Preventing complications of laparoscopy

A technique for open trocar placement in laparoscopic surgery using the umbilical cicatrix tube

BACKGROUND

Increasingly the open method for placement of the initial or first trocar is replacing the conventional technique with the Veress needle. Indeed, it is preferred because it affords peritoneal access under direct vision. A number of methods have been described in the literature using a variety of approaches and different instruments.

METHODS

We describe a method of open trocar placement in the supra- or subumbilical region that follows a stepwise procedure and employs specific instruments sequentially, while utilizing the umbilical cicatrix pillar or tube.

RESULTS

This technique has been done in 525 cases with no complications or port site hernias.

CONCLUSION

This is a simple technique that is safe and easy to learn. It can be performed rapidly and is a reliable method for the insertion of the first port under vision.

Complications of hepatic surgery in companion animals

The most common hepatic procedures performed in companion animals are liver biopsies and partial or complete liver lobectomies. Although these procedures are relatively simple to perform in healthy animals, surgery in clinical patients with liver disease is often complicated by the presence of significant systemic illness or by the technical challenges associated with removing massive hepatic tumors. An in-depth understanding of the possible complications that can occur with hepatic surgery helps to provide the best possible outcome for the patient by allowing the surgeon to not only take precautions to try to prevent complications but allows one to monitor for them postoperatively and treat them early if noted.

The efficacy and safety of different techniques for trocar insertion in laparoscopic surgery

A review of the available published data reveals no discernable difference in the safety of the three commonly-used methods of trocar insertion (Veress needle, direct and open) for laparoscopic surgery. Each method has individual advantages and disadvantages, with similar morbidity and mortality, when performed by experienced operators with appropriate indications. The individual surgeon should assess which technique best suits his or her operating style in light of the particular circumstance of each patient. Preference should be given to the method with which the surgeon is most comfortable, or with which he or she has the most experience. All patients should be warned prior to undergoing abdominal surgery that, regardless of the method employed for laparoscopy, penetrating injury to internal structures occurs in approximately 1 in 1000 cases.

ERCP in the management of biliary complications after cholecystectomy

Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative biliary injury. Laparoscopic cholecystectomy, which has become the first-line surgical treatment of calculous gallbladder disease, has been associated with a 2.5-fold to fourfold increase in the incidence of postoperative bile duct injury. The biliary endoscopist can expect to see a varied spectrum of complications after cholecystectomy by either technique, including postoperative biliary strictures, bile leaks, and retained calculi in the biliary tree. Proper diagnosis and treatment are paramount in ensuring a satisfactory outcome after bile duct injury. Endoscopic retrograde cholangiopancreatography (ERCP) has become the primary modality for treatment and effectively manages most bile duct injuries.

Comparison between direct trocar and Veress needle insertion in laparoscopic cholecystectomy

Although the Veress needle (VN) is widely used for insufflation of the peritoneum, direct trocar (DT) insertion is going to be more popular. A lot of complications have been reported because of the use of VN. We designed a prospective, nonrandomized study for the comparison of VN and DT insertion techniques. A pneumoperitoneum was created using the VN in 135 patients and using DT insertion technique in 148 patients during a 3-year period. Although no major complication was seen in the DT group, three major complications were seen in the VN group, but there was no statistically significant difference between both groups. More frequent minor complications were seen in the VN group, but it was statistically insignificant. Surgical skill and experience of the surgeon with the entry technique who is using it is an important factor for the selection of the abdominal insufflation technique.

Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center

BACKGROUND

Laparoscopic cholecystectomy has a higher incidence of bile-duct injuries than open cholecystectomy. Although a learning curve phenomenon was attributed to biliary injuries early after its introduction, we were interested in trends in biliary injury rates over time as laparoscopic cholecystectomy has become a mature technology.

OBJECTIVE

To analyze the frequency and anatomic distribution of bile-duct injuries referred after laparoscopic cholecystectomy over a 10-year period.

DESIGN

Retrospective, case-series.

SETTING

Tertiary, referral hepatobiliary unit.

PATIENTS

Referrals to ERCP unit for diagnosis and treatment of biliary injuries after laparoscopic cholecystectomy.

INTERVENTION

ERCP to diagnose level and severity of bile duct injury.

