Large bowel injuries during gynecological laparoscopy

Day surgery for endometriosis in Canada: A retrospective cohort of trend and regional variation in types of surgeries and their complications

BACKGROUND

A significant proportion of patients with endometriosis require surgery for management of the disease.

AIMS

We aimed to assess the trend and regional variation in day surgeries for endometriosis across Canada and to identify perioperative complications associated with types of surgeries and their temporal trend and regional variation.

MATERIALS AND METHODS

We conducted a retrospective cohort study of women undergoing day surgeries for endometriosis between 2015 and 2019 using Canadian administrative data from the National Ambulatory Care Reporting System, which includes data from four provinces (Ontario (ON), Alberta (AB), Nova Scotia (NS) and Prince Edward Island (PEI)). Multivariate logistic regression models were used to compare perioperative complication rates, while adjusting for site(s) of endometriosis lesion, age, type of surgical intervention, and comorbidities.

RESULTS

During the study period, the rate of day surgeries for endometriosis remained nearly constant at 80-90 cases per 100 000 women of reproductive age (P = 0.12). The rate of day surgeries was significantly different between provinces (AB = 94, NS = 93 vs ON = 85 per 100 000 women of reproductive age: P < 0.02). The odds of complications decreased with time (2019 vs 2015; adjusted odds ratio (aOR): 0.84; 95% CI: 0.73-0.98). There was a significant regional variation in the frequency of perioperative complications (PEI vs ON aOR: 4.13, 95% CI: 2.58-6.62; and NS vs ON aOR: 1.47, 95% CI: 1.11-1.95).

CONCLUSION

The rates of day surgery for endometriosis remained stable and the risks of perioperative complications decreased during the five-year study period. However, there were significant regional variations in the risk of perioperative complications.

Extraperitoneal Laparoscopy in Severe Intra-abdominal Adhesions: A Safe Alternative to Laparotomy

Surgery in a frozen abdomen can be difficult and dangerous with a significant risk of visceral injuries. We report a case of a 26-year-old lady with chronic pelvic pain diagnosed to have large bilateral adnexal cysts on magnetic resonance imaging with normal tumor markers. She had previous two laparotomies for benign conditions. Laparoscopy was planned, but pneumoperitoneum could not be created due to dense intraperitoneal adhesions. Direct entry was done into the preperitoneal space followed by insufflation of gas in this space. Blunt and sharp dissection of this space was done without breaching the peritoneum to reach the adnexa. The adnexal cyst was found to be encysted collection due to adhesions from previous surgeries. Deroofing was done followed by the visualization of pelvic structures intraperitoneally. Extraperitoneal laparoscopy may be used as a safe alternative to laparotomy in patients with dense intra-abdominal adhesions with the advantage of faster postoperative recovery.

The Clinical Application of a Self-developed Gasless Laparoendoscopic Operation Field Formation Device on Patients Undergoing Cholecystectomy

BACKGROUND

We have designed a new gasless laparoscopic operation field formation (LOFF) device for cholecystectomy which was successfully tested on animal model. The goal of this study is to investigate the feasibility, safety and effectiveness of this LOFF device on patients undergoing cholecystectomy.

METHODS

Patients with cholecystolithiasis or gallbladder polyps who underwent single port cholecystectomy from June 2015 to May 2016 were retrospectively reviewed. Either the LOFF-assisted laparoendoscopic single-port surgery (LESS) (LOFF-LESS) or the traditional LESS was performed. Operation time, intraoperative bleeding, postoperative hospital stay, surgical complications, incision pain score, shoulder and back pain and cosmetic satisfaction were compared.

RESULTS

A total of 186 patients were included in this study, with 79 in the LOFF-LESS group and 107 in the LESS group. There was no significant difference between LOFF-LESS group and LESS group in operation field establishment time, cholecystectomy time, intraoperative bleeding, postoperative hospital stay, incision pain and cosmetic satisfaction. A lower intraoperative arterial carbon dioxide pressure was documented in the LOFF-LESS group (P<0.01). The incidence of postoperative shoulder and back pain was significantly lower in LOFF-LESS group (P<0.01).

CONCLUSION

LOFF-LESS has comparable benefits of traditional LESS; it deceases incidence of pneumoperitoneum related complications as well.

