cx of laparoscopy

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Complications of Complications of laparoscopylaparoscopy

Dr .Ashraf Fouda

Damietta General Hospital

[email protected]. mail :


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As:As:1.1. Operative laparoscopy becomesOperative laparoscopy becomes

more widely accepted,more widely accepted,2.2. New techniques are beingNew techniques are beingdeveloped anddeveloped and

3.3. More surgeons are adopting thisMore surgeons are adopting thisform of management,form of management,The complication rate can beThe complication rate can be

expected to rise.expected to rise.

INTRODUCTIONINTRODUCTION


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The incidence of laparoscopicThe incidence of laparoscopic

complications is:complications is:1.1. 11..11% to% to 55..22% in minor proc edur es% in minor proc edur es

andand2.2. 22..55% to% to 66% in major on es% in major on es


((K an e & K re js,K an e & K re js, 19841984).).


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To r educ e t he prevalence of To r educ e t he prevalence of complications:complications:

1.1. Training programm esTraining programm es must includ e must includ e sup e rvision at all l eve ls of sup e rvision at all l eve ls of deve lopm ent anddeve lopm ent and

2.2. The re must b e a high degree of The re must b e a high degree of awar enessawar eness of t he pot ential risks of of t he pot ential risks of laparoscopic surg ery.laparoscopic surg ery.



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Complications may beComplications may beassociated with:associated with:

1.1. The an est he ticThe an est he tic2.2. The induction of pn eumop e riton eumThe induction of pn eumop e riton eum3.3. Ins e rtion of primary and s econdaryIns e rtion of primary and s econdary

trocarstrocars

4.4. The rmal Instrum entsThe rmal Instrum ents5.5. Mechanical Instrum entsMechanical Instrum ents6.6. Ot he r associat ed conditionsOt he r associat ed conditions


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A.THE

ANESTHETIC

A.THE

ANESTHETIC

Local an est he sia may b e

Local an est he sia may b e us ed forus ed for tubal st e rilizationtubal st e rilizationand som e ot he r minorand som e ot he r minor

proc edur es.proc edur es.


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The us e of aThe us e of a st ee p Trend e lenburgst ee p Trend e lenburgpositionposition and t he and t he dist ension of t he dist ension of t he abdom enabdom en may bot h reduc e may bot h reduc e ex cursion of t he diap hragm.ex cursion of t he diap hragm.Carbon dio x ide (COCarbon dio x ide (CO22)) can b e can b e absorb ed particularly duringabsorb ed particularly duringprolong ed op erations.prolong ed op erations.

A. THE A NESTHETIC A. THE A NESTHETIC


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Monitoring by :Monitoring by :1.1. Pulse ox ime try,Pulse ox ime try,2.2. The us e of endotrac he alThe us e of endotrac he al

intubation andintubation and3.3. Positive pressur e assist edPositive pressur e assist ed

ventilationventilationReduc e t he risk of hype rcarbiaReduc e t he risk of hype rcarbia

to a minimum.to a minimum.



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If If arrhythmiaarrhythmia occursoccursthe anesthetist will be responsiblethe anesthetist will be responsible

for its management and for its management and The surgeon should :The surgeon should :1.1. Return the patient to the supineReturn the patient to the supine

position, position,2.2. Evacuate the pneumoperitoneumEvacuate the pneumoperitoneum and and

3.3. Discontinue the surgeryDiscontinue the surgery ..



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Vaso vagal r e flex Vaso vagal r e flex may produc e may produc e shock and collaps eshock and collaps e esp ecially if th e esp ecially if th e an esth e tic isan esth e tic is not d ee pnot d ee p en ough.en ough.It may b e It may b e preven t ed bypreven t ed by e fficien t e fficien t

ane sth esia a n d shouldane sth esia a n d should on ly be on ly be diag n oseddiag n osed wh en oth e r caus es of wh en oth e r caus es of shock ha ve been ex cluded.shock ha ve been ex cluded.



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11 . A nxiety. A nxiety

May b e preve nt ed byMay b e preve nt ed byadministration of administration of DiazepamDiazepam 2020 mgmg

orally about on e hourorally about on e hourprepre--operati ve ly.operati ve ly.


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The treatment should include:The treatment should include:1.1. Atropin e Atropin e 00..55 mg gi ven intra ve nously (I V)mg gi ven intra ve nously (I V)2.2. Ox ygenOx ygen give n by endotrac he al tub e at agive n by endotrac he al tub e at a

rat e of rat e of 44--66 litr es/minut e litres/minut e 3.3. Adrenalin e Adrenalin e 00..55--11..00 ml of ml of 11::100100,,000000

solution gi ve n slowly I V solution gi ve n slowly I V 4.4. RespiratoryRespiratory andand cardiac r esuscitationcardiac r esuscitation ..

22 . Vasovagal reaction. Vasovagal reaction


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33 . Pain. Pain

Pain may b e preve nt ed to som e Pain may b e preve nt ed to som e ex t ent by t he administration of ex t ent by t he administration of

nonnon --st e roidal antist e roidal anti --inflammatory drugsinflammatory drugssuc h assuc h as

mefanimic acid,mefanimic acid,napros ene ornapros ene or

f entanyl.f entanyl.


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44 . A llergic reactions and. A llergic reactions andanaphylaxisanaphylaxis

A ny local anaesthetic should be given A ny local anaesthetic should be giveninitially as ainitially as a small test dose small test dose to determineto determine

if an unsuspected if an unsuspected hypersensitivityhypersensitivity exists.exists. If it does, no more medication should be If it does, no more medication should beadministered.administered.

If it occurs it will be characterized by If it occurs it will be characterized byagitation, flushing, palpitations,agitation, flushing, palpitations,

bronchospasm, pruritus and urticaria.bronchospasm, pruritus and urticaria.


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B . INDUCTION OFB . INDUCTION OFPNEUMOPERITONEUMPNEUMOPERITONEUM


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11 . Extra. Extra- -peritoneal gasperitoneal gas

insufflationinsufflationF ailure to introduc e t he F ailure to introduc e t he Ve ress' n ee dle Ve ress' n ee dle into t he into t he pe riton eal ca vity may produc e pe riton eal ca vity may produc e ex traex tra --pe riton eal emp hysemape riton eal emp hysema ..This occurs in about This occurs in about 22%% of of cas es.cas es.


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The The diagnosisdiagnosis is mad e byis mad e by

palpation of palpation of crepituscrepitus caus ed bycaus ed bybubbl es of Cbubbl es of C 22 und e r t he skin..und e r t he skin..If t his is r ecogniz ed earlyIf t his is r ecogniz ed early, t he gas, t he gasmay b e allowed to escap e and t he may b e allowed to escap e and t he nee dle renee dle re--introduc ed t hroug h t he introduc ed t hroug h t he

sam e or anot he r sit e .sam e or anot he r sit e .

