Principles and Complications of Laparoscopy Jeong H. Yoon Brigham and Women’s Hospital January 15, 2003

Relative Contraindications Prior abdominal and/or pelvic surgery Morbid obesity Hiatal Hernia Pelvic fibrosis Organomegaly Iliac or Aortic Aneurysm Pregnancy Ascites

Absolute Contraindications Abdominal wall infections Generalized peritonitis Bowel obstruction Uncorrected coagulopathy Severe COPD Malignant ascites Massive hemoperitoneum

Preoperative Preparation Informed consent with possibility of conversion to open procedure Possible bowel preparation and antibiotics Cross matching or type and screening

Laparoscopic Approach Retroperitoneal Small, nonfunctioning kidney, multiple prior abdominal surgeries, ostomy, peritoneal dialysis catheter Transperitoneal Nonfunctioning hydronephrotic kidney, non prior abdominal surgery Hand-assisted History of XGP, perirenal inflammation, chronic inflammation, prior surgeries, RCC

Intraoperative Preparation Patient positioning: supine, flank, semi-lateral decubitus Antiembolism stockings or pneumatic compression stockings ETT NGT/OGT for upper abdominal surgery or lengthy cases Foley catheter Laparotomy tray General anesthesia (preferably with agents other than nitrous gas) Surgical field prepared and draped in preparation for a laparotomy

Establishing the Pneumoperitoneum Veress Needle Technique Two distinct points of resistance fascia and peritoneum

Establishing the Pneumoperitoneum Saline drop test place a drop of saline at the hub of the needle, lifting the abdominal wall should suck the drop downward Aspiration-injection test aspiration should not yield blood, bowel contents, etc. Injection of 5-10 mL saline should flow easily without return on reaspiration Initial intraperitoneal pressure <7 mmHg with initial flow rate 1-2 liters per minute Insufflate abdomen to 15 mmHg pressure slowly with a total volume used 3-6 L CO2

Establishing the Pneumoperitoneum Hassan Cannula Technique Consists of a 10-11 mm sheath with a blunt tip obturator with a cone shaped outer adjustable sleeve designed to occlude the larger abdominal wall opening Used in patients where blind insertion of the Veress needle is considered dangerous (multiple adhesions, multiple surgeries, obese)

Establishing the Pneumoperitoneum Hassan Cannula Technique (cont.)

Access to the Peritoneal Cavity or Retroperitoneum Transabdominal Laparoscopic Nephrectomy Patient in semi-lateral decubitus position Pneumoperitoneum established with either a Hassan cannula or Veress needle in the infra or supraumbilical position 12mm Hassan trocar in infra or supraumbilical site (working port), 5mm trocar in midclavicular line at level of umbilicus, 10mm trocar in the midline 7cm cephalad to the umbilicus (camera port). For Right, 5mm trocar in midclavicular line at the costal margin (liver margin) 12mm Hassan trocar in infra or supraumbilical site. 2 10mm ports in midclavicular line, one under costal margin, one 2cm below level of umbilicus, 5mm port midaxiallry line halfway between costal margin and anterior iliac crest

Access to the Peritoneal Cavity or Retroperitoneum Hand-assisted Laparoscopic Nephrectomy Patient in near supine position Length of hand incision usually equal to glove size Trocars placed not too close to the hand-assist device In larger patients, trocars placed to reach the most cephalad aspect of the dissection Right HAL- Hand incision in the RLQ lateral to the rectus, just above the umbilicus. Incised and lined with the external oblique fascial fibers. Can also make incision in oblique fashion in the line of the internal oblique fascial fibers. Camera port in supraumbilical midline, and working port in the infraumbilical midline. 3rd port in the right midclavicular line at the costal margin for liver retraction. Left HAL- Hand port in the infra or periumbilical region. Camera port in the anterior axillary line at the level of umbilicus. Working port in the midclavicular line below level of the umbilicus. For large tumors, additional superior midclavicular port.

Access to the Peritoneal Cavity or Retroperitoneum Retroperitoneal Laparoscopic Nephrectomy Patient in full lateral decubitus position with flank exposed and table flexed 2 cm incision incision made below the tip of the 12th rib Lumbodorsal fascia exposed and incised Fingertip dissection or balloon dilation of the retroperitoneal space

Clinical Aspects of Pneumoperitoneum

Hemodynamic Considerations of Pneumoperitoneum Physiology Mechanical effects of increased intra-abdominal pressure Hemodynamic effects of CO2 Effects of positioning

Mechanical Effects of Increased Intra-abdominal Pressure (IAP) Insufflation Increased IAP leads to increased systemic vascular resistance (SVR) Direct compression of vasculature Most prominent in visceral circulation

Mechanical Effects of Increased Intra-abdominal Pressure (IAP) Magnitude of effect of IAP on SVR dependent on volume status Normovolemic: Cardiac Output (CO) falls modestly at 20 mmHg Hypervolemic: CO increases Hypovolemic: CO decreases markedly

Hemodynamic Effects of CO2 Direct effects of CO2 are primarily inhibitory on the CV system CO2 stimulates the sympathetic nervous system (cardio-stimulatory) Overall, moderate hypercapnia increases CO and BP and decreases vascular resistance These effects counteract those of increased IAP

