Sunteți pe pagina 1din 25

Categorization of Laparoscopy

Complications ??

dr. Cepi Teguh Pramayadi, SpOG,MARS


Departemen Obstetri dan Ginekologi
Divisi Kesehatan Reproduksi
FKUI-RSCM
What is injured ??
• Viscera : Bowel, Bladder, Ureters
• Vascular : Major and minor vessels
• Nerve injury

How does it happens ??


• Entry
• Procedural

When do you recognize it ??


• Intra-operatively
• Post- operatively
Risk Assessment….
• Overall : injuries occur in 0,1 – 10 % of
surgeries
• 50 % of injuries occur at entry
• 25% of injuries delayed diagnosis

• During first 20 cases of laparoscopy surgeon’s


Learning Curve complication rate and
conversion rate is much higher
The Principles of Minimally Invasive Surgery (MIS)
Technique is EVERYTHING
• AVOIDANCE
Preventing complications is better than fixing them later
• PLANNING
Set yourself up for success and anticipate obstacles
• ACCESS
Appropriate entry technique and trochar location helps you
accomplish what you need to do
• PATHWAY
Staying in the correct plane keeps you out of bleeding and out
of trouble
• RECOGNITION
Immediate recognition and appropriate repair is better than
delayed management
6 Phases of Complications
Phase I : Patient identification , selection
Avoidance Planning
Phase II : Anesthesia and positioning

PhaseIII : Abdominal entry and port placement


Access
Phase IV : Surgical procedure
Pathway
Phase V : Postoperative recovery
Recognition Repair
Phase VI : Postoperative counseling
Patient Identification
• Responsibility of the surgical team  routine of
checking
Include :
• Patient identity
• Consent form
• Listed procedure
• Site of surgery
• Allergy
 Carefull about obese women, had previous
midline abdominal midline surgery and those
with inflammatory bowel.
 Before an incision is made !!!
Anesthesia Concerns
• Patient condition
• Expectations
• Vascular access
• Positioning
• Entry
• Trendelenberg
• Insufflation pressure
• Blood loss
• Time
Anaesthesia and Positioning
Pneumoperitoneum
• Initial gas insufflation  bradyarrhythmias and
even asystole  vasovagal reflex from peritoneal
stretch.
• intra-abdominal pressure  venous return
via the inferior vena cava and SVR raised
CO.
• Hypoxaemia and hypercarbia.
Entry-related Injury
• Most dangerous part in laparoscopic surgery,
more than 50% complications in laparoscopy
occur at the entry phase
• Types of complications
– Vascular
– Intestinal
– Urinary tract
Vascular Injury
• Abdominal wall bleeding
• Inferior epigastric artery
• Intraperitoneal vessel injury
• Mesentery
• Ovarian artery
• Uterine artery
• Retroperitoneal major vessel injury
• Iliac artery
• Vena cava
• Aorta
• 9–17% mortality rate
• Incidence from 0.04% to 0.5%
Vascular Injury
Prevention
• Abdominal wall elevation while making a 1-cm vertical
incision.
• Abdominal wall elevation while inserting a blunt or tip
trocar.
• Insufflation only after confirmation of correct placement
of the laparoscope.
• The insertion of the secondary trocars is always under
direct vision  transillumination or direct visualisation.
Vascular Injury
Prinsipal  SAAS
• Stop the bleeding: occlude the
vessels with atraumatic grasping
forceps or tampon. Do Not
Coagulate
• Alert the team: for resuscitation,
preparation for laparotomy, consult
to vascular surgeon
• Assess the bleeding site with
quickest & safest route: conversion
of laparotomy, handling the injury
with laparoscopy
• Secure the bleeding site
Intestinal Injury
• 0.06 to 0.5% for diagnostic
laparoscopy to 0.3–0.5% in
operative laparoscopy.
• Mortality rate 3.6%.
• Sites of injury are small
bowel (58%), colon (32%) and
stomach (8%).
• Up to half of happen during
the entry phase.
• An open entry technique has
not been shown to reduce
the incidence but may allow
immediate recognition of the
bowel injuries.
Intestinal Injury
Symptoms :

• mild abdominal distension, pain at the trocar site


near the injured segment, low-grade fever,
diarrhoea with normal bowel sounds

• peritoneal signs, acute abdominal pain, vomiting

• tachycardia, hypotension.
Management Intestinal Injury
• Faecal contamination at the tip of the Veres
needle or trocar, or subtle signs such as
bowel-wall haematoma , bowel surface for
possible injury.
• Should be repaired immediately.
• Laparoscopically or by exteriorising the injured
loop through a mini-laparotomy
• Two-layered closure using 4/0 Vicryl or PDS
Urinary Tract Injury
• Occuring 0.05 - 8.3%.
• Common site: bladder (0,05 - 8%),
ureter (0.5 - 3%)
• Bladder: dome (common),
posterior base
• Ureter: near the infundibulopelvic
ligament
• Diagnosis: direct vision of injury.
• Late: vesicovaginal fistula, loin
pain, loss of renal function,
peritonitis.
• IVP, CT-Scan with contrast,
cystoscopy
Urinary Tract Injury
Therapy:
• Early recognition
• Bladder injury: repair with 2 layers of
absorbable suture. Catheter placement for 7 -
10 days
• Ureter injury: consult to urology, repair by
laparotomy or laparoscopy (if far from
bladder, injury < 1.5 cm)
Urinary Tract Injury
Prevention:
• Empty the bladder prior to trocar insertion
• Direct vision of insertion of secondary
trocar
• Identifying the ureter prior ligating the
tissue adjacent to the ureter
• Cystoscopy to assess for sutures in bladder,
kinking of ureter, and efflux from ureter
Laparoscopy Tips….
• Always watch the TIP of your scissors
• Always watch TISSUE EFFECT with grasping
• Beware of CROSSING instrument Shafts
• COMMUNICATE with and watch your assistant
• LOOK twice BURN once
• If you don’t KNOWwhat it is DON’T burn it !!
• IDENTIFY ANATOMY !
• IF DISORIENTED ZOOM OUT !!
Conclusion
• “ Knowledge is Power “
• Know your ANATOMY
• Know your TOOLS
• Know your PROCEDURE
• Know how to AVOID complications
Patient selection
Planning , anticipation and preparation
Entry
• Know how to RECOGNIZE complications
• Intra-op
• Post-op
• Know how to MANAGE complications
• Know your LIMITATIONS
• Major complications during laparoscopy are rare but can be
catastrophic.
• Surgical training, patient selection, understanding of anatomy
and energy sources, planning of surgery.
• Complications can be encountered preoperatively,
intraoperative, postoperative
TERIMA KASIH

S-ar putea să vă placă și