Complications in Laparoscopic Urology
Dr. Anmar Nassir, FRCS(C)
Fellowship in Andrology (U of Ottawa)Fellowship in EndoUrology and Laparoscopy (McMaster Univ)
Chairman, Department of Surgery Umm Al-Qura UnivConsultant Urology, King Faisal Specialist Hospital, Jeddah
Major Complications of Transperitoneal Abdominal Laparoscopic Surgery
Urology 2004; J Urol 2002Urology 2004; J Urol 2002
Total Procedures 894Abdominal
Overall complications 13.2%
Intraoperative/ postoperative
5.7%7.5%
Deaths 0.2%
Vascular injury 2.8%
Bowel injury 1.1%
Adjacent organ injury 1.1%
Conversion rate 1.7%
Procedural Complications
Complications Related to Obtaining the Pneumoperitoneum Placement of Secondary Trocars GA Unique to Laparoscopy Exiting the Abdomen
Complications in the Early Postoperative Period Late Postoperative Complications
Complications of Obtaining the Pneumoperitoneum Malfunction of Equipment Closed Access (Veress Needle Placement) Insufflation and Pneumoperitoneum Open Access (Hasson Technique) "Blind" Placement of the First Trocar after
Veress Needle
Complications Associated with Closed Access
(Veress Needle Placement) Preperitoneal Placement Vascular Injuries Visceral Injuries
Complications Related to Insufflation and Pneumoperitoneum
Bowel Insufflation Gas Embolism Barotrauma Subcutaneous Emphysema Pneumomediastinum, Pneumothorax, and
Pneumopericardium
Complications Related to Initial "Blind" Placement of the First Trocar
Injury to GI Organs Injury to the Urinary Tract Injury to Intra-abdominal Vessels
Contents of Hemorrhage Tray for Laparoscopic Surgery
Laparoscopic Satinsky clamp 10-millimeter suction/irrigation tip Endostitch device with 4-0 absorbable suture LapraTy clip applier and clips 4-0 vascular suture on an SH needle with a
LapraTy clip preplaced on the end Two laparoscopic needle drivers Topical hemostatic agent of choice
Complications Related to Placement of Secondary Trocars
Bleeding at the Cannula Site
Position-Related Problems
Complications Related to GA Unique to Laparoscopy
Cardiac Arrhythmias and Cardiac Arrest Changes in Blood Pressure Aspiration of Gastric Contents Hypothermia
Complications Related to the Surgical Procedure Bowel Injury:
Electrosurgical Mechanical
Vascular Injury Pancreatic Injury Splenic Injury Injury to the Urinary Tract
Bladder Injury Ureteral Injury
Injury to Nerves
Injury to Nerves
45/1650 = 2.7%. These include
abdominal wall neuralgia (14) extremity sensory deficit (12) extremity motor deficit (8)clinical rhabdomyolysis (6) shoulder contusion (4) back spasm (2)
Wolf et al, Urology 2000Wolf et al, Urology 2000
Complications Related to Exiting the Abdomen
Bowel Entrapment Bleeding at the Sheath Site
Complications in the Early Postoperative
Acute Hydrocele Scrotal and Abdominal Ecchymosis Pain Incisional Hernia Deep Venous Thrombosis Wound Infections Rhabdomyolysis
Late Postoperative Complications
Lymphocele Formation Chylous Ascites
Ergonomics
8-22 of Lap. Surgeons reported pain, numbness, stiffness and eye strain (Hemal, 2002)
It is due to; Posture Visualization Manipulation
Monitor should be at the head level or 10-20 degrees lower
Use step stool to work comfortably
Pt w severe COPD further studies (i.e., ABG and PFT) are required. In severe COPD, helium as an alternate.
Significant cardiac arrhythmias evaluated treated
hypercarbia and the resulting acidosis may have adverse effects on the myocardium.