MAIN OUTCOME MEASUREMENTS

Type and anatomy of bile-duct injury, reason for cholecystectomy, mean time between injury and diagnosis, presenting symptoms, ratio of bile-duct injuries diagnosed over total ERCPs done per year.

RESULTS

There were 87 bile-duct leaks, 28 leaks with stones, 51 strictures, and 17 complete duct transactions. The bile-duct injury rate calculated per 100 ERCPs per year was 0.84 (1994), 0.99 (1995), 1.36 (1996), 1.41 (1997), 1.03 (1998), 1.31 (1999), 0.84 (2000), 0.75 (2001), 1.15 (2002), and 0.94 (2003).

LIMITATIONS

Single institution, retrospective analysis, unknown denominator of cholecystectomies done in referral area per year to calculate true bile-duct injury rate.

CONCLUSIONS

Static incidence in frequency, anatomic distribution, and rate per 100 ERCPs per year of postcholecystectomy bile-duct injuries at a tertiary referral hepatobiliary unit over a 10-year period of observation.

Impact of laparoscopic cholecystectomy: a population-based study

BACKGROUND

We assessed the effect of the introduction of laparoscopic cholecystectomy on surgical outcomes in routine practice.

METHODS

Hospital discharge and death-certificate data were linked for all patients undergoing cholecystectomy (n=85120) in Scottish public-sector hospitals (n=51) between January, 1981, and June, 1999. The primary endpoints were cholecystectomy rate, hospital stay, and postoperative mortality. Regression methods were used to examine the effect of laparoscopic experience and surgeon caseload on postoperative mortality and hospital stay.

FINDINGS

From 1989 to 1999, the proportion of cholecystectomies done laparoscopically rose from none to 80%, and the age-standardised cholecystectomy rate increased by 20% (95% CI 15-26). Postoperative mortality did not change in the 1990s (odds ratio 0.99 [0.7-1.4], p=0.99). The mean postoperative hospital stay fell from 8.0 (SD 3.7) to 2.9 (3.2) days. There was wide variation between hospitals in the proportion of cholecystectomies done laparoscopically and in average hospital stay. For individual surgeons, increasing laparoscopic experience and annual caseload were associated with higher proportions of laparoscopic procedures and shorter hospital stays. Postoperative mortality was higher during the first ten laparoscopic cholecystectomies done by a surgeon (compared with >200 procedures, odds ratio 2.3 [1.2-4.6], p=0.015).

INTERPRETATION

The laparoscopic method reduced hospital stay but had no overall effect on postoperative mortality. Studies to assess the appropriateness of the increased cholecystectomy rate are merited. The wide variation in the proportion done laparoscopically, together with evidence of better results for surgeons doing more procedures, suggests scope for further reductions in hospital stay and morbidity.

Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study

BACKGROUND

Previous studies suggest that laparoscopic cholecystectomy (LC) is associated with an increased risk of intraoperative injury involving the bile ducts, bowel, and vascular structures compared with open cholecystectomy (OC). Population-based studies are required to estimate the magnitude of the increased risk, to determine whether this is changing over time, and to identify ways by which this might be reduced.

METHODS

Suspected cases of intraoperative injury associated with cholecystectomy in Western Australia in the period 1988 to 1994 were identified from routinely collected hospital statistical records and lists of persons undergoing postoperative endoscopic retrograde cholangiopancreatography. The case records of suspect cases were reviewed to confirm the nature and site of injury. Ordinal logistic regression was used to estimate the risk of injury associated with LC compared with OC after adjusting for confounding factors.

RESULTS

After the introduction of LC in 1991, the proportion of all cholecystectomy cases with intraoperative injury increased from 0.67% in 1988-90 to 1.33% in 1993-94. Similar relative increases were observed in bile duct injuries, major bile leaks, and other injuries to bowel or vascular structures. Increases in intraoperative injury were observed in both LC and OC. After adjustment for age, gender, hospital type, severity of disease, intraoperative cholangiography, and calendar period, the odds ratio for intraoperative injury in LC compared with OC was 1.79. Operative cholangiography significantly reduced the risk of injury.

