Major Laparoscopic Complications: A Review in Two Parts

Simulated management of urinary tract injury during robotic pelvic surgery utilizing the porcine model

Urologic injury is an infrequent but serious complication of pelvic surgery. Training in the assessment and management of this injury might be enhanced through animated simulation. Our objective was to assess the intraoperative management of urologic injury with robotic pelvic surgery using a simulated injury animal model. We used a female domestic pig to create three types of urologic injury, which we then managed with robotically assisted surgery. An edited video of the model was assessed by 14 senior learners and 10 attending faculty. The assessments included key competencies and domains of fidelity. A scale of poor, fair, or good was utilized. The defects and repairs simulated those seen in humans, both anatomically and surgically, although deficiencies were noted. Related to fidelity of the anatomy of the ureter and bladder, lower ratings were given for some of the key competencies (determining the relationship to the trigone, ureteral mobilization, repair of all 3 injuries). The porcine model for simulation of urologic injury during robotically assisted pelvic surgery may be useful for training purposes.

Vascular injury at laparoscopy: a guide to management

Vascular laparoscopic injuries are rare (0.2/1000), however, they are associated with 6-13% morbidity and mortality. Commonest sites for catastrophic haemorrhage are the right iliac vessels, inferior vena cava and less commonly the abdominal aorta. The injuries commonly occur at entry using a Veress needle or insertion of trocars. These risks are inherent to all laparoscopic surgery. A systematic approach for managing these includes prompt recognition, communication within the operative team, immediate resuscitation and specific operative strategies for the control of vascular haemorrhage based on the location and severity of the injury. Major vascular injuries may require midline laparotomy and vascular surgeons. 1:1:1 resuscitation and adjunct haemostatic agents may help. Major vascular injury is a rare but a potentially fatal complication. We propose a skills and drills approach to improve outcomes. We also propose a practical algorithms for the management of haemorrhage in the acute situation.