www.slh.nhs.uk

Complica)onsoflaparoscopicsurgery

Mr Mahesh Patwardhan M.D., F.R.C.O.G.

Consultant Laparoscopic Surgeon South East London NHS Healthcare

London, U.K.

What is a complication? l  A Complication is a concurrence of various

causes and conditions in the course of surgical procedure, which do not normally form part of it and which usually make it more serious.

l  Historical Evolution of the risks of complications

Period Laparoscopic Surgery

Complications

’70 – ’85

Initial Period Due to Technique

’85-’90 Development Due to indications ’90- date

Globalisation Due to Surgeon

Patterns of Risk factors

l The use of incorrect or unfamiliar instruments.

l First and subsequent access routes. l Surgical Technique and alternative route. l Electrosurgical applications. l  Level of proficiency of the surgical team.

Learning the correct technique – the governance side!

l Successful results of laparoscopic surgery are essentially accomplished by good technique and application of ergonomic principle.

l  .

System in U.K.

l U.K. – Single standardising body (R.C.O.G.)

l Advising bodies – B.S.G.E., NICE. l Advanced and intermediate level

certification. l Training period – Minimum number. l Private sector – Practices have to be

consistent with NHS practice. l Compulsory approved training courses. l G.M.C.

Complications related to Access entry

l  Veress needle or direct entry?

l  Umbilical port or Palmer’s point.

l  Metal ports or newer ports?

l  Correct entry and placement of the second port.

Inferior Epigastric Artery Landmarks

Inferior epigastric - Anatomy

Inferior epigastric artery

Phipp’s Needle

What to do?

l  Phipp’s Needle. l  Endocatch. l  Deep Suture. l  Foley’s catheter. l  Suturing under direct

vision.

Injury due to port entry

l  Injury to bowel – serosal, complete, small / large bowel.

l  Injury to major vessel such as aorta, common iliac, external iliac etc.

l  Surgical emphysema.

What to do?

l Bowel Injury – Most important – identification.

l  Laparoscopic suturing only if proficient. l Major Vessel Injury - call for help. l Pressure to stop the loss. l Always a multidisciplinary approach. l Correct documentation and

communications.

Port Hernias l  Larger Ports –

Morcellator. l  What to do? l  Prevention – Phipp’s

Needle, Endocatch, J Shaped Needle.

l  If Recognised early, - Jet wash to separate, check viability

l  Multidisciplinary approach

Complications due to electrosurgery

l  Grounded versus isolated generators. Current division and alternate site burns

l  Direct coupling l  Capacitive coupling l  Insulation failure l  Return electrode site

burns – Large area, low impedance ( excess hair, fatty tissue, bony prominence, adhesive failure, fluid invasion, scar tissue)

ACTIVE SURGICAL TEMPERATURES

Vaporization of water dessicates tissues

Eschar forms when tissues burn

Eschar (oxidation)

Protein Coagulation

Proteins disorganize to form a coagulum

HARMONIC Electrosurgery/Laser Surgery

50º C 100º C 150º C 400º C+

Tissue Dessication

Amaral JF, Chrostek CA. SAGES, 1995.

0

10

20

30

40

50

60

70

Time (sec)

Lateral spread

(cc²)

Electrosurgery

UltraCision

0 1 2 3 4 5 6 7 8 9 10

LATERAL SPREAD OF COAGUALTION

What to do?

l Many of these are unrecognised at the time.

l Awareness. l Risk reporting. l Use of disposable instruments wherever

possible. l Knowledge of electrosurgical principles.

Unfamiliar tools in inexperienced hands!

l  Morcellator. – Paediatric complication in Oxford.

l  Lap Loop. l  Unnecessary use of

traumatic graspers l  Advanced laparoscopic

surgery – should it be allowed without proper training?

Complications due to procedure.

l  Cauterisation of endometriosis – ureteric injuries. l  Adhesiolysis – Bowel injuries. l  Myomectomy – Bleeding l  Colposuspension – Bladder injuries. l  Laparoscopic Hysterectomy – Bleeding form the

uterine arteries, bladder injuries. l  Laparoscopic sacropexy, pelvic lymph node

dissection – Injury to major vessels, bowel, ureter

Intra operative resolution of complications

l Correct diagnosis l Knowledge of the limits of laparoscopic

surgery – Avoiding cowboy approach! l Maximum coordination of surgical team l Appropriate complexity of the admitting

hospital l Multidisciplinary approach.

Causing awareness!

l  Those who do not have complications either do not operate or they conceal them and therefore do not publish them!

Causing awareness

l  The best way to treat the complications is to recognise them and the best way to recognise is to show it to the medical community.

Prevention

l Balance between indications, technical abilities and instruments

l Team work l Safety standards valid during surgery l Awareness that the complications exist! l Training and education. l  Informed consent and appropriate

documentation

Role of responsible bodies

l  Standardisation across the country.

l  Certification. l  Mandatory training

courses. l  Regular auditing of

practices. l  Revalidation.

Thank you

… any questions?