CONCLUSION

Operative cholangiography has a protective effect for complications of cholecystectomy. Compared with OC, LC carries a nearly twofold higher risk of major bile, vascular, and bowel complications. Further study is required to determine the extent to which potentially preventable factors contribute to this risk.

Routine use of open laparoscopy: 1,006 consecutive cases

Blind insertion of the Veress needle and of the first trocar is a significant cause of laparoscopic surgery complications. Despite this risk, the closed technique is still more popular than the open one. The authors retrospectively evaluated 1006 consecutive laparoscopic operations in which Hasson's technique was routinely performed. The overall complication rate was 2.2%, but the vast majority of complications occurred during the first 50 cases (6% vs. 1.9%). They conclude that after a learning phase of about 50 cases, Hasson's technique is a quick and safe procedure.

Improving the ease and safety of laparoscopy: a technique for open insertion of the umbilical trocar

BACKGROUND

Sharp cannulation of the abdominal cavity for laparoscopy occasionally causes life-threatening injury to major vessels.

METHODS

A technique of open cannulation is described to minimize this risk.

RESULTS

In over 2000 general surgical laparoscopies performed the Flinders Medical Centre, there were no major vessel injuries and only one bowel injury (prior to laparotomy).

CONCLUSIONS

We advocate the use of open technique to minimize injuries caused by abdominal cannulation for laparoscopy.

Laparoscopic biliary injury: more than a learning curve problem

BACKGROUND

The increase in the incidence of iatrogenic injury to the extrahepatic biliary tree that has been documented since the introduction of laparoscopic cholecystectomy (LC) has been explained as a 'learning curve' problem. The early New Zealand experience has been published and the present study was undertaken to determine whether there had been any change in the incidence, nature and management of laparoscopic biliary injuries (LBI) after further experience with LC.

METHODS

A nationwide audit was undertaken in 1995 by two confidential postal questionnaires: to all active general surgeons (n=184, response rate 60%), and to all endoscopists performing endoscopic retrograde cholangiopancreatography (ERCP) (n=18, response rate 100%).

RESULTS

The total number of LBI was 21, compared with 41 for 1991-92. The site and nature of the injuries were similar for the two survey periods. More of the injuries appeared to be diagnosed after the operation and prior to discharge (25% vs 47%). Calculating the national incidence of LBI was not possible without complete reporting, but in the subset of surgeons responsible for the LBI there was no apparent decrease in the incidence of all LBI (2.8% vs 2.9%), those requiring active re-intervention (2.4% vs 2.7%) and major duct injury (1.1% vs 0.7%), despite a significant increase in the surgeons' prior experience with LC (20% vs 61% of surgeons had performed more than 100 LC). There were some concerning trends in management: a less frequent use of ERCP in patients with LBI diagnosed after surgery (76% vs 65%) and a higher proportion of patients with minor injuries managed by re-operation (26% vs 50%).

CONCLUSIONS

The present study indicates that iatrogenic biliary injury is a persistent problem in New Zealand, despite increasing experience with LC, and suggests the need for more intensive scrutiny of operative technique and training. There is scope to manage more patients with minor duct injuries conservatively.

Clinical experience with open laparoscopy

A modified method of open laparoscopy was performed on 568 consecutive patients requiring laparoscopy or laparoscopic surgery. There were no intraoperative complications related to the technique. All patients were reviewed at 1 week following surgery; 4% had minor umbilical sepsis, while none had a postoperative hernia. The modifications to the technique of open laparoscopy described here make it simple and efficient while maintaining the safety inherent with this technique.

Open versus closed establishment of pneumoperitoneum in laparoscopic surgery

BACKGROUND

Closed laparoscopy, employing a Veress needle and blind insertion of the first trocar, is favoured by most laparoscopic surgeons. The potential danger of this technique is the occurrence of visceral or vascular injury. Establishment of pneumoperitoneum by an open technique using a blunt-tipped trocar may be a safer alternative.

