Complications of laparoscopy. Strategies for prevention and cure

Two-detector Computed Tomography Map of the Inferior Epigastric Vessels for Percutaneous Transabdominal Intervention Procedures

BACKGROUND

It is crucial to know anatomic variations and the exact course of an inferior epigastric artery (IEA) to prevent any complications during percutaneous abdominal interventions.

AIMS

The aim of this study was to map the inferior epigastric vessels using reconstructed two-detector computed tomography images and measure the distance from the inferior epigastric artery (IEA) to the midline to determine a safe route for percutaneous abdominal interventions.

STUDY DESIGN

Retrospective comparative study.

METHODS

Coronal reconstructed two-detector computed tomography images of 200 patients were evaluated to measure the distances between the IEA and midline at three levels (origin, middle, and distal). Vein and artery arrangements were documented.

RESULTS

The most frequently encountered arrangement (41.5%) was a single vein and artery on both sides. Mean distances on the right and left sides were 4.01 and 4.47 cm at the umbilical level, 3.81 and 4.26 cm at the midlevel, and 5.62 and 5.51 cm at the origin level. On both sides, measurement differences between the three levels were highly significant (p<0.05). In addition, a total of 56 IEA bifurcations were depicted in all 200 patients. Thirteen of the 56 bifurcations occurred only on the right side, 11 only on the left side, and 32 on both sides.

CONCLUSION

It is important to be attentive to the IEA's course, at different midline levels, when attempting percutaneous interventions via an abdominal approach.

Safety and efficacy of laparoendoscopic single-site surgery for abdominal wall hernias

In a specialized hernia center, laparoendoscopic single-site surgery was found to be safe and effective for many types of abdominal wall hernias including parastomal hernias.

Background:

Laparoendoscopic single-site surgery has rapidly progressed from the animal laboratory to clinical use since mass production of multichannel ports began in 2007. Indeed, it has now been shown to be feasible and safe for many commonly performed operations.

Methods:

This study cohort comprised 22 unselected patients with abdominal wall hernias of varying types: multiply recurrent inguinal (n=2), suprapubic (n=1), ventral/incisional (n=17), and parastomal hernias (n=2), who underwent laparoendoscopic single-site ventral hernia repair between December 2009 and February 2011. Standard dissecting instruments and a 52cm/5.5mm/30^°angle laparoscope were used.

Results:

Patients included 14 men and 8 women, with a median age of 56 (range, 32 to 78) years and a mean body mass index of 31.5±4.7kg/m². The mean mesh size was 460cm² (range, 225 to 884cm²). Mean operation time was 125 minutes for ventral/incisional hernias and 270 minutes for parastomal hernias. No conversions to multiport or open surgeries were necessary. There was no mortality or morbidity, and no recurrence at 6- to 18-month follow-up. The mean satisfaction score was 2.7 (range, 2 to 3) with no patients reporting dissatisfaction with the procedure.

Conclusion:

This series, though relatively small, represents a diverse group of patients with varying abdominal wall hernias, including parastomal hernias. These successful laparoendoscopic single-site surgeries, with no complications, demonstrate safety and efficacy, albeit in a specialized hernia center. This study is a prelude to the eventual validation of laparoendoscopic single-site hernia surgery with prospective randomized controlled trials.

Malpractice claims and avoidance of complications in endoscopic surgery

Laparoscopy has become a valuable tool for the gynaecologist in the diagnosis and treatment of a variety of gynecological disorders. Its quicker recovery time and other advantages has benefitted countless women. Laparoscopic procedures, however, have their own associated risks and complications, and the surgeon must become thoroughly familiar with these. This awareness will help reduce patient morbidity and mortality, and potentially avoid the stress and burden of litigation, which has been increasing in recent years. Complications of gynaecologic laparoscopy include entry-related problems, and injuries to bowel, urinary tract, blood vessels, and nerves. Although some of these complications have been well described, some have emerged recently in relation to new technology and techniques. In this chapter, we discuss some of the complications of endoscopic surgery, including their incidence, prevention, and medico-legal implications, and provide a brief overview of their management.

Robotic single-port hernia surgery

BACKGROUND AND OBJECTIVES

Since the introduction of single-incision laparoscopic surgery in 2009, an increasing number of surgical procedures including hernia repair are being performed using this technique. However, its large-scale adoption awaits results of prospective randomized controlled studies confirming its potential benefits. Parallel with single-port surgery development, the issue of the chronic lack of good camera assistants is being addressed by the robotic Freehand® camera controller, which has the potential to replace camera assistants in a large percentage of routine laparoscopic surgery. Although the robotic Freehand has been used in certain operations in urology and gynecology, there have been no published reports in robotic (single-port) hernia surgery.

METHODS

This study reports the first case and a series of 16 patients who underwent robotic single-port total extraperitoneal inguinal hernia repair compared to 16 consecutive cases of conventional single-port inguinal hernia repair. Patients were matched for age, sex, body mass index, American Society of Anesthesiologists classification, and types of hernia.

RESULTS

Although operation time was comparable in both, the time wasted for scope cleaning was 8.5 minutes for conventional compared to 1.5 minutes for robotic surgery.

