laparoscopy · complications. the problem is not that there are problems. the problem is expecting...
TRANSCRIPT
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BAYLOR COLLEGE OF MEDICINEBAYLOR COLLEGE OF MEDICINEBAYLOR COLLEGE OF MEDICINE
SCOTT DEPARTMENT OF UROLOGY
Laparoscopy:Complications
Lars J Cisek MD PhD
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Ooops!
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Complications
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The problem is not that there are problems. The problem is expecting otherwise.
Theodore Rubin
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Judgement comes from experience.Experience comes from living through the results of bad judgement.
Patrick Walsh
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There is a snake under every bush.
Edmond Gonzales
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The Snakes
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• Access/ports
• Visceral injury
• Inadvertent energy transfer
• Procedure based
• Closure
• Surgery in general
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NOTE
Conversion is not on this list!
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Fix’n Trouble
Convert for
• Problem you are not able to address
• Surgical Dystocia
• Have predetermined indications and benchmarks for the case
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• Inadvertent laceration or perforation of intraabdominal structure or vascular structure.
• Usually initial access.
• Occurs with all access methods
• Most common injury - epigastric laceration
Access/Ports
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• 5 per 10,000 to 3 per 1000
• Bowel or vascular injury comprises 76% of access injuries
• 13% mortality
Access/Ports
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Access/Ports
• “Safety shields” are not safe
• Based on review of FDA device reporting database the term was removed from port advertising.
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Anatomy
• Umbilicus at level of bifurcation
• A-P distance is ~1-3 cms
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Access/Ports
Methods• Open or Hasson
• Closed or Veress
• Direct
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Access/Ports
Hasson Veress Direct
?slow/fast Fast Faster
Bigger incision Minimal incision Minimal incision
Direct vision Blind Can beDirect vision
Novice Experience required
Experience required
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Access/Ports
• A reliable and efficient method to pierce the body wall to gain access to the surgical site and establish the space is critical
• There are a number of options
• Find one which works quickly and reliably for you
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Direct Access
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Optical Trocar
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Strategies to Limit Access/Ports Problems• Avoid scared areas
• Disposable initial trocar
• less entry force
• Lift abdominal wall
• increase distance to retroperitoneum
• Angle of entry 45-60o (umbilical)
• Adjust method to fit the patient senerio
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Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
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Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
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Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
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Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
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Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
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Fix’n TroubleAccess/Ports
Epigastric vessels
• Cautery
• Harmonic
• Tie with figure of eight internally
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Fix’n TroubleAccess/Ports
Mysenteric vessels
• Tamponade
• Harmonic
• Endo loop
• Tie with figure of eight internally
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Fix’n TroubleAccess/Ports
Major vessels
• Tamponade
• Get blood
• Open
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Fix’n TroubleAccess/Ports
Major vessels
• Tamponade
• Confirm all ready to convert
• Add extra port(s)
• Lap Sitinsky or Bulldog, suturing equipment
• Expose area cautiously, ordered release of tamponade
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Fix’n TroubleAccess/Ports
Hollow Viscera
• These injuries may be harder to detect
• Veress needles may simply be removed, strongly consider a simple serosal stitch
• Larger injuries can also be closed primarily
• Look for second wall injury
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Fix’n TroubleAccess/Ports
Hollow Viscera
• A surgical stapler can be used if lumen diameter for bowel is not compromised.
• A discrete injury in bowel can be exteriorized through an enlarged port site, and repaired
• Bladder injuries should prompt foley drainage, absorbable suture repair if needed
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Fix’n TroubleAccess/Ports
Solid Viscera - liver, spleen, kidney
• Tamponade
• Argon, harmonic, true fulguration
• Surgical coagulant (FloSeal)
• Open
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Gas embolism
• Sudden decrease in ET CO2 & BP
• Typically with initial insuflation/vascular injury
• Mill wheel murmur
• Advantage of Trendelenburg/left side down vs supine unclear
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Injury to Viscera
• Usually occur with manipulation
• Tears or trauma from “rough handling”
• Energy
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Electrosurgery
• Alternating current @ 5-20 x105 Hz
• Reversing polarity prevents cell depolarization
• Current heats the tissue
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Electrosurgery
• Current flow follows least resistive path
• In body tissue resistance is in inverse proportion to water content
• Preferential flow:
blood>nerve>muscle>adipose>bone
• Heat generation is proportional to current density (at any point along the path)
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Electrosurgery
• Monopolar
• 2 electrodes at a distance
• Small active electrode at site
• Large indifferent electrode at remote site
• Bipolar
• Active and indifferent electrode at the site of action
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Electrosurgery• Cutting
• Sparks
• Continuous current duty cycle
• Tissue heats and cell explodes
• Fulguration
• Short current duty cycle (10%)
• Tissue heats then cools
• Desiccation
• Dry tissue by “boiling” water
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Electrosurgery in laparoscopy
• Less cooling capacity in closed space
• High water content of gas which increases conductive capacity
• Potential for contained combustible gas (NO2, methane)
• Limited field of view
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Electrosurgery in laparoscopy
• Current concentration
• Arcing
• Direct coupling
• Capacitive coupling
• Insulation failure
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Insulation failure
Capacitive coupling
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Ultrasonic energy• Electricity induces a vibration in a crystal
• Vibration propagates down a extending rod to a “balde” (standing wave)
• Mechanical vibration transfered to tissue with heating by friction within the tissue
• Local effect
• Instrument gets hot
• Good to about 5mm vessel size
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Energy Sources
• There is less field effect with harmonic energy sources (thermal conduction but not heat production at a distance)
• The use of electrosurgical methods for bowel reflection and adhesiolysis is currently in less favor than ultrasonic
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Energy
• The most dangerous injury is the conduction injury to bowel
• Delayed perforation
• Use harmonic to take down bowel adhesions, reflect colon
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Fix’n TroubleEnergy
If a portion of bowel appears “blanched”
• Small - treat as a puncture
• Place a reinforcing suture
• Large - treat as a tear
• Oversew, exteriorize, open
• Think of electrocautery injury like high velocity GSW; harmonic - low velocity
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Post Operative
Bowel injury
• Failure to thrive
• Ileus
• Obstipation
• Low grade fever
• Pain or drainage at a port site
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Herniation
• Port sites
• More likely with:
• Larger port size
• Cutting greater than dilating trocars
• Midline greater than lateral
• Good data defends closure 10mm or greater in adults
• Peds 5mm (?3mm in infants)
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Take time to deliberate, but when the time for action has arrived, stop thinking and go in.
- Napoleon Bonaparte
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Fix’n Trouble
General considerations
• Have a plan, and a back up
• Addition of a second port to better visualize address problem
• Communicate with the surgical team
• Get help
• Open
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Fix’n Trouble
Rehearse and review your plan
Build skills to address problems
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Fix’n Trouble
Convert for
• Problem you are not able to address
• Surgical Dystocia
• Have predetermined indications and benchmarks for the case
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Fix’n Trouble
Factors to consider for an advanced repair
• Equipment available
• Your skill level
• Your assistant’s skill level, teamwork
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- Boy Scout Motto
Be prepared
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Be prepared
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• Easier to stay out of trouble than fix it
• Have a plan
• Know your limits
• Know the limits of your team
• Get help
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