METHODS AND RESULTS

Retrospective review of the literature and the authors' experience was used to compare closed and open laparoscopy. Data on closed laparoscopy in 489335 patients and on open laparoscopy in 12444 patients were culled. Rates of visceral and vascular injury were respectively 0.083 and 0.075 per cent after closed laparoscopy, and 0.048 per cent and zero after open laparoscopy. Mortality rates after closed and open laparoscopy were respectively 0.003 per cent and zero. Pearson chi 2 analysis demonstrated a statistically significant difference in terms of visceral and vascular injury between closed and open laparoscopy (P = 0.002); there was no such difference for mortality rates.

CONCLUSION

Open establishment of pneumoperitoneum is advocated in laparoscopic surgery because it is safer than the closed method.

The safety of laparoscopy performed by direct trocar insertion and carbon dioxide insufflation under vision

The records of 6,173 laparoscopies performed by specialist gynaecologists in the course of routine gynaecological care using the technique of direct insertion of the umbilical trocar and insufflation of carbon dioxide under vision were reviewed to ascertain the incidence of serious complications. A review of the published literature on laparoscopy methodology was also undertaken to complement the data obtained from this study. The nature of the records precluded accurate assessment of both indications and minor complications. There were 4 perforating bowel injuries (0.06%) requiring laparotomy (s small intestine, 2 large intestine). There were no cases of major vascular injury or gas embolus necessitating surgical or resuscitative measures. On 3 of the 4 occasions where bowel injury occurred the patients had undergone prior abdominal surgery and had midline vertical subumbilical incisions. Review of the published literature demonstrated bowel or vessel perforation rates (requiring laparotomy or resuscitation) of 1 in 1,000 regardless of whether the method of gaining peritoneal access was open (Hasson) technique, Verres needle insufflation, or direct trocar. Direct trocar insertion may reduce the risk of gas embolism by insufflating only after intraperitoneal replacement has been confirmed, moreover it allows immediate recognition and rapid treatment of major blood vessel laceration, both of which have been identified as being crucial in reducing laparoscopy associated mortality. When compared to other available methods of gaining peritoneal access for laparoscopy, direct trocar insertion followed by insufflation of carbon dioxide under vision can be performed with the same degree of safety for the patient. It is simply wrong to deduce from the available data that one particular technique of gaining peritoneal access is superior to another. Each have their individual advantages and disadvantages and similar morbidity when performed by experienced operators with appropriate indications. In light of this observation, each alternative should be considered by the individual surgeon to assess which would best suit his or her operating technique and the particular circumstance of each patient. Indeed preference should be given to the method with which the surgeon is most comfortable or with which he or she has the most experience.

Laparoscopic surgery and its potential for medical complications

Laparoscopic surgery is very popular among physicians and patients because this technique is associated with safety, shorter hospital stay, early return to normal activity, and cosmetic acceptance of the operative scar. Although the procedure involves minimal invasion and tissue damage, it has potentially serious complications, including cardiopulmonary effects that result mainly from hypercarbia and raised intraabdominal pressure caused by pneumoperitoneum. Absorbed carbon dioxide from the peritoneal cavity tends to cause acidosis. Leakage of the gas into tissue spaces may induce subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium. Cardiac effects include arrhythmias, hypotension, cardiac arrest, gas embolism, pulmonary edema, and myocardial ischemia or infarction. Some of these effects, though rare, are serious and potentially fatal. Physicians should anticipate these problems in their patients undergoing laparoscopic procedures. This review discusses the technique of and physiologic considerations in laparoscopic surgery as well as its potential complications.

Complications in laparoscopic and open cholecystectomy: a prospective comparative trial

Laparoscopic cholecystectomy (n = 250) was compared with the open procedure (n = 250) in a prospective comparative study focusing on complications. Severity grade was classified according to the Toronto system. The frequency of severity grade 1 complications was equal after open and laparoscopic cholecystectomy (5.6%), but major complications (grade 2 and higher) were significantly more frequent in the open group (10.4 versus 3.6%). The only postoperative death occurred after open cholecystectomy. The conventional advantages of laparoscopic cholecystectomy were also verified: The need for postoperative analgesics was significantly reduced from 7 (range, 4-16) standard opiate doses in the open group to 3 (range, 0-7) in the laparoscopic group. Hospital stay was reduced from 6 (range, 4-31) days after open surgery to 2 (range, 1-7) days after laparoscopic surgery and sick leave from 28 (range, 18-48) to 10 (range, 2-21) days, respectively. The overall complication rate was significantly higher in the open group (16 versus 9%, p < 0.01). In our hands, laparoscopic cholecystectomy carries a lower risk of serious complications than the open procedure.

