin injury.

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Inferior epigastric artery

• It may be necessary to insert two
  sutures, one above and
  one below the site of
  bleeding.

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Inferior epigastric artery

• Occasionally it may be necessary to open the
  wound wider to locate the bleeding artery.
• This should be reserved for those cases where
  there is profuse bleeding or primary laparoscopic
  suturing is ineffective.

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2. Injury to an
intra-abdominal vessel

• Injury to minor blood vessels is usually
  self-limiting or can be controlled by bipolar
  electro-coagulation.
• Damage to major vessels is more serious than with
  a Verres' needle because of the size of the
  trocar tip and may result in profuse bleeding.

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2. Injury to an intra-abdominal vessel

• Injury to omental vessels may compromise the
  vitality of a segment of bowel.
• Treatment of these injuries is by
• Resuscitation,
• Laparotomy,
• Vascular repair or ligation and, where necessary,
  
• Bowel resection and anastomosis with the
  assistance of the appropriate surgical colleague.

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2. Injury to an
intra-abdominal vessel

• A small leak from the a major vein may not be
  immediately apparent.
• The intra-abdominal pressure of the
  pneumoperitoneum and the decreased venous
  pressure induced by the Trendelenburg position
  may temporarily control it.
• However, as soon as the intra-abdominal and
  venous pressures return to normal, the bleeding
  may recommence and produce a retro-peritoneal
  haematoma and shock.

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2. Injury to an intra-abdominal vessel

• It is essential therefore, at the completion of
  any laparoscopic procedure, but especially those
  involving the pelvic side wall, to
  inspect the course of the major
  vessels and look for a haematoma.
• This applies particularly to the treatment of
  endometriosis at this site.

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2. Injury to an
intra-abdominal vessel

• A small haematoma may be the only evidence of
  injury to a vein at the pelvic brim.
• Occasionally there may be a defect in the
  overlying peritoneum which indicates the site of
  entry of the trocar.

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2. Injury to an
intra-abdominal vessel

• It is essential to proceed to laparotomy to
  repair the vessel.
• A vascular surgeon should be consulted and the
  vessel compressed until the arrival of
  specialized assistance.

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3. Injury to a hollow viscus

• Injury to a hollow viscus may vary from
  superficial damage of the serosa to
  complete penetration into the lumen.
• If penetration has occurred
• The viscus may slip off the trocar,
• The trocar may remain within the lumen
  or, rarely
• The trocar may pass right through the a loop of
  bowel which becomes impaled upon it.

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3. Injury to a hollow viscus

• It is always important to inspect the bowel at
  the axis of insertion of the primary trocar and
  cannula to ensure that it has not been damaged.

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3. Injury to a hollow viscus

• If the cannula remains within the bowel the
  injury will be obvious by the recognition of
  mucosal folds.
• A through and through injury may be missed and
  only become apparent by the sight of faecal
  soiling, a faecal smell when the pneumoperitoneum
  is released or the subsequent development of
  peritonitis.

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3. Injury to a hollow viscus

• Injury to the stomach or bowel are always
  serious.
• The management depends on the skill
  of the surgeon.
• The classical treatment is to perform laparotomy
  and suture the bowel in two layers.
• A skilled surgeon may perform the repair by
  laparoscopic suturing.

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3. Injury to a hollow viscus

• The defect should be closed in two layers in such
  a way as to avoid stricture formation, there
  should be copious peritoneal irrigation and a
  drain should be inserted into the abdomen.
• Appropriate antibiotic therapy should be
  instituted.

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3. Injury to a hollow viscus

• It may not be possible to identify the site of
  bowel injury by laparoscopy.
• In this case it is essential to perform
  laparotomy to find and treat the bowel injury.
• Failure to do this will result in the patient
  developing faecal peritonitis and becoming
  dangerously ill.

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3. Injury to a hollow viscus

• Bladder laceration may occur during mobilization
  of the bladder in advanced pelvic surgery.
• It should be sutured in two layers using
  laparoscopic suturing technique and a Foley
  catheter inserted into the bladder.