11 . Extra. Extra- -peritoneal gasperitoneal gas

insufflationinsufflation


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If the complication isIf the complication is not recognizednot recognizedduring the introduction o f gasduring the introduction o f gas , the typical, the typical

appearance o f extraappearance o f extra--peritoneal gas may be peritoneal gas may berecognized when an attempt is made torecognized when an attempt is made tointroduce the telescope.introduce the telescope.I t is always essential toI t is always essential to view through theview through thetelescope during its insertiontelescope during its insertion through itsthrough its

cannula.cannula.

11 . Extra. Extra- -peritoneal gasperitoneal gasinsufflationinsufflation


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The typical The typical spider spider--webwebappearance caused by preappearance caused by pre- -

peritoneal insufflation will be seen peritoneal insufflation will be seenwhen the telescope reaches the end when the telescope reaches the end

of the cannula and of the cannula and further further stripping of the peritoneum by the stripping of the peritoneum by the

tip of the telescopetip of the telescope avoided avoided ..



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TheThe laparoscope should be withdrawnlaparoscope should be withdrawnand attempts made to express the gas.and attempts made to express the gas.TheThe needle may then be reneedle may then be re- -introduced introduced through the same or another site.through the same or another site. A lternatively the trocar and cannula A lternatively the trocar and cannulamay be introduced bymay be introduced by

'open laparoscopy'open laparoscopy '.'.



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TheThe aspiration test and theaspiration test and thehigh insufflation pressurehigh insufflation pressurewill make it obvious that will make it obvious that

the needle is sited incorrectlythe needle is sited incorrectlyin which case it should bein which case it should bewithdrawn and rewithdrawn and re- -sited sited ..

11 . Extra. Extra- -peritoneal gas insufflationperitoneal gas insufflation


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Complications from theComplications from thedistension mediumdistension medium

Carbon dio x ide (COCarbon dio x ide (CO22))is t he dist ension m ediumis t he dist ension m ediummost commonly us ed formost commonly us ed for

ope rati ve laparoscopy.ope rati ve laparoscopy.


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Carbon dio x ide (COCarbon dio x ide (CO22))Gas embolismGas embolism is possibl e but is possibl e but uncommon b ecaus e t he gas isuncommon b ecaus e t he gas is highlyhighly

solubl e and is r eabsorb ed so quicklysolubl e and is r eabsorb ed so quicklyt hat, eve n if t he re has b ee n a mod erat e t hat, eve n if t he re has b ee n a mod erat e embolus, t he circulatory c hang es r e turnembolus, t he circulatory c hang es r e turnto normal wit hin a f ew minut es and t he to normal wit hin a f ew minut es and t he pati ent r ecove rs.pati ent r ecove rs.Up toUp to 400400ml of gasml of gas may b e intra vasat edmay b e intra vasat ed

wit hout producing c hang es in t he ECG.wit hout producing c hang es in t he ECG.


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Cardiac arrythmiaCardiac arrythmiamay be due to excessivemay be due to excessiveabsorption of COabsorption of CO22..Monitor the intraMonitor the intra--abdominal pressureabdominal pressure throughoutthroughoutthe operation and use anthe operation and use an automatic pneumoflator automatic pneumoflator for all but the simplest forms of surgery.for all but the simplest forms of surgery.This will cut out if the intraThis will cut out if the intra--abdominal pressureabdominal pressure

rises.rises.Endotracheal intubation and positive pressureEndotracheal intubation and positive pressurerespirationrespirationwill help to prevent complications fromwill help to prevent complications from

COCO22 insufflation.insufflation.

Carbon dio x ide (COCarbon dio x ide (CO22))


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P ostP ost--operative painoperative painis common with COis common with CO22insufflation due to peritoneal irritationinsufflation due to peritoneal irritation

which is a result of conversion of COwhich is a result of conversion of CO22 totocarbonic acid.carbonic acid.The chest painThe chest painmay be confused withmay be confused withcoronary heart disease and be treatedcoronary heart disease and be treatedinappropriately with antiinappropriately with anti--coagulants.coagulants.

Carbon dio x ide (COCarbon dio x ide (CO22))


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N itrous o x ide (NN itrous o x ide (N 22O)O) has b ecom e has b ecom e popular wit h som e laparoscopistspopular wit h som e laparoscopistsbecaus e t he re ar e less sid e e ff ectsbecaus e t he re ar e less sid e e ff ectst han wit h COt han wit h CO22..

Anest he tists Anest he tists can disp ens e wit h can disp ens e wit h intubation and allow t he pati ent tointubation and allow t he pati ent tobreat h t hroug h abreat h t hroug h a laryng eal masklaryng eal mask ..

Complications from theComplications from the

distension mediumdistension medium


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H oweve r, a diagnostic laparoscopy mayH oweve r, a diagnostic laparoscopy maydeve lop into a complicat ed op e rati ve deve lop into a complicat ed op e rati ve proc edur e .proc edur e .NN 22OO supports combustion.supports combustion.Me t han e gasMe t han e gas may b e re leas ed into t he may b e re leas ed into t he

periton eal ca vity following bow e l injury.periton eal ca vity following bow e l injury. A high freq uency A high freq uency monopolar curr ent monopolar curr ent us edus edduring laparoscopic surg e ry may caus e anduring laparoscopic surg e ry may caus e an

ex plosionex plosion ..



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The main plac e forThe main plac e for NN 22OO is w he nis w he nlaparoscopy is b e ing p e rform ed und erlaparoscopy is b e ing p e rform ed und er

local an est he sialocal an est he sia in w hich cas e t he in w hich cas e t he pain factor b ecom es important.pain factor b ecom es important.This is applicabl e toThis is applicabl e to tubal st e rilizationtubal st e rilizationwit h clips, rings, or bipolarwit h clips, rings, or bipolarcoagulation, but coagulation, but not to mor e not to mor e

ad vanc ed laparoscopic proc edur esad vanc ed laparoscopic proc edur es..



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22 . Mediastinal emphysema. Mediastinal emphysema

Gas may ex t end from a corr ectlyGas may ex t end from a corr ectlyinduc ed pn eumop e riton eum into t he induc ed pn eumop e riton eum into t he mediastinum and cr eat e mediastinalmediastinum and cr eat e mediastinalemp hysema.emp hysema.

Ex t ensive emp hysemaEx t ensive emp hysema may caus e may caus e cardiac embarrassm ent cardiac embarrassm ent which will be which will be diagnos ed by t he ana est he tist.diagnos ed by t he ana est he tist.


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The re will be The re will be loss of dulln essloss of dulln ess totopercussion o ve r t he precordium.percussion o ve r t he precordium.