Major vascular injury and laparoscopy

Iatrogenic vascular trauma is a hazard that must be considered constantly during any laparoscopic procedure. We present a case of vessel penetration presenting as CO2 embolism during insufflation where delayed recognition of the vascular implications of this event led to death from exsanguination. The pattern of laparoscopic vascular injuries in Australia as reported to the Medical Defence Union (UK) and the New South Wales Medical Defence Union is reviewed and compared with previously reported cases of vascular trauma in laparoscopy. Recommendations are made for the diagnosis and most importantly for the prevention of CO2 embolism and major vascular injury at laparoscopy.

Inguinal hernia repair by laparoscopic surgeons: early experience and attitudes

The introduction of laparoscopic inguinal hernia repair (LIHR) has been controversial. A questionnaire was sent to all general surgeons in New Zealand to document the early experience with LIHR and attitudes towards it. Of the 118 replies (response rate 55%), 74 were from laparoscopic surgeons, 26 of whom had performed 564 (201 public, 363 private) LIHR (23 bilateral) until January 1994. Only nine (35%) of these surgeons had assisted an experienced surgeon before performing an LIHR, and only four (15%) were supervised by an experienced surgeon during their first case. The transabdominal preperitoneal technique of LIHR was used by 14 (54%) surgeons, the extraperitoneal technique by eight (31%), and the transabdominal onlay technique by four (15%). There were 29 (5%) recurrences, 17 (3%) neuropathies, seven (1.2%) conversions, four (0.7%) major perforations, and one (0.17%) death. Of the 26 surgeons who performed LIHR, 20 (77%) were concerned about the absence of long-term results, 14 (54%) considered that the optimal technique had not been established, 13 (50%) were concerned about the unique complications associated with LIHR, 11 (42%) were less enthusiastic about performing LIHR than previously, 10 (38%) were doubtful about its advantages, and six (23%) were uncertain about its future and considered that it should only be performed within the context of a controlled trial. This study highlights a number of issues that need to be addressed before the role of LIHR can be determined.

A financial analysis of laparoscopic and open cholecystectomy

Laparoscopic cholecystectomy (LC) is now the method of choice in treatment of symptomatic gallstone disease. Despite its rapidly growing popularity, comparative costs of this new method and open cholecystectomy (OC) remain unclear. The most outstanding feature of laparoscopic cholecystectomy is the period of short recovery. In Sweden the social insurance office documents sick leave period, sickness allowance, as well as diagnosis and therefore provides a reliable basis for an economic analysis. The purpose of this study was to estimate the hospital cost and costs due to sick leave in a series of patients operated on with elective cholecystectomy using the two methods. In each group 50 consecutive patients were studied retrospectively. The total hospital cost was 10% lower in the laparoscopy group--$1,864 as compared to $2,030 per patient in the OC group. Median number of days off work was 14 after LC and 35 days after open surgery, which corresponds to a median sickness allowance of $516 per patient (LC) compared to $1,424 (OC). Laparoscopic cholecystectomy is more cost-effective than open cholecystectomy mainly due to a reduced sick leave period.

Laparoscopic groin hernia repair: results of 200 consecutive herniorraphies

Laparoscopic hernia surgery was introduced in this unit in May 1992. Up to September 1993, 175 patients with 200 inguinal and femoral hernias were treated using this approach. This prospective study deals with intraoperative and postoperative complications, patient recovery and early operative results. The median (range) age was 58 (21-87) years and the median (range) follow-up was 12 (5-24) months. A laparoscopic transabdominal preperitoneal technique was used. The median (range) operation time was 67 (23-160) min for unilateral hernias and the median (range) hospital stay was 1 (0-27) day. Major complications were two postoperative bowel obstructions and seven recurrences, six of these in the first 31 patients. Overall, 17 minor complications were recorded; 52 per cent of the patients were back at work within 1 week, and 94 per cent within 1 month. The value of laparoscopic hernia repair remains to be determined and randomized controlled trials will be necessary.