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4. Damage to other organs

• Minor injuries to other organs are usually
  self-limiting.
• They should be inspected at the completion of the
  procedure.
• Peritoneal lavage must be carried out to remove
  blood and clot and ensure that the bleeding has
  stopped.

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4. Damage to other organs

• A small puncture on the surface of the uterus may
  be treated with bipolar electro-coagulation if
  bleeding does not stop spontaneously.

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4. Damage to other organs

• Injuries to the liver and spleen are rare unless
  the organ is pathologically enlarged.
• Such injuries are more likely to occur in
  operations performed by general surgeons.
• Minor bleeding will stop spontaneously. Major
  haemorrhage requires immediate laparotomy.

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D. THERMAL DAMAGE

• Burns from electric current were one of the major
  causes of complications when monopolar tubal
  coagulation was the principle method of female
  sterilization.
• The incidence of burns was dramatically reduced
  by the introduction of bipolar and thermal
  coagulation and mechanical devices to occlude the
  tubes.

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THERMAL DAMAGE

• Monopolar electric current passes into the
  patient's body from the electrode which may be
  forceps or a needle.
• The current passes into the patient's tissues at
  the point of contact and then must return to the
  generator via the return plate.
• This is usually placed on the patient's leg.

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THERMAL DAMAGE

• The effect of the electric current will depend
  its power and the power density which, in turn
  depends on the area and duration of application.

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THERMAL DAMAGE

• To obtain maximum tissue effect the area
  of application at the target organ is small.
• The current passes from that small area along the
  path of least resistance towards the return
  plate.
• In gynecological surgery this pathway is usually
  over the surface of loops of bowel.

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THERMAL DAMAGE

• The area of the return plate is large so the
  power density at its site of application to the
  skin is low.
• However on its return pathway the current may
  pass over a small area of contact between two
  organs.
• The power density at that point may be high.

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THERMAL DAMAGE

• In this way a burn may occur outside the
  surgeon's visual field.
• Normally this does not happen and the current
  passes harmlessly to the dispersive plate.

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THERMAL DAMAGE

• Thermal injury to organs such as bowel may also
  result from leakage of current from the shaft of
  the instrument.
• This may result from
• Insufficient or faulty insulation or from
• Capacitative coupling in which there is a build
  up of current in the shaft of the instrument
  because the normal escape route has been shut
  off.

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THERMAL DAMAGE

• Current normally escapes from the metal cannula
  through the patient's anterior abdominal wall to
  the return plate.
• If a plastic cannula has been used this route is
  closed and the current may escape to bowel.
• If the contact point between instrument and bowel
  is small, the power density may be high and
  thermal injury will result.

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THERMAL DAMAGE

• Occasionally the monitoring system may not be
  properly earthed.
• If the current passes via an ECG electrode
  instead of to the return plate, the patient may
  suffer a skin burn because the ECG electrode is
  small and so the power density is high at this
  site.

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THERMAL DAMAGE

• Alternatively, the current may pass along one of
  the ancillary instruments which,
  if not properly insulated, may produce a
  skin burn at the portal of entry or the surgeon
  may suffer a burn on the hands or face.

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THERMAL DAMAGE

• There is a danger of lateral heat spread with
  monopolar or bipolar current.
• It is important to ensure that no other organ is
  in contact with or near an organ to which
  electricity is being applied.

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THERMAL DAMAGE

• Lateral spread may also be minimized by keeping
  the forceps blades close together.
• Build-up of thermal energy may be
  prevented by intermittent application of energy
  which, in effect, produces a pulsed
  current

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THERMAL DAMAGE

• The bowel is the most commonly injured organ.
• The injury may range from minor blanching of the
  serosa to frank perforation.
• Perforation requires laparotomy, excision of the
  surrounding devitalized bowel and repair of the
  defect.

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THERMAL DAMAGE

• If blanching is significant, laparotomy excision
  of the damaged tissue and surgical repair should
  be performed immediately.
• Failure to do so may result in delayed ischemic
  necrosis at the site of the burn.

