Oliver Ziegler, Collective 2014 - Which comes first metrics or experience?
Laparoscopy · Complications. The problem is not that there are problems. The problem is expecting...
Transcript of Laparoscopy · Complications. The problem is not that there are problems. The problem is expecting...
BAYLOR COLLEGE OF MEDICINEBAYLOR COLLEGE OF MEDICINEBAYLOR COLLEGE OF MEDICINE
SCOTT DEPARTMENT OF UROLOGY
Laparoscopy:Complications
Lars J Cisek MD PhD
Ooops!
Complications
The problem is not that there are problems. The problem is expecting otherwise.
Theodore Rubin
Judgement comes from experience.Experience comes from living through the results of bad judgement.
Patrick Walsh
There is a snake under every bush.
Edmond Gonzales
The Snakes
• Access/ports
• Visceral injury
• Inadvertent energy transfer
• Procedure based
• Closure
• Surgery in general
NOTE
Conversion is not on this list!
Fix’n Trouble
Convert for
• Problem you are not able to address
• Surgical Dystocia
• Have predetermined indications and benchmarks for the case
• Inadvertent laceration or perforation of intraabdominal structure or vascular structure.
• Usually initial access.
• Occurs with all access methods
• Most common injury - epigastric laceration
Access/Ports
• 5 per 10,000 to 3 per 1000
• Bowel or vascular injury comprises 76% of access injuries
• 13% mortality
Access/Ports
Access/Ports
• “Safety shields” are not safe
• Based on review of FDA device reporting database the term was removed from port advertising.
Anatomy
• Umbilicus at level of bifurcation
• A-P distance is ~1-3 cms
Access/Ports
Methods• Open or Hasson
• Closed or Veress
• Direct
Access/Ports
Hasson Veress Direct
?slow/fast Fast Faster
Bigger incision Minimal incision Minimal incision
Direct vision Blind Can beDirect vision
Novice Experience required
Experience required
Access/Ports
• A reliable and efficient method to pierce the body wall to gain access to the surgical site and establish the space is critical
• There are a number of options
• Find one which works quickly and reliably for you
Direct Access
Optical Trocar
Strategies to Limit Access/Ports Problems• Avoid scared areas
• Disposable initial trocar
• less entry force
• Lift abdominal wall
• increase distance to retroperitoneum
• Angle of entry 45-60o (umbilical)
• Adjust method to fit the patient senerio
Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
Fix’n TroubleAccess/Ports
Epigastric Vessels
• Box stitch
Fix’n TroubleAccess/Ports
Epigastric vessels
• Cautery
• Harmonic
• Tie with figure of eight internally
Fix’n TroubleAccess/Ports
Mysenteric vessels
• Tamponade
• Harmonic
• Endo loop
• Tie with figure of eight internally
Fix’n TroubleAccess/Ports
Major vessels
• Tamponade
• Get blood
• Open
Fix’n TroubleAccess/Ports
Major vessels
• Tamponade
• Confirm all ready to convert
• Add extra port(s)
• Lap Sitinsky or Bulldog, suturing equipment
• Expose area cautiously, ordered release of tamponade
Fix’n TroubleAccess/Ports
Hollow Viscera
• These injuries may be harder to detect
• Veress needles may simply be removed, strongly consider a simple serosal stitch
• Larger injuries can also be closed primarily
• Look for second wall injury
Fix’n TroubleAccess/Ports
Hollow Viscera
• A surgical stapler can be used if lumen diameter for bowel is not compromised.
• A discrete injury in bowel can be exteriorized through an enlarged port site, and repaired
• Bladder injuries should prompt foley drainage, absorbable suture repair if needed
Fix’n TroubleAccess/Ports
Solid Viscera - liver, spleen, kidney
• Tamponade
• Argon, harmonic, true fulguration
• Surgical coagulant (FloSeal)
• Open
Gas embolism
• Sudden decrease in ET CO2 & BP
• Typically with initial insuflation/vascular injury
• Mill wheel murmur
• Advantage of Trendelenburg/left side down vs supine unclear
Injury to Viscera
• Usually occur with manipulation
• Tears or trauma from “rough handling”
• Energy
Electrosurgery
• Alternating current @ 5-20 x105 Hz
• Reversing polarity prevents cell depolarization
• Current heats the tissue
Electrosurgery
• Current flow follows least resistive path
• In body tissue resistance is in inverse proportion to water content
• Preferential flow:
blood>nerve>muscle>adipose>bone
• Heat generation is proportional to current density (at any point along the path)
Electrosurgery
• Monopolar
• 2 electrodes at a distance
• Small active electrode at site
• Large indifferent electrode at remote site
• Bipolar
• Active and indifferent electrode at the site of action
Electrosurgery• Cutting
• Sparks
• Continuous current duty cycle
• Tissue heats and cell explodes
• Fulguration
• Short current duty cycle (10%)
• Tissue heats then cools
• Desiccation
• Dry tissue by “boiling” water
Electrosurgery in laparoscopy
• Less cooling capacity in closed space
• High water content of gas which increases conductive capacity
• Potential for contained combustible gas (NO2, methane)
• Limited field of view
Electrosurgery in laparoscopy
• Current concentration
• Arcing
• Direct coupling
• Capacitive coupling
• Insulation failure
Insulation failure
Capacitive coupling
Ultrasonic energy• Electricity induces a vibration in a crystal
• Vibration propagates down a extending rod to a “balde” (standing wave)
• Mechanical vibration transfered to tissue with heating by friction within the tissue
• Local effect
• Instrument gets hot
• Good to about 5mm vessel size
Energy Sources
• There is less field effect with harmonic energy sources (thermal conduction but not heat production at a distance)
• The use of electrosurgical methods for bowel reflection and adhesiolysis is currently in less favor than ultrasonic
Energy
• The most dangerous injury is the conduction injury to bowel
• Delayed perforation
• Use harmonic to take down bowel adhesions, reflect colon
Fix’n TroubleEnergy
If a portion of bowel appears “blanched”
• Small - treat as a puncture
• Place a reinforcing suture
• Large - treat as a tear
• Oversew, exteriorize, open
• Think of electrocautery injury like high velocity GSW; harmonic - low velocity
Post Operative
Bowel injury
• Failure to thrive
• Ileus
• Obstipation
• Low grade fever
• Pain or drainage at a port site
Herniation
• Port sites
• More likely with:
• Larger port size
• Cutting greater than dilating trocars
• Midline greater than lateral
• Good data defends closure 10mm or greater in adults
• Peds 5mm (?3mm in infants)
Take time to deliberate, but when the time for action has arrived, stop thinking and go in.
- Napoleon Bonaparte
Fix’n Trouble
General considerations
• Have a plan, and a back up
• Addition of a second port to better visualize address problem
• Communicate with the surgical team
• Get help
• Open
Fix’n Trouble
Rehearse and review your plan
Build skills to address problems
Fix’n Trouble
Convert for
• Problem you are not able to address
• Surgical Dystocia
• Have predetermined indications and benchmarks for the case
Fix’n Trouble
Factors to consider for an advanced repair
• Equipment available
• Your skill level
• Your assistant’s skill level, teamwork
- Boy Scout Motto
Be prepared
Be prepared
• Easier to stay out of trouble than fix it
• Have a plan
• Know your limits
• Know the limits of your team
• Get help