Fibrin sealants as an adequate treatment alternative to traditional suturing for confined bowel lesions: A hypothesis for future experimental research

Bowel perforation is a rare, but serious complication of laparoscopic surgery with a mortality rate that reaches 20%. There are several risk factors that could predispose to bowel perforation, but the surgeon's experience and the difficulty of each case play the most important role. Delayed bowel injuries happen due to conduction of electrical energy through the abdominal cavity, and in the majority of cases require reoperation. Early bowel injuries are caused by thermal injury of an electrosurgical instrument or during the insertion of the laparoscopic instruments inside the peritoneal cavity. Such injuries are recognized during the operation and are usually fixed by placing sutures. TISSEEL™ is a fibrin sealant with various applications in several surgical specialties, that simulates the latter stages of the coagulation cascade, and could be used as an alternative treatment for confined bowel perforations during laparoscopy. The efficacy of fibrin sealants in closing bowel gaps has been tested in some experimental models as well as its adequacy in enhancing bowel anastomoses performed with sutures. In addition, there is scarce evidence that fibrin sealants enhance the healing process after bowel enclosure either combined to suturing or not, which is supported by an experimental pilot study, that was conducted by our study group. The present study tries to combine all the available data in order to propose an effective alternative treatment for confined bowel injuries or controversial cases, that happen during laparoscopic surgery. In that way, every surgeon could face them even without huge expertise, conversions to open surgery would diminish and the disadvantages of suturing would disappear. Future experimental studies should be designed in the terms of extensive comparison of the two methods, with the purpose of this comparison to be tested in humans in the future.

Evaluation of the diagnostic potential of trans abdominal ultrasonography in detecting intra-abdominal adhesions: A double-blinded cohort study

Background

Intra-abdominal adhesion is one of the most important complications of abdominopelvic surgery. It increases morbidity and mortality for patients. Although laparoscopy is the gold standard of adhesion diagnosis, it can cause visceral damage during the operation. Therefore, surgeons prefer to use non-invasive methods for planning the operation. We designed this study to evaluate transabdominal ultrasonography ( TAU) accuracy for diagnosing Intra-abdominal Adhesions

Material & methods

This double-blinded cohort study was conducted on 47 patients with previous laparotomy who undergo another surgery. Spontaneous visceral slide (SVS) and induced visceral slide (IVS) were measured during TAU.

Results

The mean age and BMI of 47 patients were 43.21±10.3 and 27.545±5.76. The majority of the patients were female (76%). Mean SVS and IVS in patients with intra-abdominal adhesion were 8.73±1.60 and 44.84±11.60. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of TAU in intra-abdominal diagnosis were 83.33%, 51.72%, 51.72%, 83.33%, 63.83%.

Conclusions

Although TAU is an appropriate method for detecting the intra-abdominal adhesion, it isn't good enough for diagnosing free adhesion area. We recommended further researches with greater sample size and other non-invasive techniques.

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Evaluation of accuracy, sensitivity, specificity, PPV, NPV for adhesion diagnosis.

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There are not a lot of studies on ultrasonography accuracy before.

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It’s an only double-blinded cohort study.

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Our study refers to high sensitivity and NPV for diagnosing the adhesion.

Latif's point: A new point for Veress needle insertion for pneumoperitoneum in difficult laparoscopy

INTRODUCTION

Creating pneumoperitoneum is the most challenging step during laparoscopy. The periumbilical area is the classic site for Veress needle insertion. We adopted a new access point for peritoneal insufflation.

METHODS

We introduced a new point for Veress needle insertion to create pneumoperitoneum during difficult laparoscopic procedures. The needle is placed between the xiphoid process and the right costal margin, and it then proceeds toward the patient's right axilla. We collected data to compare using this new method of peritoneal insufflation with using Palmer's point for pneumoperitoneum.

RESULTS

Since 2013, we have used this new technique in 570 patients (first group) and Palmer's point in 459 patients (second group). Among these patients, 196 patients (20%) had had previous abdominal operations, 98 patients (10%) had irreducible ventral hernia, and 735 patients (70%) were morbidly obese. The two groups were comparable in terms of patient characteristics. The mean time to create pneumoperitoneum in the first group was 0.8 ± 0.002 min compared to 1.08 ± 0.007 min in the second group (P ≤ 0.5). The mean number of punctures was 1.57 ± 1.02 in the first group compared to 2.9 ± 1.5 in the second group (P≤ 0.5); in the first group, 97% were successful on the first attempt entry, whereas this figure was 91% in second group. In the first group, the liver was punctured in 13 patients without any further complications; no other viscera were punctured. In the second group, gastric puncture occurred in 5 cases, transverse colon in 2 cases, and omental injury in 12 cases.

CONCLUSION

This new access point may represent a safe, fast, and easy way to create pneumoperitoneum, as well as a promising alternative to Palmer's point in patients who are not candidates for classic midline entry.

Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy for morbid obesity

Portomesenteric vein thrombosis (PMVT) is a rare, life-threatening pathology associated with increased prevalence in laparoscopic sleeve gastrectomy (LSG) versus other gastric bypass procedures. Gaining popularity, LSG is becoming the first choice of patients and physicians alike due to its low complication profile compared to the gastric bypass procedure. We present the case of a 34-year-old woman who underwent an uncomplicated LSG for the treatment of morbid obesity, and presented on postoperative day 13 with PMVT. The patient underwent mechanical thrombectomy and thrombolytic therapy. After 2 days, patency was restored and the patient was discharged in stable condition. A high index of suspicion for PMVT should be considered in patients reporting diffuse abdominal pain after LSG. Owing to its lethality, upon confirmation of PMVT, therapy should begin immediately along with extended anticoagulation therapy on discharge.

Open Versus Closed Laparoscopy: Yet an Unresolved Controversy

INTRODUCTION

Safe placement of the Verres needle or the primary trocar for establishment of pneumoperitoneum is the most critical step in laparoscopic procedure as it is associated with bowel, bladder and life threatening vascular injuries and embolism. In the last few decades many techniques and guidelines have been introduced to eliminate complications in creation of pneumoperitoneum. Classical closed technique (Verres needle) and the open classic technique (Hasson) are the most commonly used techniques for creation of pneumoperitoneum.

AIM

To compare the rate of occurrence and nature of complications in open and closed laparoscopy during establishment of pneumoperitoneum in different surgical and gynaecological procedures.

MATERIALS AND METHODS

This was a comparative study conducted at three hospitals in Dibrugarh district, Assam, India from January 2012 to December 2014. Total 3000 cases were included in the study with 1500 cases of open laparoscopy and 1500 cases of closed laparoscopy. Complications occurring in both the groups were compared by using Fisher's-exact test.

RESULTS

In closed laparoscopy group minor complications occurred in 80 (5.33%) and major complications in 20 (1.33%) cases. In open laparoscopy group minor complications were observed in 60 (4%) and major complications in 2 (0.13%). The p-value of the difference between the two groups for minor complications was 0.0834 and for major complications was 0.0001(significant).

CONCLUSION

Open laparoscopy was seen to be better than closed laparoscopy in terms of not only the rate of occurrence of complications but also the nature and severity of the complications. This study is clinically relevant as there is no consensus for a particular method of safe entry in to the peritoneal cavity warranting the need for more research. Open technique can be performed in all cases irrespective of previous operative scar, suspected intra peritoneal adhesions or obesity. Favourable outcome may be achieved in closed technique in cases of normal BMI, absence of postoperative scar in the abdomen, absence of abdominal and genital tuberculosis and pelvic inflammatory disease.

[Management of more frequent complications of laparoscopic surgery. Minimally invasive or always open surgery?]

BACKGROUND

Two decades after the far-reaching establishment of elective laparoscopic surgery, the questions arise whether and when the benefits of this technology can be sufficiently and safely implemented even in cases of complications.

MATERIAL AND METHODS

The currently available literature was analyzed in the context of recommendations for the management of complications in laparoscopic surgery.

RESULTS

Intraoperative and postoperative complications of minimally invasive surgery necessitating treatment are extremely rare and can be expected in only 0.1–5 % of interventions, depending on the complexity of the intervention. In addition to adhesion-related and anatomical limitations, they are responsible for the necessity to convert to open surgery in approximately 40–60 % of the cases.

DISCUSSION

Due to the relative rarity and great variety of potential complications, there is no scientific evidence at the study level that can give reliable recommendations for a management strategy in every situation. It still has to be decided on an individual basis and depending on the particular clinical situation if a successful laparoscopic management can be sufficiently and safely carried out. It has been found that a number of complications can be well controlled by minimally invasive procedures; however, in addition to a high level of personal experience in laparoscopy, optimal technical, institutional and instrumental conditions must be available. If these factors are not present in total, a conventional open approach should still be given preference.

[Complicated course of a laparoscopic cholecystectomy]

The case presented deals with the complicated course of a laparoscopic cholecystectomy in a 45-year-old female patient due to cholecystolithiasis. The patient complained that during the operation an injury to the small intestine occurred, which was only operatively treated at midday of the despite massive pain and insufficient pain treatment. The intervention was claimed to have resulted in mental and physical suffering. The case is assessed by two independent experts in the sense of a "scientifically founded comment" with respect to the decision of the arbitration board and taking the surgical standards into consideration.