The laparoscopy must b e The laparoscopy must b e abandon edabandon edand as muc h gas as possibl e and as muc h gas as possibl e evacuat ed.evacuat ed.The pati ent must b e kept und e r clos e The pati ent must b e kept und e r clos e obs e rvation until t he gas has b ee nobs e rvation until t he gas has b ee n

absorb ed.absorb ed.

22 . Mediastinal emphysema. Mediastinal emphysema


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33 . Pneumothorax. Pneumothorax

May result from ins e rtion of t he May result from ins e rtion of t he Veress' n ee dle Veress' n ee dle into t he pleural ca vity.into t he pleural ca vity.Whe neve r aWhe neve r a high sit e of ins e rtionhigh sit e of ins e rtion isischosen t he nee dle should b e direct edchosen t he nee dle should b e direct edaway from t he diap hragm and, asaway from t he diap hragm and, as

always, t he standard protocol of always, t he standard protocol of aspiration and sounding t estsaspiration and sounding t estsemploy ed.employ ed.


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Should b e susp ect ed if t he re is difficulty inShould b e susp ect ed if t he re is difficulty inve ntilating t he pati ent.ve ntilating t he pati ent.The re may b e a contraThe re may b e a contra --lat e ral m ediastinal s hift lat e ral m ediastinal s hift

and incr eas ed tympanism o ve r t he aff ect edand incr eas ed tympanism o ve r t he aff ect edar ea.ar ea.The proc edur e should b e abandon ed and t he The proc edur e should b e abandon ed and t he gas allow ed to escap egas allow ed to escap e ..The pati ent s hould b e kept und e r obs e rvation.The pati ent s hould b e kept und e r obs e rvation.Occasionally assist ed ve ntilation and ins e rtionOccasionally assist ed ve ntilation and ins e rtionof a pl eural tub e may b e req uired.of a pl eural tub e may b e req uired.

33 . Pneumothorax. Pneumothorax


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44 . Pneumo. Pneumo- -omentumomentum

The om entum is p ene trat ed by t he Ve ress'The om entum is p ene trat ed by t he Ve ress'nee dle in about nee dle in about 22 % of cas es% of cas es..The misplac ement s hould b e recogniz ed by t he The misplac ement s hould b e recogniz ed by t he

aspiration t est and t he position of t he tipaspiration t est and t he position of t he tipalt e red to fr ee t he nee dle .alt e red to fr ee t he nee dle .The re will also b e aThe re will also b e a rais ed insufflation pr essur erais ed insufflation pr essur e

which should l ead t he surg eon to susp ect anwhich should l ead t he surg eon to susp ect ane rror in t he position of t he nee dle .e rror in t he position of t he nee dle .The condition is usually innocuous unl essThe condition is usually innocuous unl essom ental blood ve ss e l is punctur ed.om ental blood ve ss e l is punctur ed.


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55 . Injury to gastro. Injury to gastro- -intestinal tractintestinal tract

Ce rtain conditions may pr edispos e toCe rtain conditions may pr edispos e toinjury by t he Veress' n ee dle .injury by t he Veress' n ee dle .

The se includ e :The se includ e :1.1. Dist ension of t he gastroDist ension of t he gastro --int estinalint estinal

tract ortract or2.2. Adhe sions of bow e l to t he Adhe sions of bow e l to t he

abdominal wall.abdominal wall.


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P enetration of the stomach P enetration of the stomach

may occur when an upper may occur when an upper abdominal site of insertionabdominal site of insertionis chosen or the stomach isis chosen or the stomach isdistended during inductiondistended during induction

of anesthesia.of anesthesia.



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G astric distensionG astric distension may also occur if may also occur if anesthesia is maintained with a mask anesthesia is maintained with a mask and should be suspected if there isand should be suspected if there isupper abdominal distension or upper abdominal distension or

increased tympanism.increased tympanism. In this case the In this case the stomach should be stomach should beaspirated with a nasoaspirated with a naso - -gastric tube gastric tube ..



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The diagnosis ofThe diagnosis of gastricgastricperforation by the Veress' needleperforation by the Veress' needlemay be made when the patientmay be made when the patientbelches gas.belches gas.

The laparoscope should beThe laparoscope should beintroduced and the stomachintroduced and the stomachinspected carefully.inspected carefully.



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Provided t he Provided t he stomac h wall has not stomac h wall has not bee n tornbee n torn , no surgical tr eatm ent is, no surgical tr eatm ent is

necessary but a broad sp ectrumnecessary but a broad sp ectrumantibiotic s hould b e given.antibiotic s hould b e given.If t he stomac h has b ee n torn,If t he stomac h has b ee n torn,surgical r epairsurgical r epair e it he r by laparotomye it he r by laparotomyor laparoscopy is mandatory.or laparoscopy is mandatory.



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AspirationAspiration following initialfollowing initial

insertion of the needleinsertion of the needleshould permit earlyshould permit earlyrecognition of perforationrecognition of perforationof the bowel but it is notof the bowel but it is not

foolfool--proof.proof.



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Bowel penetrationBowel penetration should beshould besuspected if there issuspected if there is

1.1. Asymmetric abdominalAsymmetric abdominaldistension,distension,

2.2. Belching,Belching,3.3. Passing of flatus or a fecal odour.Passing of flatus or a fecal odour.



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It is important thatIt is important that bothbothsides of the bowel be examined sides of the bowel be examined as the exit wound may beas the exit wound may belarger than the entry wound.larger than the entry wound.

Fecal soilingFecal soiling demandsdemandsimmediate laparotomy and immediate laparotomy and repair of the bowel.repair of the bowel.



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It is important to ensure thatIt is important to ensure that

there has not been athere has not been athroughthrough- -andand--through injurythrough injuryof a loop of bowelof a loop of bowel

which is adherent to thewhich is adherent to theperitoneum at the site ofperitoneum at the site of

insertion.insertion.



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AA simple needlesimple needle

penetrationpenetration requiresrequires nonotreatmenttreatment but the patientbut the patientshould be kept undershould be kept underobservationobservation and givenand given

broad spectrumbroad spectrum antibioticsantibiotics ..



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66 . B ladder injury. B ladder injury

RoutineRoutine catheterizationcatheterization ofof

the bladder andthe bladder and properpropersittingsitting of the needle shouldof the needle should

prevent bladder penetration.prevent bladder penetration.


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IfIf pneumaturiapneumaturia is noted theis noted the

needle should be partiallyneedle should be partiallywithdrawn and the creationwithdrawn and the creationof pneumoperitoneumof pneumoperitoneum

continued.continued.



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The bladder peritoneum shouldThe bladder peritoneum shouldbe carefully inspected to ensurebe carefully inspected to ensurethat no significant injury has beenthat no significant injury has beencaused.caused.

