Open versus closed establishment of pneumoperitoneum in laparoscopic surgery

[Complications of laparoscopy in gynecology]

In the field of surgery the development of operative laparoscopy has been one of the most important steps forward over the past fifteen years. This technique has become the surgical treatment of choice for a number of indications in gynaecology. The advantages of laparoscopy as compared with laparotomy are weil known, and assessment of the risk of complications is essential. A multicentric study was carried out in seven top French centres for laparoscopic gynaecological surgery. This series runs over a period of nine years and covers 29,966 diagnostic and operative laparoscopies. The risk of complications has been assessed according to the complexity of the laparoscopic procedure in question. The means of diagnosis and treatment of the complications have been analysed together with the importance of the surgeon's degree of experience. The mortality rate is 3.33 per hundred thousand laparoscopies. The overall complication rate is 4.64 per thousand laparoscopies (139 cases). The rate of complications requiring laparotomy is 3.20 per thousand (96 cases). The complication rate is significantly correlated with the complexity of the laparoscopic procedure (p = 0.0001). One out of three complications (34.1%; 43 cases) occurred while setting up for laparoscopy, and one out of four complications (28.6%) were not diagnosed during the operation. As new indications for laparoscopic surgery in gynaecology have appeared, there has been a parallel and statistically significant increase in the rate of urological complications (p = 0.001). Increased experience of the surgeons has had three consequences: a statistically significant drop in the number of bowel injuries (p = 0.0003), a drop in the rate of complications requiring laparotomy for those laparoscopic surgical procedures which are weil-defined (p = 0.01) and a change in the way complications are treated, with a significant increase in the proportion of incidents treated by laparoscopy (p = 0.0001). Laparoscopic surgery is a reliable technique. The risk of complications exists whatever the indication for laparoscopy. None of the phases in the operation must be neglected. The risk of accidents being overlooked means that the methods for postoperative follow-up must be adapted, bearing in mind the shorter hospital stay. The part played by the surgeon's experience raises the major problem of practitioner training.

The current status of gynecological laparoscopic surgery in educational facilities in Japan

A questionnaire survey was administered by Tohoku University hospital to investigate the current status of gynecological laparoscopic operations in teaching hospitals in which residents were trained as obstetricians and gynecologists. Thirty-eight senior doctors in 18 hospitals were sent a postal questionnaire. The response rates of facilities and doctors were 94.4% and 76.3% respectively. Diagnostic and operative laparoscopy was performed in all of the hospitals surveyed, however only a few hospitals performed more than 100 laparoscopies per year, and many surgeons did not perform advanced laparoscopic operations including hysterectomy, myomectomy and lymphadenectomy. Half of the doctors performed minilaparotomy, which is a so-called "open" technique. The standard surgical style involved the use of a carbon dioxide (CO2) pneumoperitoneum and an endoscope 10 mm in diameter. Unipolar endocoagulating instruments were generally used for hemostasis and incision. Most of the doctors surveyed thought that operative laparoscopy would become a necessary procedure in gynecological field, and half of them hoped to receive training in the technique. Instruction of expert endoscopic surgeons is necessary, especially in teaching hospitals, for the spread of safe and advanced laparoscopic surgery. An educational and training system for established surgeons as well as for young residents is urgently needed in Japan.

Trocar and Veress needle injuries during laparoscopy

BACKGROUND

Inadvertent lesions of the intraabdominal organs and vessels caused by trocars and Veress needles are rare but serious complications of laparoscopic surgery. Establishing the pneumoperitoneum is believed to be the most dangerous step.

METHODS

The Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 14,243 patients undergoing various standard laparoscopic procedures between 1995 and 1997. This database was investigated with special regard to intraabdominal complications caused by trocars and Veress needles.

RESULTS

There were 22 trocar and four needle injuries (incidence, 0.18%). Nineteen lesions involved visceral organs; the remaining seven were vessel injuries. The small bowel was the single most affected organ (six cases), followed by the large bowel and the liver (three cases each). All vascular lesions, except for one laceration of the right iliac artery, occurred as venous bleeding of either the greater omentum or the mesentery. Fourteen trocars were inserted under direct vision. Nineteen trocar injuries were recognized intraoperatively; diagnoses of two small bowel and one bladder injuries were made postoperatively. Needle injuries were all diagnosed intraoperatively. Only five injuries could be repaired laparoscopically; the remaining lesions were repaired openly. Four patients underwent an open reoperation, and another patient needed five reoperations. There was one death (4.0%).

CONCLUSIONS

Trocar and needle injuries are rare complications of laparoscopy. However, if not recognized intraoperatively and repaired immediately, they induce increased morbidity and mortality. Both open and closed establishment of the pneumoperitoneum are related to a potential danger of perforating lesions, but inserting the first trocar under direct vision allows early recognition and immediate repair.