Before starting select your patient
Absolute contraindications
Uncorrectable coagulopathy Intestinal obstruction Abdominal wall infection Massive hemoperitoneum/hemoretroperitoneum Generalized peritonitis Retroperitoneal abscess Suspected malignant ascites
Relative contraindications
BMI, according to the WHO
Overweight =
25 to 29.9 kg/m25 to 29.9 kg/m22
Obese =
30 to 34.930 to 34.9 kg/mkg/m22
Morbid obesity=
> 35 kg/m> 35 kg/m22
Relative contraindications(if …)
Morbid Obesity Extensive Prior Abdominal or Pelvic Surgery Organomegaly Ascites: Benign Etiology Pregnancy Hernia Iliac or Aortic Aneurysm
Relative contraindications(if …)
Morbid Obesity Extensive Prior Abdominal Organomegaly Ascites: Benign Etiology Pregnancy Hernia Iliac or Aortic Aneurysm
Creating a pneumoperitoneum
There are 4 basic techniques used
1. Veress needle
2. direct trocar insertion
3. optical trocar insertion
4. open laparoscopy
Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005
Sites for verse needleUpper quadrant access
622 consecutive cases. Prior abdominal surgery in 31% body mass index was 30 or greater in 98 patients.
92% successful placement 5% minor liver laceration, managed conservatively 3% the omentum or falciform ligament was traversed without
significant injury.
No major complications, such as vascular or hollow-organ perforation, were caused by either the Veress needle or trocar.
No patient developed an incisional hernia at the upper quadrant trocar site
Chung et al, Urology 2003Chung et al, Urology 2003
Direct trocar insertion
In 578 laparoscopic procedures:
1. blind insertion of the Veress needle (group 1, n = 301)
2. direct trocar insertion with elevation of the rectus sheath using 2 towel clips (group 2, n = 277).
Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005
Results:Total complication rates:
gr 1 = 15.7% (n = 33) gr 2 = 3.3% (n = 4)
(P < 0.05) Conclusion:Direct trocar insertion with elevation of the rectus sheath
using 2 towel clips is an easy, safe, and effective technique.
Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005
Ralph V. Clayman,
J of urol. Pg 1847. Nov, 2005J of urol. Pg 1847. Nov, 2005
Having been a Veress needle advocate throughout my career, I am loath to change. However, this scientifically well-done study gives me “pause”;quicker pneumoperitoneum with fewer complications is certainly a compelling argument for considering a change.
Physiological changes to pneumoperitoneum
Pressure Effects : 5, 10, 20, and 40 mm Hg
Effects 5 mm Hg 10 mm Hg 20 mm Hg 40 mm Hg
Cardiovascular
Heart rate ↑ ↑ ↑ ↓
Mean arterial pressure ↑ ↑ ↑ ↑
Systemic vascular resistance ↑ ↑ ↑ ↑
Venous return →/↓ ↓↑ ↓↑ ↓
Cardiac output →/↓ →/↑ →/↓ ↓
Renal
Glomerular filtration rate → ↓ ↓↓ ↓↓
Urine output → ↓ ↓↓ ↓↓
Respiratory
End-tidal CO2 → →/↑ →/↑ ↑
PCO2 → ↑ ↑ ↑
Arterial pH → →/↓ ↓ ↓
Few words about HAL
Hand-port incisional hernias
50 laparoscopic hand-assisted radical nephrectomies.
Closed with #1 polydioxanone sulfate suture in a running fashion.
Three (6%) patients developed hernia. All in midline hand-port sites.
The average body weight of those who developed an incisional hernia was 137 kg.
JSLS, 9: 196–198, 2005 JSLS, 9: 196–198, 2005
Hand-port incisional hernias
Risk Factors obesity earlier return to activity
Conclusion: nonabsorbable suture + interrupted closure limited activity 4-6 wks post op if high risks.
No further wound hernias since adopting these changes
JSLS, 9: 196–198, 2005 JSLS, 9: 196–198, 2005
Clayman. J of Urol, Dec 2005 Clayman. J of Urol, Dec 2005
WOUND COMPLICATIONS AFTER HALS
MONTGOMERY, et al. J of Uro, Dec 2005 MONTGOMERY, et al. J of Uro, Dec 2005
WOUND COMPLICATIONS AFTER HALS
MONTGOMERY, et al. J of Uro, Dec 2005 MONTGOMERY, et al. J of Uro, Dec 2005
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