The treatment of aThe treatment of a simplesimplepuncturepuncture isis conservativeconservative withwithpostoperative bladder drainage.postoperative bladder drainage.



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77 . B lood vessel injury. B lood vessel injury

The Veress' n ee dle mayThe Veress' n ee dle maypene trat e :pene trat e :

1.1. om ental orom ental or2.2. mesent eric vess e lsmesent eric vess e ls oror3.3. any of t he any of t he major abdominalmajor abdominal

or p e lvic art eries or ve ins.or p e lvic art eries or ve ins.


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Minor vascular injuriesMinor vascular injuries involvinginvolvingthe omental or mesenteric vesselsthe omental or mesenteric vessels

areare difficult to preventdifficult to prevent asasit is impossible to ensure thatit is impossible to ensure that

the omentum is not close to thethe omentum is not close to theabdominal wall duringabdominal wall during blindblindinsertion of the insufflatinginsertion of the insufflating

needle.needle.



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Injury may b e susp ect ed if:Injury may b e susp ect ed if:1.1. blood r e turns upblood r e turns up t he open n ee dle t he open n ee dle

or if :or if :2.2. free bloodfree blood is s ee n in t he is s ee n in t he

pe riton eal ca vity aft e r ins e rtion of pe riton eal ca vity aft e r ins e rtion of t he laparoscop e .t he laparoscop e .



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If blood returns up the needle andIf blood returns up the needle andthe patient's condition isthe patient's condition is stablestable ,,the site of injury may bethe site of injury may beinvestigated laparoscopicallyinvestigated laparoscopically ..

The needle should be left in placeThe needle should be left in placeand aand a 55 mm laparoscopemm laparoscope introducedintroducedthrough athrough a suprapubic cannula.suprapubic cannula.



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Minimal bleedingMinimal bleeding may usually bemay usually becontrolled bycontrolled by bipolar coagulationbipolar coagulation or aor alaparoscopic suturelaparoscopic suture ..

LaparotomyLaparotomy is not usually necessaryis not usually necessaryexcept in the case of injury to theexcept in the case of injury to thesuperior mesenteric artery.superior mesenteric artery.Such injury requires repair by aSuch injury requires repair by avascular surgeonvascular surgeon


(Bassil e t al,(Bassil e t al, 19931993))


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I njury to the major vessels may beI njury to the major vessels may be prevented by: prevented by:

1 .1 . Lifting Lifting the abdominal wall,the abdominal wall,2.2. A ngling A ngling the needle towards the pelvisthe needle towards the pelvis

once the initial thrust through theonce the initial thrust through the

fascia has been made and by fascia has been made and by3.3. Inserting Inserting only as much of the needleonly as much of the needle

as necessary.as necessary.



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Thin patients and childrenThin patients and children areareat particular risk of this injury.at particular risk of this injury.Withdrawal Withdrawal of blood on aspirationof blood on aspiration

following insertion of the needle following insertion of the needle

should should allow early detectionallow early detection of of blood vessel injury.blood vessel injury.



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If injury to a vessel such as theIf injury to a vessel such as theaorta, inferior vena cava oraorta, inferior vena cava or

common iliac vesselcommon iliac vesselis suspected,is suspected,

the needle should be left placethe needle should be left place

to mark the site of the injuryto mark the site of the injuryandand laparotomylaparotomy performedperformedthrough a midthrough a mid- -line incision.line incision.



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There is usually aThere is usually a largelargehaematomahaematoma which obscures thewhich obscures the

site of the injury.site of the injury.TheThe aortaaorta should be compressedshould be compressedwith a clamp or hand until awith a clamp or hand until avascular surgeonvascular surgeon arrives toarrives toperform definitive surgery.perform definitive surgery.



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Dramatic collapseDramatic collapse may result frommay result frompenetration of apenetration of a major vesselmajor vessel but thebut thebleeding may not be immediatelybleeding may not be immediatelyevident if it isevident if it is retroretro- -peritonealperitoneal ..The loose areolar tissue anterior toThe loose areolar tissue anterior tothe aorta can allow accumulation of athe aorta can allow accumulation of aconsiderable amountconsiderable amount of blood beforeof blood beforefrank intrafrank intra- -abdominal bleeding isabdominal bleeding isseen.seen.



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A thorough search must beA thorough search must bemade to determine the extentmade to determine the extentof vessel damage.of vessel damage.This includes retraction ofThis includes retraction ofbowel to expose thebowel to expose the aortaaorta

above the pelvic brimabove the pelvic brim which iswhich isthethe most common site ofmost common site ofperforation.perforation.



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F ailure to do search mayF ailure to do search mayresult in continued bleedingresult in continued bleeding

and formation of a largeand formation of a largehaematoma leading to ahaematoma leading to a

second episode of shocksecond episode of shock somesomehours laterhours later



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88 . Gas embolism. Gas embolism

Intravascular insufflation ofIntravascular insufflation ofgas may lead togas may lead to gas embolismgas embolism

or even death.or even death.This can only happen if theThis can only happen if the

penetration by the Veress'penetration by the Veress'needle goes unrecognized andneedle goes unrecognized andinsufflation commences.insufflation commences.


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It should be prevented byIt should be prevented by routineroutineuse of the aspiration test.use of the aspiration test.

The patient should beThe patient should be turned onturned onto the left lateral positionto the left lateral position and,and,If immediate recovery does notIf immediate recovery does nottake place,take place, cardiac puncturecardiac punctureperformed to release the gas.performed to release the gas.

88 . Gas embolism. Gas embolism


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99 . Puncture of liver or spleen. Puncture of liver or spleen

The live r or spl ee n may b e The live r or spl ee n may b e punctur ed by t he Ve resspunctur ed by t he Ve ress


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C. INTRODUCTION OF TROC A RSC. INTRODUCTION OF TROC A RS A ND C A NNUL A E A ND C A NNUL A E

Some of theSome of the most serious injuriesmost serious injuriesthat occur during laparoscopy arethat occur during laparoscopy arecaused by the insertion of thecaused by the insertion of thetrocars and cannulaetrocars and cannulae ..

Insertion of the primary trocar andInsertion of the primary trocar andcannula is, of necessity,cannula is, of necessity, blindblind ..


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The causation of injuries byThe causation of injuries by

thethe primary trocarprimary trocar arearesimilar to those caused bysimilar to those caused bythe Veress' needle but thethe Veress' needle but the

magnitude of the injurymagnitude of the injuryis greater.is greater.

INTRODUCTION OF TROC A RSINTRODUCTION OF TROC A RS A ND C A NNUL A E A ND C A NNUL A E


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TheThe sitessites of theof the secondarysecondary

portalsportals of entry must beof entry must beselected carefully and theselected carefully and theinsertion must always beinsertion must always be

mademade under visual controlunder visual control ..