CONCLUSION

Robotic single-port inguinal hernia repair is feasible and efficient. This represents a further milestone in laparoscopic surgery.

Prevention and treatment of abdominal wall bleeding complications at trocar sites: review of the literature

Abdominal wall bleeding may complicate any laparoscopic procedure. Piercing or laceration of vessels transversing the abdominal wall during trocar placement is generally the cause. Bleeding may occur at the very beginning of the surgery but, in some cases, it may go unrecognized for a while complicating the operation and the postoperative course. Planned and careful trocar placement can prevent most of these instances that otherwise can be readily managed avoiding severe morbidity.

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.

Vascular injuries during gynecological laparoscopy--the vascular surgeon's advice

CONTEXT

Iatrogenic vascular problems due to laparoscopy are a well recognized problem and lead to significant repercussions. In this context, a ten-year review of cases topic is presented, based on experience gained while heading two important vascular surgery services.

CASES

Five patients with vascular injuries during elective laparoscopy are described. These patients presented with seven lesions of iliac vessels. All cases were evaluated immediately and required laparotomy, provisional hemostasis and urgent attendance by a vascular surgeon. Direct suturing was performed in three cases. One aortoiliac bypass and one ilioiliac reversed venous graft were made. Venous lesions were sutured. One case of a point-like perforation of the small bowel was found. There were no deaths and no complications during the postoperative period.

DISCUSSION

Important points on this subject are made, and advice is given. There needs to be immediate recognition of the vascular injury, and expert repair by a vascular surgeon is recommended, in order to significantly reduce the degree of complications.

Adhesions in patients with chronic pelvic pain: A role for adhesiolysis?

OBJECTIVE

To review the relation between adhesions and pelvic pain and the effectiveness of adhesiolysis in pain control.

DESIGN

Selective review of the literature.

PATIENT(S)

Patients with pelvic pain and/or undergoing adhesiolysis for pain control.

RESULT(S)

Intraabdominal adhesions are accepted as etiologic factors for infertility and small bowel obstruction; however, the contribution of adhesions to pelvic pain is less clear. The most common laparoscopic findings in patients with and without pelvic pain were endometriosis and adhesions. Immunohistologic studies also have shown evidence of nerve fibers in adhesions that had been removed from patients with and without pelvic pain. Multiple adhesiolysis techniques have been employed, with outcome of surgical procedures ranging from no pain relief to pain relief in 90% of patients. However, randomized trials have shown that adhesiolysis is ineffective in improving the outcome of the treatment of pelvic pain, possibly because of adhesion reformation. Interestingly, adhesions are usually not described as an etiologic factor for pelvic pain in men; this might be related to a gender difference in pain perception or the possibility that adhesions per se do not cause pain.

CONCLUSION(S)

The correlation between pelvic pain and adhesions is uncertain. Adhesiolysis has not been shown to be effective in achieving pain control in randomized clinical studies.

Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy

BACKGROUND

Serious complications may occur during laparoscopic surgery, as in any surgical procedure. Injuries of major retroperitoneal vascular structures are uncommon but important complications of laparoscopy.

METHODS

We report on 9 major vascular injuries in 8 patients in the course of 8 laparoscopic procedures between 1994 and 2002.

RESULTS

The primary operations were cholecystectomy in 7 patients and appendectomy in one patient. Six vascular injuries occurred during placement of the first umbilical trocar, two in the course of the insertion of a Veress needle, and one during the insertion of the second trocar. A laparotomy was performed immediately in all cases. Left common iliac arteries were injured in two patients, aorta in three patients, right common iliac vein in one patient, both right common iliac artery and vein in one patient, and inferior vena cava in one patient. Polytetrafluoroethylene (PTFE) graft interposition was employed in two common iliac arteries and a tubular PTFE graft in one aortic injury, and Dacron patchplasty in one common iliac artery injury. Two aortic, two common iliac vein, and an inferior vena cava injury were repaired primarily. There were also four visceral organ injuries, which were repaired primarily. The major retroperitoneal vascular complication rate was 0.07%. An average of 3.5 units of whole blood were transfused in each case and the average stay in hospital was 6.8 days. There was no mortality.

CONCLUSIONS

The surgeon's experience and knowledge are the essential factors for prevention of major vascular injuries during laparoscopic procedures. In case of an injury, immediate laparotomy must be performed to achieve hemostasis and a surgeon who is familiar with vascular surgery should employ the definitive treatment.

Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels

OBJECTIVE

To determine the efficacy of CT scan in mapping the superior and inferior epigastric vessels, relative to landmarks apparent at laparoscopy.

SUMMARY BACKGROUND DATA

Trauma to abdominal wall blood vessels occurs in 0.2% to 2% of laparoscopic procedures. Both superficial and deep abdominal wall vessels are at risk. The superficial vessels may be located by transillumination; however, the deep epigastric vessels cannot be effectively located by transillumination and, thus, other techniques should be used to minimize the risk of injury to these vessels.