[Major vascular complications from gynecologic laparoscopy]

OBJECTIVE

To specify the circumstances of occurence, the means of diagnosis, the risk factors and the means of prevention for major vascular injuries (MVI) during gynecologic laparoscopic procedure.

STUDY DESIGN

Retrospective case review study of 24 patients.

RESULTS

Twenty-four patients with 31 MVI were identified. The average age of the patients was 32.8 +/- 10.6 years and the mean body index mass was 22.4 +/- 4.0 kg/m2. Three of four of the MVI occurred during the setting-up phase of laparoscopy (19 cases; 79.2%). In five cases (20.8%) MVI occurred during the laparoscopic surgical procedure. Fifteen of the MVI occurring during the set up phase were secondary to insertion of the umbilical trocar and four to insertion of the needle used to create the pneumoperitoneum. A minimum of six MVI secondary to insertion of the umbilical trocar were observed with disposable trocars. In every case diagnosis was performed during the laparoscopic procedure. Five patients (20.8%) died and three others (12.5%) presented serious complications (phlebitis (one case); ischemia (two cases) with a reoperation for one patient).

CONCLUSION

MVI are rare but serious complications of gynecologic laparoscopy. Prevention relies on the surgeon's experience and strict respect of the safety rules. In the vast majority of cases, it is necessary to convert to laparotomy immediately, calling in a vascular surgeon.

Complications of laparoscopic surgery for benign ovarian cysts

STUDY OBJECTIVE

To assess complications of laparoscopic surgery in the management of ovarian cysts.

DESIGN

Prospective observational study (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

Consecutive patients (513) undergoing laparoscopic surgery for ovarian cysts not suspected to be malignant.

INTERVENTION

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

A total of 587 ovarian cysts were removed from 513 women. Conversion to laparotomy was necessary in five cases (<1%). Mean +/- SD cyst diameter was 5.5+/-2.9 cm, with endometriomas (44. 5%) and dermoids (24.3%) being the two most common pathologies; 6.6% were functional. Mean +/- SD operating time was 69+/-31 minutes, and hospital stay and postoperative convalescence was 2.6+/-1.5 and 14.3 +/-9.6 days, respectively. The overall complication rate was 13.3%. Major complications occurred in three patients (0.6%): one small bowel injury and two ureter injuries. Cannula site complications were five inferior epigastric vessel injuries and four incisional hernias at the 10-mm lateral port site.

CONCLUSION

Laparoscopic ovarian surgery was associated with 13.3% complications, with 0.6% being major. Careful patient selection and proper surgical training are critical to ensure safe performance of laparoscopy.

COSMETIC SCAR AND SCOPE OF REVERSAL AFTER PUERPERAL STERILISATION

Female sterilisation is an important component of National Family Welfare Programme. The target group is best motivated during the puerperium for such a procedure. However laparoscopic sterilisation which has got some distinct advantages, is not technically feasible at this time. The authors have used a technique where the advantages of cosmetic appearance, reduced post operative morbidity and reversibility can be conferred on the puerperal women. After trying out the method individually in some cases, a formal case control study design has been made and an evaluation study has been performed in 122 cases. The technique has been found to be cosmetically more acceptable, both at clientele and peer evaluation levels (p<0.001). Though all the four parameters of post operative morbidity have shown better results for the technique evaluated as against the conventional technique, statistical significance has been achieved in two of the parameters (p<0.05).

Introducing diagnostic laparoscopy for patients with suspected acute appendicitis

BACKGROUND

The diagnostic accuracy in patients with suspected acute appendicitis varies from 60% to 90% depending on age and gender. The aim of this study was to evaluate the use of diagnostic laparoscopy for diagnostic purposes in patients with suspected acute appendicitis to prevent unnecessary laparotomy and to leave a macroscopically normal appendix in place.

METHODS

For this study, 500 consecutive patients with suspected acute appendicitis admitted between January 1994 and October 1996 were included prospectively in a surgical training program set to provide diagnostic laparoscopy on a 24-h-a-day basis. Primary open operation was performed when no laparoscopically trained surgeon was available. Short-term outcome measurements were recorded, and a retrospective long-term follow-up evaluation was performed.

RESULTS

We succeeded in performing a diagnostic laparoscopy in 376 patients and a primary open operation in 124 patients. The overall appendicitis rate was 78%. A diagnostic laparoscopy alone was performed in 66 patients (56 of which were fertile women), with a median operating time of 36 min and a complication rate of 0%. The overall complication rate was 8.0%. During a median follow-up period of 19 months one patient returned on a later occasion with appendicitis. At completion of the study, 85% of the surgeons were skilled in diagnostic laparoscopy.