INTRODUCTION OF TROC A RSINTRODUCTION OF TROC A RS A

ND C A

NNUL A

E A

ND C A

NNUL A

E

11 j l i hj l i h


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11 . Injury to vessels in the. Injury to vessels in theabdominal wallabdominal wall

Superficial bleedingSuperficial bleeding from thefrom theincisionincision rarely gives rise torarely gives rise toconcern and always stops withconcern and always stops withapplication of pressure.application of pressure.

B leeding from puncture of theB leeding from puncture of thedeepdeep inferior epigastric arteryinferior epigastric arteryis more serious.is more serious.


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The artery is at riskThe artery is at riskduring the insertion ofduring the insertion ofsecondary trocars andsecondary trocars and

cannulae.cannulae.

Inferior epigastric arteryInferior epigastric artery


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Injury may be prevented byInjury may be prevented bytransilluminatingtransilluminating the abdominalthe abdominal

wall before insertion in a thinwall before insertion in a thinpatient or by visualizing thepatient or by visualizing the

artery laparoscopically as it runsartery laparoscopically as it runslateral to the obliteratedlateral to the obliterated

umbilical arteryumbilical artery ..

Inf erior epigastric art eryInf erior epigastric art ery


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The sit e of ins ertion can t he n b e The sit e of ins ertion can t he n b e chosen bychosen by depressing t he wall skindepressing t he wall skin

wit h t he handl e of t he scalp e l andwit h t he handl e of t he scalp e l andnoting its r e lations hip to t he noting its r e lations hip to t he vess e ls.vess e ls.

The The diagnosisdiagnosis may b e mad e by t he may b e mad e by t he sight of sight of blood drippingblood dripping into t he into t he pe lvis from t he trocar wound.pe lvis from t he trocar wound.



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Occasionally blood may actuallyOccasionally blood may actuallybe see nbe see n spurtingspurting across t he across t he

abdominal ca vity.abdominal ca vity. Alt e rnati ve ly t he Alt e rnati ve ly t he immediat e orimmediat e orde layed app earanc e of a larg e de layed app earanc e of a larg e abdominal wall haematomaabdominal wall haematomaindicat es injury to t he dee pindicat es injury to t he dee pinf e rior epigastric art e ry.inf e rior epigastric art e ry.



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The treatment is usuallyThe treatment is usually simplesimple ..The trocar and cannula should beThe trocar and cannula should be

left in situleft in situ to act as a marker and alsoto act as a marker and alsoprevent the artery slipping away.prevent the artery slipping away.AA F oley catheterF oley catheter passed down thepassed down the

cannula and inflated may act as acannula and inflated may act as acompress and control the bleeding.compress and control the bleeding.



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Alternatively theAlternatively the incisionincision should beshould beenlarged to aboutenlarged to about 2 2 cmcm in length toin length to

expose the anterior rectus sheath.expose the anterior rectus sheath.A round bodiedA round bodied needleneedle should beshould beinserted through the full thickness ofinserted through the full thickness of

the abdominal wall from the sheaththe abdominal wall from the sheathto the peritoneum underto the peritoneum underlaparoscopic control.laparoscopic control.



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TheThe needle pointneedle point should be brought outshould be brought outagain to the surface of the rectusagain to the surface of the rectussheath and asheath and a knot tiedknot tied firmly on thefirmly on thesheath.sheath.This is preferable to tying theThis is preferable to tying the knot onknot onthe skinthe skin which iswhich is painfulpainful and leaves anand leaves anunsightlyunsightly scarscar although it is acceptablealthough it is acceptableto tie the knot over a gauze swab toto tie the knot over a gauze swab toprevent skin injury.prevent skin injury.



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It may be necessaryIt may be necessary

to insert two sutures,to insert two sutures,one above andone above and

one belowone belowthe site of bleeding.the site of bleeding.



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Occasionally it may be necessaryOccasionally it may be necessaryto open theto open the wound widerwound wider toto

locate the bleeding artery.locate the bleeding artery.This should be reserved for thoseThis should be reserved for thosecases where there iscases where there is profuseprofusebleedingbleeding or primary laparoscopicor primary laparoscopicsuturing issuturing is ineffectiveineffective ..

Inf erior epigastric art eryInf erior epigastric art ery

22 Injury to anInjury to an


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22 . Injury to an. Injury to anntrantra- -abdominal vesselabdominal vessel

Injury toInjury to minor blood vess e lsminor blood vess e ls isisusuallyusually se lf se lf --limitinglimiting or can b e or can b e

controll ed by bipolar e lectrocontroll ed by bipolar e lectro --coagulation.coagulation.Damag e toDamag e to major vess e lsmajor vess e ls isis mor e mor e seriousserious t han wit h a Ve rres' n ee dle t han wit h a Ve rres' n ee dle becaus e of t he size of t he trocar tipbecaus e of t he size of t he trocar tipand may r esult in profus e blee ding.and may r esult in profus e blee ding.

22 I j iI j i bd i l lbd i l l


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Injury toInjury to om ental ve ss e lsom ental ve ss e ls may compromis e may compromis e t he vitality of at he vitality of a segm ent of bow e l.segm ent of bow e l.Treatm ent of t he se injuries is by:Treatm ent of t he se injuries is by:

1.1. Resuscitation,Resuscitation,2.2. Laparotomy,Laparotomy,3.3. Vascular r epair or ligation and, w he re Vascular r epair or ligation and, w he re

necessary,necessary,4.4. Bowe l resection and anastomosis wit h t he Bowe l resection and anastomosis wit h t he

assistanc e of t he appropriat e surgicalassistanc e of t he appropriat e surgicalcolleagu e .colleagu e .

22 . Injury to an intra. Injury to an intra- -abdominal vesselabdominal vessel

22 . Injury to an. Injury to an


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A small l eak from t he a A small l eak from t he a major veinmajor vein may not may not be immediat e ly appar ent.be immediat e ly appar ent.The The intraintra --abdominal pr essur eabdominal pr essur e of t he of t he pn eumop e riton eumpn eumop e riton eum and t he and t he decreas ed ve nousdecreas ed ve nouspressur epressur e induc ed by t he Trend e lenburg positioninduc ed by t he Trend e lenburg positionmay t emporarily control it may t emporarily control it ..

H oweve r, as soon as t he intraH oweve r, as soon as t he intra --abdominal andabdominal andve nous pr essur es r e turn to normal, t he ve nous pr essur es r e turn to normal, t he blee ding may r ecomm ence and produc e ablee ding may r ecomm ence and produc e are trore tro --pe riton eal haematoma and s hockpe riton eal haematoma and s hock..