METHODS

Abdominal and pelvic CT images of 100 patients were studied. The location of the superior and inferior epigastric vessels from the midline were determined at five levels, correlated with each other and with the patient age, body mass index, and history of midline laparotomy using Pearson's correlation coefficient and multivariate analysis.

RESULTS

CT scan was successful in mapping the epigastric vessels in 95% of patients. At the xiphoid process level, the superior epigastric vessels (SEA) were 4.41 +/- 0.13 cm from the midline on the right and 4.53 +/- 0.14 cm on the left. Midway between xiphoid and umbilicus, the SEA were 5.50 +/- 0.16 cm on the right of the midline and 5.36 +/- 0.16 cm on the left. At the umbilicus, the epigastric vessels were 5.88 +/- 0.14 cm on the right and 5.55 +/- 0.13 on the left of the midline. Midway between the umbilicus and symphysis pubis, the inferior epigastric (IEA) were 5.32 +/- 0.12 cm on right and 5.25 +/- 0.11 cm on the left. At the symphysis pubis, the IEA were 7.47 +/- 0.10 cm on the right and 7.49 +/- 0.09 cm away from the midline on the left side.

CONCLUSIONS

Epigastric vessels are usually located in the area between 4 and 8 cm from the midline. Staying away from this area will determine the safe zone of entry of the anterior abdominal wall.

A Nonincisional, Doppler-Guided Transvaginal Approach to Uterine Artery Identification and Control of Uterine Perfusion

STUDY OBJECTIVE

To determine the location and depth of uterine arteries from the vaginal fornix using a Doppler-guided nonincisional transvaginal approach.

DESIGN

Observational study (Canadian Task Force classification II-3).

SETTING

Two women's health and fertility centers.

PATIENTS

One hundred nine healthy premenopausal women (age >18 yrs).

INTERVENTION

Transvaginal uterine artery identification.

MEASUREMENTS AND MAIN RESULTS

After uterine size and position were determined, with a standard bivalve speculum in place, uterine arteries were located bilaterally using the DWL Multi-Dop B+ system with 8-MHz probe (Sipplingen, Germany) in toggle mode. Continuous Doppler mode was used to locate uterine arteries, and pulsed Doppler to estimate depth of the arteries from the vaginal fornix. The average uterine size was less than 8 weeks, with the largest measuring 18 weeks' gestational size. The right uterine artery could be identified between 8 and 11 o'clock positions, and was most commonly found at the 9 o'clock position (average depth 9.30 mm, range 4-17 mm). The left uterine artery could be identified between 1 and 4 o'clock positions and was most commonly found at the 3 o'clock position (average depth 8.88 mm, range 4-15 mm).

CONCLUSION

Due to ease of identification of uterine arteries transvaginally, despite differences in parity, uterine size, and position, access to and occlusion of uterine arteries with a Doppler-guided device might offer an alternative to invasive procedures intended to occlude uterine artery blood flow in women with symptomatic uterine leiomyomas.

Evaluation of laparoscopic adhesiolysis for the treatment of experimentally induced adhesions in pony foals

OBJECTIVE

To assess the efficacy of laparoscopic adhesiolysis in the treatment of experimentally induced adhesions in foals.

ANIMALS

8 healthy pony foals.

PROCEDURE

Celiotomy was performed and adhesions created at the jejunoileal junction and at sites 0.5 and 1 m proximal to this junction, using a serosal abrasion method. Ten days after celiotomy, exploratory laparoscopy was performed. Laparoscopic adhesiolysis was performed in the treatment group only (4 foals, randomly selected). Thirty days after the exploratory laparoscopy, a final laparoscopic examination was performed, and the foals were euthanatized. The number and characteristics of abdominal adhesions were recorded during laparoscopy 10 and 30 days after celiotomy and during necropsy.

RESULTS

At 30 days after celiotomy, the number of adhesions in the control group was significantly higher than the number in the treatment group. In the control group, all adhesions observed during the exploratory laparoscopy were still evident at the final laparoscopy and necropsy. In the treatment group, adhesions did not form again after separation. During final laparoscopy and necropsy, a focal adhesion between the omentum and site of the initial laparoscope portal was observed in 5 of 8 foals.

CONCLUSIONS AND CLINICAL RELEVANCE

The serosal abrasion model is useful for studying abdominal adhesions in foals. Laparoscopic adhesiolysis was an effective technique to break down experimentally induced adhesions in the early maturation stage of formation in pony foals. Studies are required to investigate prevention of de novo adhesions at the laparoscope portal sites.

Complications of laparoscopic surgery for rectal cancer: avoidance and management

Since laparoscopy was first introduced as a diagnostic tool for pelvic pathology 15 years ago, the technique has been successfully adapted by general and specialty surgeons as a therapeutic tool for a variety of diseases. Laparoscopic surgery has been used to treat colon and rectal pathology since 1991. The introduction and acceptance of this new access technique also brought the realization of specific complications associated with a laparoscopic approach. Advanced laparoscopic skills are required for laparoscopic pelvic and, to minimize laparoscopic-associated complications, specialized training is required. We will review the specific complications of the laparoscopic approach in pelvic surgery with a view to their recognition, prevention, and treatment.