The E.A.E.S. Consensus Development Conferences on laparoscopic cholecystectomy, appendectomy, and hernia repair. Consensus statements--September 1994. The Educational Committee of the European Association for Endoscopic Surgery

Under the mandate of the Educational Committee of the European Association of Endoscopic Surgery (E.A.E.S.), three consensus development conferences (CDCs) were performed in order to assess the current status of the endoscopic surgical approaches for the treatment of cholelithiasis, appendicitis, and inguinal hernia. Consensus panels for the different disease states (10-13 members each) selected by the education committee on the basis of members' clinical expertise, academic activity, community influence, and geographical location weighed the evidence on the basis of published results according to the criteria for technology assessment: feasibility, efficacy, effectiveness, economy. Draft statements were prepared, discussed by the panels, and presented at plenary sessions of the 2nd European Congress of the E.A.E.S. in Madrid September 15-17, 1994. Following discussions final consensus statements were formulated to provide specific answers for each topic to a minimum of the following questions: 1. What stage of technological development is the endoscopic surgical procedure at (in September 1994)? 2. Is endoscopic surgery safe and feasible? 3. Is it beneficial to the patients? 4. Who should undergo endoscopic surgery? 5. What are the training recommendations? Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Laparoscopic appendectomy is presently at the efficacy stage of development, because most of the data on feasibility and safety originate from centers with special interest in endoscopic surgery: it is not yet the gold standard for acute appendicitis. Endoscopic hernia repair is presently a feasible alternative for conventional hernia repair if performed by experienced endoscopic surgeons. It appears to be efficacious in the short-term. The full text of the consensus panel's statements is given in this publication.

Laparoscopic versus open inguinal hernia repair: randomised prospective trial

Laparoscopic surgery benefits patients because it reduces pain and enables earlier mobilisation. There is concern that laparoscopic hernia repair may enter surgical practice without proper evaluation. We have done a randomised, prospective study comparing laparoscopic and open inguinal hernia repair performed under day-case general anaesthesia. 150 patients were randomised to have laparoscopic (group L) or open (group O) herniorrhaphy. Group L underwent transabdominal stapling of preperitoneal Prolene mesh. Group O underwent open repair, with a tension-free nylon darn. Postoperatively patients completed pain analogue scales eight times over 7 days, and use of analgesia was recorded. Time of return to normal domestic activity and to work was assessed. The groups were similar in age, sex, and body surface area. Self-administered co-proxamol was a median of 18 tablets (1 tablet = 325 mg) in group O (n = 75) and 6 in group L (n = 75, p < 0.001). Overall mean pain analogue score was 3.1 (SD 1.8, n = 70) in group O and 1.8 (SD 1.1, n = 71) in group L (p < 0.0001). Return to normal domestic activity was a median of 7 days in group O (n = 72) and 3 days in group L (n = 73) (p < 0.001). Return to work was a median of 28 days in group O (n = 39) and 14 days in group L (n = 40) (p < 0.002). These data suggest that laparoscopic hernia repair induces less pain than open hernia repair, and enables patients to return to normal activity and work more quickly.

Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial

Although laparoscopic cholecystectomy has rapidly become routine practice in the UK, there has been no rigorous comparison of it with open cholecystectomy. In our trial, 302 patients were randomised to laparoscopic or minilaparotomy cholecystectomy. Recovery after surgery was assessed by length of hospital stay, outpatient review at 10 days and 4 weeks, and patient questionnaires 1, 4, and 12 weeks after surgery. The mean operation time was 14 min shorter for minilaparotomy, while median post-operative hospital stay was 2 days shorter after laparoscopic cholecystectomy. The hospital costs were about 400 pounds greater for the laparoscopic procedure. Laparoscopic patients returned to work in the home sooner; at 1 week, they had better physical and social functioning, were less limited by physical problems, and had less pain and depression. At 4 weeks, only physical functioning and depression scores were better in the laparoscopic group, and by 3 months there were no differences. Laparoscopic patients were more satisfied with the appearance of their scars. The incidence of complications after both procedures was 20%. Compared to minilaparotomy cholecystectomy, laparoscopic cholecystectomy results in shorter hospital stay, less postoperative dysfunction, and quicker return to normal activities, but is more costly.