22 . Injury to an. Injury to antratra--abdominal vesselabdominal vessel


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It is essential therefore, at theIt is essential therefore, at thecompletion of any laparoscopiccompletion of any laparoscopicprocedure, but especially those involvingprocedure, but especially those involvingthe pelvic side wall, tothe pelvic side wall, toinspect the course of the major vesselsinspect the course of the major vesselsand look for a haematoma.and look for a haematoma.This applies particularly to theThis applies particularly to thetreatment of endometriosis at this site.treatment of endometriosis at this site.

22 . Injury to an intra. Injury to an intra- -abdominal vesselabdominal vessel

22 Injury to anInjury to an


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AA small haematomasmall haematoma may be themay be theonly evidence of injury to a veinonly evidence of injury to a veinat the pelvic brim.at the pelvic brim.Occasionally there may be aOccasionally there may be a

defect indefect in the overlyingthe overlyingperitoneumperitoneum which indicates thewhich indicates thesite of entry of the trocar.site of entry of the trocar.

22 . Injury to an. Injury to antratra--abdominal vesselabdominal vessel


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It is ess ential to proc ee d toIt is ess ential to proc ee d to

laparotomylaparotomy toto repair t he repair t he ve ss e lve ss e l.. A A vascular surg eonvascular surg eon should b e should b e consult ed and t he ve ss e lconsult ed and t he ve ss e lcompr ess ed until t he arrival of compr ess ed until t he arrival of

s ecialized assistanc e .s ecialized assistanc e .

22 . Injury to an. Injury to an

intraintra- -abdominal vesselabdominal vessel

33 I j h ll iI j h ll i


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33 . Injury to a hollow viscus. Injury to a hollow viscus

Injury to a hollow viscus may vary fromInjury to a hollow viscus may vary fromsup erficial damag e of t he se rosasup erficial damag e of t he se rosa totocompl e t e pene tration into t he lumencompl e t e pene tration into t he lumen..

If p ene tration has occurr ed:If p ene tration has occurr ed:1.1. The viscus may slip off t he trocar,The viscus may slip off t he trocar,2.2. The trocar may r emain wit hin t he lumenThe trocar may r emain wit hin t he lumen

or, rar e ly:or, rar e ly:3.3. The trocar may pass rig ht t hroug h t he aThe trocar may pass rig ht t hroug h t he a

loop of bow e l which becom es impal edloop of bow e l which becom es impal ed

upon it.upon it.


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It is always important toIt is always important toinspect the bowel at the axisinspect the bowel at the axis

of insertion of the primaryof insertion of the primarytrocar and cannulatrocar and cannula to ensureto ensure

that it has not beenthat it has not beendamaged.damaged.



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If theIf the cannula remains within the bowelcannula remains within the bowelthe injury will be obvious by thethe injury will be obvious by therecognition ofrecognition of mucosal foldsmucosal folds ..AA through and through injurythrough and through injury may bemay bemissed and only become apparent by themissed and only become apparent by thesight ofsight of faecal soilingfaecal soiling , a, a faecal smellfaecal smellwhen thewhen the pneumoperitoneum is releasedpneumoperitoneum is releasedor the subsequent development ofor the subsequent development ofperitonitis.peritonitis.


33 I j h ll iI j h ll i


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Injury to theInjury to the stomach or bowelstomach or bowel arearealways serious.always serious.The management depends on theThe management depends on theskill of the surgeonskill of the surgeon ..TheThe classical treatmentclassical treatment is to performis to performlaparotomylaparotomy and suture the bowel in twoand suture the bowel in twolayers.layers.A skilled surgeon may perform theA skilled surgeon may perform the

repair byrepair by laparoscopic suturinglaparoscopic suturing ..



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The defect should be closed inThe defect should be closed in twotwolayerslayers in such a way as to avoidin such a way as to avoid

stricture formation, there should bestricture formation, there should becopious peritoneal irrigation and acopious peritoneal irrigation and adrain should be inserted into thedrain should be inserted into theabdomen.abdomen.AppropriateAppropriate antibiotic therapyantibiotic therapyshould be instituted.should be instituted.


33 I j t h ll iI j t h ll i


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It may not be possible to identify theIt may not be possible to identify thesite of bowel injury by laparoscopy.site of bowel injury by laparoscopy.In this case it is essential to performIn this case it is essential to performlaparotomylaparotomy to find and treat theto find and treat thebowel injury.bowel injury.

F ailure to do this will result in theF ailure to do this will result in thepatient developingpatient developing faecal peritonitisfaecal peritonitisand becoming dangerously ill.and becoming dangerously ill.



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B ladder lacerationB ladder laceration may occurmay occurduring mobilization of the bladderduring mobilization of the bladder

in advanced pelvic surgery.in advanced pelvic surgery.It should be sutured inIt should be sutured in two layerstwo layersusing laparoscopic suturingusing laparoscopic suturingtechnique and atechnique and a F oley catheterF oley catheterinserted into the bladder.inserted into the bladder.


44 Damage to other organsDamage to other organs


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44 . Damage to other organs. Damage to other organs

Minor injuriesMinor injuries to other organs areto other organs areusuallyusually selfself--limitinglimiting ..They should be inspected at theThey should be inspected at thecompletion of the procedure.completion of the procedure.Peritoneal lavagePeritoneal lavage must be carriedmust be carried

out to remove blood and clot andout to remove blood and clot andensure that the bleeding hasensure that the bleeding hasstopped.stopped.


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AA small puncture on thesmall puncture on thesurface of the uterussurface of the uterus maymay

be treated with bipolarbe treated with bipolarelectroelectro- -coagulation ifcoagulation if

bleeding does not stopbleeding does not stopspontaneously.spontaneously.


44 Damage to other organsDamage to other organs


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Injuri es to t he Injuri es to t he live r and spl ee nlive r and spl ee n ar e rar e ar e rar e unless t he organ is pat hologicallyunless t he organ is pat hologicallyenlarg ed.enlarg ed.

Such injuries ar e mor e like ly to occur inSuch injuries ar e mor e like ly to occur inope rations p erform ed byope rations p erform ed by generalgeneralsurg eons.surg eons.Minor blee dingMinor blee ding will stop spontan eously.will stop spontan eously.Major haemorr hag eMajor haemorr hag e req uires imm ediat e req uires imm ediat e laparotomy.laparotomy.


D THERM A L DA MA GED THERM A L DA MA GE


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D. THERM A L D A M A GED. THERM A L D A M A GE

Burns from e lectric curr ent Burns from e lectric curr ent we re one of we re one of t he major caus es of complications w he nt he major caus es of complications w he nmonopolar tubal coagulationmonopolar tubal coagulation was t he was t he principl e me t hod of principl e me t hod of f emal e st erilizationf emal e st erilization ..The incidence of burns was dramaticallyThe incidence of burns was dramaticallyreduc ed by t he introduction of reduc ed by t he introduction of bipolarbipolar andandt he rmal coagulationt he rmal coagulation andand mechanicalmechanicaldev icesdev ices to occlud e t he tub es.to occlud e t he tub es.

