MIS Complications:Managing the

Emergency Consultation

MIS MIS Complications:Complications:Managing the Managing the

Emergency ConsultationEmergency Consultation

MIS MIS Complications:Complications:Managing the Managing the

Emergency ConsultationEmergency ConsultationGeorge S. Ferzli MD, FACS

Professor of SurgerySUNY HSC, Brooklyn, NY

George S. Ferzli MD, FACSProfessor of Surgery

SUNY HSC, Brooklyn, NY

George S. Ferzli MD, FACSGeorge S. Ferzli MD, FACSProfessor of SurgeryProfessor of Surgery

SUNY HSC, Brooklyn, NYSUNY HSC, Brooklyn, NY

Is there a Is there a laparoscopiclaparoscopicsurgeon in the house?surgeon in the house?

A 12 year old boy has inserted an eyebrow pencil A 12 year old boy has inserted an eyebrow pencil into his penis. into his penis.

CT scan shows the pencil is now lodged in his CT scan shows the pencil is now lodged in his bladder-bladder-

- he’s waiting in the- he’s waiting in the emergency room... emergency room...

When is there an urgent need When is there an urgent need for a laparoscopic surgeon?for a laparoscopic surgeon?

I. Before an operation begins

II. Upon entry into the abdomen

III. Difficulty visualizing intra-peritoneal space

IV. Upon discovery of an injury to an intra-abdominal structure

V. Use of diagnostic laparoscopy in critical care setting

QuickTime™ and aCinepak decompressor

are needed to see this picture.

I. Before an operation begins:I. Before an operation begins:

Assistance with port-

placement decisions

I. Before an operation begins:I. Before an operation begins: Difficulty in entry with

Veress / Hassan

I. Before an operation begins:I. Before an operation begins:

Assistance with access in an obese patient

I. Before an operation begins:I. Before an operation begins:

Assistance with access into a re-operative abdomen

II.II. Upon entry into the abdomen-Upon entry into the abdomen-Untoward eventsUntoward events

• Injury to abdominal wall blood vessels • Incidence of 0.2–2.0%

• May see blood externally around port site or drip internally at peritoneal entry site

• Injury may be unrecognized secondary to tamponade by trocar / pneumo-peritoneum

• Transillumination may not identify deep epigastic vessels, especially in obese patients

Injury to abdominal wall blood vessels-Injury to abdominal wall blood vessels-PreventionPrevention

• Place trocars in midline or lateral to rectus muscles

• At completion of case, examine port sites after trocar removal to assess for unrecognized bleeding

Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

Injury to abdominal wall Injury to abdominal wall blood vessels-blood vessels-

ManagementManagement

Cautery / ligation from within the peritoneal cavity

Cautery / suture-ligation via cutdown over the trocar site

Suture-ligation through the abdominal wall with Keith needle / endoscopic suture passer

II.II. Entry into the Entry into the abdomenabdomen--Vascular injuryVascular injury

• Incidence 0.01%-0.05%; Mortality 8-17%• Incidence closed > open technique• Warning signs:

- Blood from Veress needle

- Sudden hypotension

- Hemoperitoneum open camera entry

- Retroperitoneal hematoma• Once recognized, majority of major

vascular injuries require conversion

Harkki-Sirren P et al. Major Complications of laparoscopy: Follow-up Finnish study. Obst Gyned 1999; 94:95Deziel DJ et cl. Complications of laproscopic cholecystectomy. Am J Surg 1993; 165:9Saville L et al. Laparoscopy and major retroperitoneal vascular injuries. Surg Endosc 1995; 9:1096Chapron et al. Major vascular injuries during gynecologic laparoscopy. JACS 1997

Vascular injury-Vascular injury-ManagementManagement

• Early diagnosis is critical to minimize morbidity/mortality

• For most major vessel injuries, the rule is to convert to laparotomy

• Minor injuries (e.g. omental bleeding) may be managed laparoscopically

• Appropriate vascular principles apply to any repair

III.III. Difficulty visualizing intra-peritoneal Difficulty visualizing intra-peritoneal spacespace

Assistance with adhesiolysis•Associated with prior surgery, peritonitis, radiation, inflammation, endometriosis

Curet M. Surg Clinic NA; 80:1093

III.III. Intra-peritoneal space -Intra-peritoneal space -ManagementManagement

Enhanced view with 30º scope, use multiple

ports for visualization

Judicious placement of additional 5mm ports

Use sharp dissection whenever possible

Lyse only adhesions interfering with trocar

placement or exposure of operative field

IV.IV. Injury to an intra-abdominal Injury to an intra-abdominal structurestructureBowel injuryBowel injury

• Incidence of 0.1%-0.7%*• Caused by Veress or trocar puncture,

grasping forceps, shears / ultrasonic shears, thermal burns

• Penetrating injuries usually recognized intra-operatively

• Thermal injuries may have delayed presentation

• Timely diagnosis / treatment requires high index of suspicion and minimizes morbidity / mortality