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THERMAL DAMAGE

• Initially there may be few symptoms but commonly
  the patient will complain of feeling unwell and
  this feeling may not improve as quickly as usual.

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THERMAL DAMAGE

• It should be realized that any patient who feels
  unwell on the day after surgery and whose
  condition does not improve over the next few
  hours, may have an unsuspected injury to the
  bowel.
• The unwary physician may allow the patient to
  return home.

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THERMAL DAMAGE

• The insidious development of vague abdominal
  symptoms, discomfort, anorexia and possibly
  pyrexia may not be recognized by her medical
  attendants.
• A faecal fistula may not form for 48-72 hours.

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THERMAL DAMAGE

• Fecal peritonitis slowly develops and the patient
  may become seriously ill over a period of days
  before re-admission is requested.
• Radiology followed by laparotomy reveals the
  desperate situation.

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THERMAL DAMAGE

• Laparotomy is followed by repair of the bowel or,
  more often, colostomy and drainage of the
  peritoneum.
• A prolonged period of serious illness may follow.

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THERMAL DAMAGE

• It must always be remembered that
  electric current is potentially dangerous and all
  the safety rules for its use must be strictly
  obeyed.

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INJURY FROM MECHANICAL INSTRUMENTS

• The main injuries caused by scissors or forceps
  are to a blood vessels.
• Bleeding will be immediately obvious and should
  be controlled by bipolar or thermocoagulation or
  by suturing.
• Direct inadvertent injury to other organs by
  mechanical instruments may result from careless
  or clumsy use.

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OTHER COMPLICATIONS

• A number of other complications may result from
  laparoscopy.

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1. Cervical laceration

• It is common for the cervical tenaculum to cause
  a laceration of the anterior lip of
  cervix.
• The cervix should always be inspected at the end
  of the procedure.
• The bleeding may usually be controlled by
  pressure from sponge forceps but occasionally
  requires suturing.

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2. Uterine perforation

• May be caused by the manipulating cannula or
  during dilatation and curettage.
• The perforation should always be inspected with
  the laparoscope during and at the end of the
  procedure.
• Bleeding is usually slight and the complication
  does not usually require treatment.

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3. Shoulder pain

• Carbon dioxide is converted to carbonic acid when
  it is in solution with body fluids.
• This is irritant to the peritoneum.
• Diaphragmatic peritoneal irritation produces pain
  which is referred to the shoulder by the phrenic
  nerve.
• This pain may be confused with cardiac pain by
  the unwary physician and treated inappropriately.

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4. Pelvic inflammatory disease

• There is a small risk of producing or
  exacerbating a pelvic infection by uterine
  cannulation and chromopertubation.
• Post-operative pelvic infection is probably less
  common after laparoscopic surgery than after
  laparotomy.

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5. Omental and Richter's herniation

• If the primary cannula is withdrawn with its
  valve closed, it is possible to draw a piece of
  omentum into the umbilical wound by the negative
  pressure so produced.
• This is usually recognized immediately and the
  omentum is easily replaced.

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5. Omental and Richter's herniation

• Herniation may occur some hours after the
  operation.
• It is usually easy to replace it under local
  anesthesia and resuture the wound.
• Herniation does not occur commonly with 5 mm skin
  incisions.
• Incisions greater than 7 mm should be sutured in
  layers to prevent formation of a Richter's hernia.

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6. Injuries from the operating table

• Care must always be taken in positioning the
  patient on the operating table.
• Injury can be caused to the nerves of the leg and
  to the hip and sacro-iliac joints.
• Compression of the leg veins may predispose to
  venous thrombosis.

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6. Injuries from the operating table

• The brachial plexus may be injured if the
  arm is abducted.
• The hands may be caught in moving parts of the
  table.
• It is important that the patient touches no
  metallic parts of the table if electric energy is
  being used.

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7. Foreign bodies

• Occasionally tubal clips or rings or parts of
  instruments such as saphire laser tips may be
  inadvertently dropped and lost in the peritoneal
  cavity.
• They should be removed if they are easily found
  but there have been no reports of long term
  complications from such foreign bodies

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Thank you