THERM A L DA MA GETHERM A L DA MA GE


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Monopolar electric currentMonopolar electric current passes intopasses intothe patient's body from the electrodethe patient's body from the electrodewhich may be forceps or a needle.which may be forceps or a needle.The current passes into theThe current passes into the patient'spatient'stissuestissues at the point of contact and thenat the point of contact and thenmust return to the generator via themust return to the generator via thereturn platereturn plate ..This is usually placed on theThis is usually placed on the patient's leg.patient's leg.

THERM A L D A M A GETHERM A L D A M A GE


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The effect of the electricThe effect of the electriccurrent will depend itscurrent will depend itspowerpower and theand the powerpowerdensitydensity which, in turnwhich, in turn

depends on thedepends on the areaarea andanddurationduration of application.of application.




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To obtainTo obtain ma x imum tissu e e ff ect ma x imum tissu e e ff ect t he ar ea of application at t he targ e t t he ar ea of application at t he targ e t organ is small.organ is small.

The curr ent pass es from t hat smallThe curr ent pass es from t hat smallar ea along t he pat h of least r esistanc e ar ea along t he pat h of least r esistanc e towards t he re turn plat e .towards t he re turn plat e .In gyn ecological surg ery t his pat hwayIn gyn ecological surg ery t his pat hwayis usuallyis usually ove r t he surfac e of loops of ove r t he surfac e of loops of

bow e l.bow e l.

THERM L D M GETHERM L D M GE



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The area of the return plate isThe area of the return plate islarge so the power density at itslarge so the power density at itssite of application to the skin issite of application to the skin is

low.low.However on its return pathway theHowever on its return pathway thecurrent may pass over a small areacurrent may pass over a small areaof contact between two organs.of contact between two organs.The power density at that pointThe power density at that pointmay be high.may be high.



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In this way aIn this way a burnburn may occurmay occuroutside the surgeon's visual field.outside the surgeon's visual field.NormallyNormally this does not happenthis does not happenand the current passesand the current passesharmlessly to the dispersiveharmlessly to the dispersiveplate.plate.




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The rmal injury to organs suc h asThe rmal injury to organs suc h as bow e lbow e lmay also r esult from l eakag e of curr ent may also r esult from l eakag e of curr ent from t he shaft of t he instrum ent.from t he shaft of t he instrum ent.

This may r esult from :This may r esult from :1.1. Insuffici ent or faulty insulation or fromInsuffici ent or faulty insulation or from2.2. Capacitati ve coupling in w hich t he re is aCapacitati ve coupling in w hich t he re is a

build up of curr ent in t he shaft of t he build up of curr ent in t he shaft of t he instrum ent b ecaus e t he normal escap e instrum ent b ecaus e t he normal escap e rout e has b ee n s hut off.rout e has b ee n s hut off.




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Current Current normally escap es from t he normally escap es from t he me talme talcannulacannula t hroug h t he pati ent's ant eriort hroug h t he pati ent's ant eriorabdominal wall toabdominal wall to t he re turn plat et he re turn plat e ..

If aIf a plastic cannulaplastic cannula has b ee n us ed t hishas b ee n us ed t hisrout e is clos ed and t he curr ent mayrout e is clos ed and t he curr ent mayescap e to bow e lescap e to bow e l..

If t he If t he contact point contact point be twee n instrum ent be twee n instrum ent and bow e l is small, t he and bow e l is small, t he pow er d ensitypow e r d ensity maymaybebe highhigh and t he rmal injury will r esult.and t he rmal injury will r esult.




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Occasionally theOccasionally the monitoring systemmonitoring systemmay notmay not be properly earthedbe properly earthed ..If the current passes via anIf the current passes via an ECGECGelectrodeelectrode instead of to theinstead of to the returnreturnplateplate , the patient may suffer a, the patient may suffer a skinskinburnburn because thebecause the ECG electrodeECG electrode isissmallsmall and so theand so the power densitypower density isishighhigh at this site.at this site.



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Alternatively, the current mayAlternatively, the current maypass along one of thepass along one of the

ancillary instrumentsancillary instruments which,which,if not properly insulated, mayif not properly insulated, mayproduce aproduce a skin burnskin burn at the portalat the portal

of entry or theof entry or the surgeonsurgeon maymaysuffer asuffer a burnburn on the hands oron the hands or

face.face.




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There is a danger ofThere is a danger of laterallateralheat spreadheat spread with monopolarwith monopolar

or bipolar current.or bipolar current.It is important to ensure thatIt is important to ensure that

no other organno other organ is inis in contactcontactwith or nearwith or near an organ to whichan organ to whichelectricity is being applied.electricity is being applied.



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Lateral spread may also beLateral spread may also beminimized by keeping theminimized by keeping the forcepsforceps

blades close together.blades close together.BuildBuild--up of thermal energyup of thermal energymay be prevented by intermittentmay be prevented by intermittentapplication of energy which,application of energy which,in effect, produces ain effect, produces a pulsed currentpulsed current




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TheThe bowelbowel is the most commonlyis the most commonlyinjured organ.injured organ.The injury may range fromThe injury may range from minorminorblanchingblanching of the serosa toof the serosa to frankfrankperforationperforation ..PerforationPerforation requiresrequires laparotomylaparotomy ,,excision of the surroundingexcision of the surroundingdevitalized bowel and repair ofdevitalized bowel and repair ofthe defect.the defect.




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If blanching is significant,If blanching is significant,laparotomy excisionlaparotomy excision of theof thedamaged tissue and surgicaldamaged tissue and surgicalrepair should be performedrepair should be performedimmediately.immediately.

F ailure to do so may result inF ailure to do so may result indelayed ischemic necrosisdelayed ischemic necrosisat the site of the burn.at the site of the burn.




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Initially there may be fewInitially there may be fewsymptoms but commonlysymptoms but commonly

the patient will complain ofthe patient will complain offeeling unwellfeeling unwell and thisand this

feeling may not improve asfeeling may not improve asquickly as usual.quickly as usual.


A A AA A A


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It should be realized that any patientIt should be realized that any patientwhowho feels unwell on the day afterfeels unwell on the day aftersurgerysurgery and whose condition doesand whose condition doesnot improve over the next few hours,not improve over the next few hours,may have anmay have an unsuspected injury tounsuspected injury tothe bowel.the bowel.The unwary physician may allow theThe unwary physician may allow thepatient to return home.patient to return home.