Schrenk P et al. Mechanism, management and prevention of laparoscopic bowel injuries. Gastroin Endosc 1996; 43:572Bishoff J et al. Laparoscopic bowel injury: Incidence and clinical presentation. J Urol 1999; 161:887

Bowel injury-Bowel injury-ManagementManagement

Repair of injuries detected at initial surgery:• Puncture injuries & serosal tears may be repaired with simple

intra-corporeal suturing avoiding need for conversion

• Thermal and extensive injuries may require segmental resection / reanastamosis using advanced intra-corporeal skills

Extensive injuries to colon or those requiring resection / reanastamosis may require laparoscopic diverting ostomy

IV.IV. Injury to an intra-Injury to an intra-abdominal structureabdominal structureBladder injuryBladder injury

• The bladder can be injured upon entry into abdomen or during laparoscopic procedure

• Bladder injury may go un-recognized until end of surgery

• Signs of possibly bladder injury- Urine leak from port site

(extra- or intra-abdominally)- Blood or gas in foley bag

Bladder injuryBladder injury• Incidence of laparoscopic bladder

injury 0.02%-8.3%*

• Procedures most commonly associated with bladder injury- Lap hysterectomy (40%)

- Diagnostic laparoscopy (24%)

• Risk factors for injury• Adhesions, endometriosis, prior

radiation, bladder diverticulum

Nehzat C et al. Laparoscopic management of intentional and unintentional cystostomy. Jnl Urol 1996;156:1400 Armenakas N et al. Iatrogenic bladder perforations. JACS 2004; 198:78

Bladder injury-Bladder injury-ManagementManagement

• Mobilize the bladder around injury - Expose / inspect bladder wall, ureteral orifices, bladder neck- Allows for tension-free repair

• One or two layer repair using absorbable sutures- Avoid staples or non- absorbable sutures- Nidus for calculi, granulomas, recurrent UTI, etc

• Foley catheter drainage post-op for 7-10 days

IV.IV. Upon discovery of an injury to anUpon discovery of an injury to anintra-abdominal structureintra-abdominal structureUreteral injuryUreteral injury

•Incidence - 0.1-1.4%*•75% during gyn. procedures (1% of lap hysterectomies have ureteral injury)**•Nature of injuries- Ligation, transection, laceration, crush, ischemia

- Cautery injuries (necrosis, stenosis, leak)

•Risk factors- Large pelvic mass, dense adhesions, radiation, endometriosis, PID

Harkki-Sirren P et al. Major Complications of Laparoscopy: Follow-up Finnish Study. Obst Gyned 1999; 94:95Chan et al. Am J Obstet Gynecol; 188:1273

Ureteral injury-Ureteral injury-PreventionPrevention

• Pre-op ureteral stenting- Does not reduce rate of injury but may allow early recognition and repair

• Ureteral anatomy:- In abdomen, vessels approach medially- In pelvis, vessels approach laterally- Expose ureter by incising peritoneum laterally in abdomen, medially in pelvis

Seidman D et al. In Laparoscopic Surgery. McGraw-Hill 2003

Ureteral injury-Ureteral injury-DiagnosisDiagnosis

• Direct inspection of site of possible injury

• Extravasation of urine• Ureteral discoloration or bruising• Hematuria• Intraperitoneal spillage of IV dye• Confirm ureteral integrity by

cystoscopy or retrograde ureteral catheterization

Ureteral injury-Ureteral injury-ManagementManagement

In collaboration with urologist

Cystoscopy and stenting may suffice for minor injuries

Repair of ureteral injuries requires significant laparoscopic skills- Intracorporeal suturing in one layer with absorbable suture- Repairs should be made over stent- Place drain to analyze any urinary leak

V.V. Use of diagnostic laparoscopy Use of diagnostic laparoscopy in critical care settingin critical care setting

• Increasing use of laparoscopy in ICU setting- For evaluation of bowel in critically-ill post-

cardiac surgical patients

- For assistance during difficult PEG placement

• Precise role requires additional study

Pecoraro AP et al. The routine use of diagnostic laparoscopy in the intensive care unit. Surg Endosc. 2001Jul;15(7):638-41. Epub 2001 May 14.

Gagne DJ et al. Bedside diagnostic minilaparoscopy in the intensive care patient. Surgery. 2002 May; 131(5):491-6.

Consultation Consultation with an advanced laparoscopist with an advanced laparoscopist

plays a critical role when…plays a critical role when…• His/her participation resulted in reduced morbidity

by: - Preventing an injury

- Aiding in diagnosis of an injury

- Aiding in management of an injury

• Improved laparoscopic skills and learning curve of consulting colleague

So what happened So what happened to the eyebrow pencil?to the eyebrow pencil?

……a laparoscopic surgeon saved the day!a laparoscopic surgeon saved the day!

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2

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Thank You!Thank You!

Liability and the Liability and the laparoscopic consultationlaparoscopic consultation

• Consulting colleagues and patients are grateful

however,

• Malpractice insurance is a concern…Beware your fellow General Surgeon peer