CONCLUSIONS

Substantial education effort is needed to introduce diagnostic laparoscopy on a 24-h-a-day basis. Diagnostic laparoscopy has a high rate of accuracy, short operating time, and low associated morbidity, and prevents unnecessary laparotomy. It is possible to leave a macroscopically normal-appearing appendix in place.

Laparoscopic surgery for gynecologic cancers

In conclusion, laparoscopic techniques are useful for the evaluation and treatment of selected gynecologic malignancies and provide major benefits to patients. The benefits, however, can be expected only from gynecologic oncologists well-versed in advanced laparoscopic techniques. Results must be interpreted cautiously, depending on the laparoscopic expertise of the reporting authors. Numerous questions remain unanswered, particularly those associated with long-term recurrences and survival. The use of laparoscopic procedures for gynecologic malignancies must be considered investigational until adequate long-term survival data are available.

A nation's experience of bleeding complications during laparoscopy

BACKGROUND

Bleeding complications during laparoscopic surgery are rare but probably underreported. The aim of the current study was to elucidate the clinical relevance of bleeding complications and major vascular injuries during standard laparoscopic procedures.

PATIENTS AND METHODS

The Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 14,243 patients undergoing different standard laparoscopic procedures (1995 to 1997). These data were analyzed with special interest in intraoperative and postoperative bleeding complications and major vascular injuries.

RESULTS

In all, 331 patients (2.3%) had intraoperative bleeding complications. Whereas 44 patients suffered from an external bleed of the abdominal wall, the bleeding was internal in the remaining 287. Thirty-three patients with internal bleeding required blood transfusion with a mean blood loss of 1,630 mL. Surgical hemostasis was necessary in 68% of external and 91% of internal bleeds. There were 250 patients (1.8%) with postoperative bleeding complications. External bleeding occurred in 143 patients, and 107 patients developed internal bleeding. External bleeding was mainly treated conservatively (92%), whereas 50% of internal bleeds required further surgical intervention. Major vascular injuries occurred in 12 patients (incidence 0.08%) with open treatment being necessary in all cases.

CONCLUSIONS

Bleeding complications are, in fact, common during laparoscopic surgery. Meticulous dissection technique, immediate recognition, and adequate surgical treatment are mandatory for their management.

Post-operative complications following minimal access surgery

The growth in popularity of minimal access surgery in gynaecology has coincided with a reduction in the length of hospital stay. Patients need to be made aware of the potential for and symptoms and signs of complications to ensure that they seek help at an early stage. Clinicians need to be vigilant in the recognition of adverse events both intra- and post-operatively to minimize the risk of developing serious complications. The growth in litigation in minimal access surgery represents, in part, a failure of surgeons to adapt to the new demands of this type of surgery.

[Laparoscopic treatment of small intestine obstruction]

Laparoscopic surgery for small bowel obstruction is still under evaluation. A review of the literature retrieved over 200 published cases. Technically, the open laparoscopy procedure seems mandatory to avoid bowel injuries. Grasping the enlarged bowel and using monopolar cautery should be avoided. The surgeon should also be sure that at the end of the procedure adhesiolysis was correct. Evaluation of the results must also take into account that most studies were retrospective and included few patients. The cumulative effectiveness rate of laparoscopy was 60%. Failures were mainly due to multiple adhesions, iatrogenic perforations to the intestine, and colonic cancers not recognized before the procedure. There was no prospective study comparing laparoscopy with laparotomy. Finally, it is not proved at present that laparoscopy prevents the recurrence of adhesions after digestive surgery. Owing to the results of the literature, laparoscopic surgery for acute small bowel obstruction does not appear as based on fact.

Gastrointestinal injuries during gynaecological laparoscopy

A retrospective case review study was carried out on gastrointestinal injuries which occur during gynaecological laparoscopy. Fifty-six patients with 62 gastrointestinal injuries were identified. One-third of the complications (32.2%) occurred during the installation phase for laparoscopy. Four of the six complications attributed to electrosurgery were secondary to the use of monopolar coagulation. Diagnosis of these gastrointestinal injuries was made during surgery in only 20 patients (35.7%). The mean time before diagnosis was 4.0 +/- 5.4 (range 0-23) days. Treatment of these complications was performed by laparoscopic surgery in 16.1% of cases. Prevention relies on the surgeon's experience, strict observance of the safety rules, perfect familiarity with the physical properties of the instruments used, systematic use of bowel preparation for patients presenting a risk of bowel complications, systematic supervision of the route taken by the trocars, meticulous inspection on completion of surgery of all areas where bowel adhesiolysis has been used and, in case of any doubt, tests for leakage involving the rectosigmoid. For patients with a risk of bowel complications, the creation of a pneumoperitoneum and performing a mini laparoscopy in the left hypochondrium can be the judicious option.