complications of laparoscopic surgery fereshteh daneshmand m.d
TRANSCRIPT
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Complications of
laparoscopic surgery
Fereshteh Daneshmand M.D.
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• Intraoperative or perioperative complications
from laparoscopic gynecologic surgery are
uncommon, with overall rate 0/1% to 10%.
• Over the half of these complications are
related to the entry technique, and 20 to 25%
of intraoperative complications were not
detected intraoperatively
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Risk factors• Extremes of body weight• Any patient characteristics that could
potentially increase the risk associated with anesthesia, such as cardiopulmonary disease.
• Other factors that could potentially distort pelvic anatomy such as endometriosis, PID, pelvic adhesions.
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• Complications rate were found to be higher for operative or major laparoscopic procedures than for diagnostic or minor laparoscopic procedures, 0/1% to 18% versus 0/1% to 7%
• As expected, complication rates are also related to the surgeon’s experience, with one study demonstrating a three-fold to five-fold increase in inadequately trained surgeons compared with surgeons with more training.
• Finally faulty instrumentation like dull trocars
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Complications• Anesthetic considerations
• Neurologic Injury
• Vascular Injury
• Bowel Injury
• Urinary Tract Injury
• Port-Site Hernia
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Anesthetic considerations
• The CO2 pneumoperitoneum and Trendelenburg
position induce numerous physiologic responses
that are generally well tolerated by young healthy
patients but which may be hazardous to those
with compromised cardiopulmonary function.
• All patients should be monitored.
• Managing fluid balance may be difficult.
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• The irrigating fluid should be warmed to prevent
hypothermia.
• Hypothermia can predispose hypokalemia and
respiratory depression.
• Intra-abdominal pressures above 15 mm Hg mar
compress the Vena cava.
• Mechanical stretching of the peritoneum, as well
as veress needle or trocar insertion may cause
Vagal stimulation leading to bradycardia.
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• Two complications that impact anesthesia
care are subcutaneous emphysema and
CO2 embolism.
• Sub coetaneous emphysema results from
preperitoneal insufflations.
• Increased CO2 absorption from the large
surface area may result in significant
hypercapnea and respiratory acidosis.
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Neurologic Injury
• Neurologic complications during laparoscopic,
surgery are uncommon, and primarily consist of
peripheral nerve compression or stretch from
improper positioning during the case.
• Risk factors are duration of surgery ,BMI less
than 20Kg/m and pre-existing systemic
conditions such as diabetes.
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• Most neurologic injuries from compression
or stretch mechanisms can be
conservatively managed and will usually
resolve with supportive care.
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Vascular Injury
• The most frequent vascular injury is
laceration of the superficial or inferior
epigastric vessels during insertion of
the lateral ancillary trocars.
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• Injury to major vessels-aorta ,vena cava
and iliac is approximately 0.8% based
on large series, the mortality rate has
been reported as high as 17% and need
immediate laparotomy with a midline
incision , blood transfusion and consult
a vascular surgeon.
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Bowel Injury• Bowel injuries are uncommon during
laparoscopy, occurring at estimated rates of 0% to 0.5% with approximately one third to one half of these injuries incurring at the time of trocar insertion.
• Injuries are more frequent in cases where the bowel is distended or there is a risk of bowel being adherent to the anterior abdominal wall such as after prior laparotomy or PID
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• Bowel injuries are one of the most common causes of postoperative mortality from gynecology laparoscopy because approximately two thirds of these injuries are unrecognized intraoperatively and there is often also a delay in postoperative diagnosis.
• Electrosurgical injuries will often not become evident for several days.
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Signs and Symptoms
• Low-grade temperature elevations
• Abdominal distention
• Increasing abdominal pain
• Decreased or normal WBC
• May have normal bowel sounds with diarrhea
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Urinary Tract Injury• The incidence of damage to the urinary tract
is estimated to `be 0.02% to 3%, with bladder injuries being more common than ureteral injuries.
• Approximately a third of these injuries are not identified intraoperarively.
• Bladder damage was more likely to be found intraoperatively, whereas ureteral injuries were more likely to be missed.
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Signs and Symptoms• Hematuria, oliguria, elevated BUN, Creatinine,
and WBC, elevated temperatures,• Abdominal pain distention with nausea and
vomiting • Imaging modalities such as CT Scan IVP
sonography can be helpful.• If bladder damage is suspected intraoperatively,
retrograde filling of the bladder with indigo carmine and cystoscopy can performed.
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Uretral Injury• Ureteral injury are rare in minor laparoscopic
cases, but cn be as high as 8% in cases of laparoscopic management of malignancy or of benign disease such as endometriosis where the pelvic anatomy is distorted and there is extensive fibrosis within the rectoperitoneal space.
• The most definitive method to avoid uretral injury is to directly observe and identify the entire course of the ureter within the operative field.
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• If the uretral injuries are not identified
intraoperatively, these patients may have
flank pain postoperatively and may present
in a similar manner to patients with bladder
injuries.
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Portal-Site Hernia
• Midline ports may be placed at the umbilicus and suprapubically.
• Port-site hernias at these locations are uncommon.
• Omental herniation may occur at the umbilical site.
• It is recommended to close the fascia in midline ports that are greater than 8 cm
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Conclusions• Fortunately, complications of laparoscopic
gynecologic surgery are uncommon, with most of the complications occurring at the time of the initial trocar insertion.
• The complication rates are directly related to the general medical condition of the patient, the complexity of the case, and the extent of anatomic distortion.
• Most complications are avoidable and / or can be recognized interaoperatively, allowing for immediate correction to avert further potential sever consequences.
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• Emphasis must be placed on prevention and intraoperative detection of complications.
• The key to preventing most neurologic injuries is proper patient positioning.
• The stomach should be decompressed • Foley catheter placed in bladder prior to
trocar insertion.• Attention should be paid to anatomical
landmarks to reduce vascular and neurological injuries when inserting trocar.
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• Placement of the initial trocar in the left upper quadrant should be considered when there is a risk of bowel adhesions to the anterior abdominal wall.
• Most laparoscopic complications may be treated immediately by laparoscopy including bladder, ureter, bowel, and minor vascular injuries.
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• One of the main advantages of laparoscopic
surgery is a rapid postoperative recovery.
• There should be a high index of suspicion
for an unrecognized complication if
postoperative pain is getting worse or the
patient has any problems with bladder or
bowel function.
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