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The insidious development ofThe insidious development ofvague abdominal symptoms,vague abdominal symptoms,

discomfort, anorexia and possiblydiscomfort, anorexia and possiblypyrexia may not be recognized bypyrexia may not be recognized byher medical attendants.her medical attendants.

A faecal fistula may not form forA faecal fistula may not form for4848--7272 hours.hours.

THERM L D M GETHERM L D M GE



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F ecal peritonitisF ecal peritonitis slowly developsslowly developsand the patient may becomeand the patient may become

seriously illseriously ill over a period of daysover a period of daysbefore rebefore re- -admission is requested.admission is requested.RadiologyRadiology followed byfollowed bylaparotomylaparotomy reveals the desperatereveals the desperatesituation.situation.



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It must always b e It must always b e rememb ered t hat rememb ered t hat

e lectric curr ent e lectric curr ent is pot entiallyis pot entiallydang e rous and all t he saf e tydang erous and all t he saf e ty

rules for its us e must b e rules for its us e must b e strictly ob eyed.strictly ob eyed.


INJURY FROM MECH A NIC A LINJURY FROM MECH A NIC A L


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INSTRUMENTSINSTRUMENTS

The main injuri es caus ed byThe main injuri es caus ed by scissors orscissors orforcepsforceps ar e to aar e to a blood vess e lsblood vess e ls..

Blee ding will b e immediat e ly ob vious andBlee ding will b e immediat e ly ob vious andshould b e controll ed byshould b e controll ed by bipolarbipolar orort he rmocoagulationt he rmocoagulation or byor by suturing.suturing.

Direct inad ve rt ent injury to ot he r organsDirect inad ve rt ent injury to ot he r organsby m echanical instrum ents may r esult by m echanical instrum ents may r esult fromfrom car e less or clumsy us ecar e less or clumsy us e ..

OTHER COMPLIC A TIONSOTHER COMPLIC A TIONS


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OTHER COMPLIC A TIONSOTHER COMPLIC A TIONS

A numb er of ot he r A numb er of ot he r

complications may r esult complications may r esult from laparoscopy.from laparoscopy.

11 Cervical lacerationCervical laceration


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11 . Cervical laceration. Cervical laceration

It is common for t he It is common for t he ce rvical t enaculumce rvical t enaculumto caus e a lac e ration of t he to caus e a lac e ration of t he ant e riorant e riorlip of c ervix .lip of c ervix .The cervix should always b e insp ect ed at The cervix should always b e insp ect ed at t he end of t he proc edur e .t he end of t he proc edur e .

The blee ding may usually b e controll edThe blee ding may usually b e controll edbyby pressur e from spong e forcepspressur e from spong e forceps but but occasionally r eq uires suturing.occasionally r eq uires suturing.

22 . Uterine perforation. Uterine perforation


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Uterine perforationUterine perforation

May b e caus ed by t he May b e caus ed by t he manipulatingmanipulatingcannulacannula or duringor during dilatation anddilatation andcur e ttag e .cur e ttag e .The perforation s hould always b e The perforation s hould always b e insp ect ed wit h t he laparoscop einsp ect ed wit h t he laparoscop e duringduringand at t he end of t he proc edur e .and at t he end of t he proc edur e .Blee dingBlee ding is usuallyis usually slight slight and t he and t he complication do es not usually r eq uire complication do es not usually r eq uire treatm ent.treatm ent.

33 . Shoulder pain. Shoulder pain


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pp

Carbon dio x ideCarbon dio x ide is con ve rt ed tois con ve rt ed to carboniccarbonicacidacid whe n it is in solution wit h body fluids.whe n it is in solution wit h body fluids.This isThis is irritant to t he pe riton eumirritant to t he pe riton eum ..

Diaphragmatic p e riton eal irritationDiaphragmatic p e riton eal irritationproduc es pain w hich is re f e rred to t he produc es pain w hich is re f e rred to t he should er by t he should er by t he phrenic n ervephrenic n erve ..This pain may b e confus ed wit h This pain may b e confus ed wit h cardiaccardiacpainpain by t he unwary p hysician and tr eat edby t he unwary p hysician and tr eat edinappropriat e ly.inappropriat e ly.

44 . Pelvic inflammatory disease. Pelvic inflammatory disease


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Pelvic inflammatory diseasePelvic inflammatory disease

The re is aThe re is a small risksmall risk of producing orof producing orex ace rbating a p e lvic inf ection byex ace rbating a p e lvic inf ection byut e rine cannulationut e rine cannulation andandchromop e rtubationchromop e rtubation ..Post Post --ope rati ve ope rati ve pe lvic inf ection ispe lvic inf ection is

probably l ess common aft e rprobably l ess common aft e rlaparoscopic surg e ry t han aft e rlaparoscopic surg e ry t han aft e rlaparotomy.laparotomy.

55 . Omental and Richter's herniation. Omental and Richter's herniation


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55 . Omental and Richter s herniation. Omental and Richter s herniation

If t he primary cannula is wit hdrawnIf t he primary cannula is wit hdrawnwit h its valve closed, it is possibl e towit h its valve closed, it is possibl e to

draw adraw a piece of om entumpiece of om entum into t he into t he umbilical wound by t he negati ve umbilical wound by t he negati ve pressur e so produc ed.pressur e so produc ed.This is usuallyThis is usually recogniz ed imm ediat e lyrecogniz ed imm ediat e lyand t he om entum is easily r eplac ed.and t he om entum is easily r eplac ed.

55 . Omental and Richter's herniation. Omental and Richter's herniation


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H e rniation may occur som e hours aft e rH e rniation may occur som e hours aft e rt he operation.t he operation.It is usuallyIt is usually easy to r eplac eeasy to r eplac e it und e r localit und e r localan est he sia and r esutur e t he wound.an est he sia and r esutur e t he wound.H e rniationH e rniation does not occurdoes not occur commonly wit h commonly wit h 55 mmmm skin incisions.skin incisions.IncisionsIncisions great er t hangreat er t han 77 mmmm should b e should b e sutur ed in lay erssutur ed in lay ers to pr eve nt formation of ato pr eve nt formation of a

Richt er's he rniaRicht er's he rnia ..

55 Omental and Richter s herniationOmental and Richter s herniation


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77 . Foreign bodies. Foreign bodies


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Foreign bodiesForeign bodies

OccasionallyOccasionally tubal clipstubal clips oror ringsrings ororparts of instruments such asparts of instruments such as saphiresaphirelaser tipslaser tips may be inadvertentlymay be inadvertently

dropped and lostdropped and lost in the peritonealin the peritonealcavity.cavity.They should beThey should be removedremoved if they areif they areeasily found but there have been noeasily found but there have been noreports of long term complicationsreports of long term complicationsfrom such foreign bodiesfrom such foreign bodies


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cx of laparoscopy

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