Effects of Positional Change Head-down tilt modestly increases CO Head-up tilt slightly decreases CO Lateral position has minimal effect on CO, unless extreme flexion limits venous return

Integrated Cardiovascular Response IAP=15 mmHg Moderate Hypercapnia (PaCO2 45 mmHg) Combined CVP Increase SVR Decrease HR MAP CO Variable

Cardiovascular Complications Tension pneumoperitoneum Cardiac dysrhythmias Fluid overload Renal failure Venous thrombosis

Tension Pneumoperitoneum Cardiovascular collapse owing to overwhelming rise in vascular resistance from increased IAP CO and BP drop precipitously Usually not until IAP > 40 mmHg Potentiated by hypovolemia Treatment: Immediate desufflation

Preventing Tension Pneumoperitoneum Communication with anesthesiologist Functional insufflator with alarm Pressure limit 15 mmHg Awareness of secondary sources of insufflated gas (argon beam coagulator) Abdominal wall relaxation No leaning on abdomen

Cardiac Dysrhythmias Occurs in 17-50% Tachycardia and PVCs due to CO2 usually benign Fatal dysrhythmias can occur with very high PaCO2 Hypercapnia can potentiate parasympathetic actions, producing bradydysrhythmias A. Asystolic arrest has been reported with hypercapnia B. Atropine for premedication for laparoscopy

Fluid Overload Insensible loss of fluid during laparoscopy less than in open surgery Intra-operative oliguria normal From direct parenchymal compression Renal function almost uniformly returns to normal Fluid overload can occur if anesthesiologist reacts to drop in urine output with excessive IVF

Venous Thrombosis Lower extremity venous return reduced Femoral vein pressure parallels IAP Relative risk compared to open surgery unknown Treat with DVT prophylaxis although no data in laparoscopic patients

Pulmonary and Acid-Base Considerations Physiology Mechanical effects of pneumoperitoneum CO2 Metabolism and Absorption

Mechanical Effects of Pneumoperitoneum Elevation of diaphragm Lung capacity and compliance decrease Worsening of ventilation/perfusion mismatch Accentuated by head-down tilt position

CO2 Metabolism and Absorption During gas insufflation, total sum of gas movement is always directed outwards towards surrounding tissue Direction of movement determined by the partial pressure gradient Rate of movement determined by the tissue permeance, nature of vascularity of tissue, temperature, and surface area exposed CO2 has the highest tissue permeance and when instilled into the peritoneum, rapidly diffuses into the bloodstream Subcutaneous emphysema, elevated intra-abdominal pressure, extraperitoneal insufflation, and increased duration of insufflation increase the rate of CO2 absorption

Pulmonary, Acid-Base, and Insufflant-related Complications Hypercapnia Acidosis Extraperitoneal gas collections Venous gas embolism Intra-abdominal explosion

Extraperitoneal Gas Subcutaneous space Pre- or Retro-peritoneum Omentum Mediastinum Pericardium Pleural cavity

Venous Gas Embolism Direct instillation of gas into the venous system causing right heart outflow obstruction Clinical incidence 0.02%, but found by Echo in 0.59% Diagnosis Hypotension Arrhythmias Cyanosis Pulmonary edema and hypoxia Change in end-tidal CO2 tracing Mill-wheel murmur Right heart strain pattern TEE

Venous Gas Embolism Treatment Immediate desufflation 100% O2 inspired gas Steep head-down, right side up, keeping gasin right ventricle, out of the pulmonary circulation Aspiration of gas in right ventricle General resuscitation

Intra-abdominal Explosion Oxygen and nitrous oxide will support combustion Nitrous oxide explosive in the presence of hydrogen or methane 2 reported deaths due to intrabdominal explosion of insufflated nitrous oxide CO2 and noble gases safe

Complications in Laparoscopy Preoperative Intraoperative Postoperative

Preoperative Planning Patient selection Obesity, complex procedures Infections, coagulopathy Prior surgery Radiologic imaging CT scan. MRI, CTA, MRA Anesthesia concerns Nitrous, IVFs, positioning Ventilation and pneumoperitoneum

Laparoscopic Complications in the Obese Mendoza et al. Laparoscopic complications in markedly obese urologic patients (a multi-institutional review). Urology. 1996 11 centers with experienced laparoscopists Retrospective analysis of 125 patients with a BMI >30 Conversion rate 12% Complication rate: 22% intra-op, 26% post-op Complications: 2 trocar injuries to abdominal wall vessels, 1 bladder injury, 3 peripheral nerve injuries, 1 dysrhythmia, 1 DVT, 1 wound seroma, 1 nephrocutaneous fistula, 1 incisional hernia, 1 death

Intraoperative Complications Neuromuscular injuries 3% of cases Usually from positioning More likely in prolonged cases

Complications of Access and Trocar Placement Veress needle and Trocar placement Insufflation injuries Extraperitoneal insertion Vascular injuries Abdominal wall, retroperitoneal, and mesenteric vessels Visceral injuries Stomach, bowel, liver , spleen, bladder

Intraoperative Bleeding Arterial Venous Dissect and clip Compression Endoavitine, surgicell, stapler, fibrin glue Preformed loop, free needle suture, endostitch Open conversion

Endovascular GIA Stapler Malfunction Chan et al. J Urol. 164. 2000 10 of 565 Lap Nephrectomies (1.7%) Etiology Deployed over clip (5), caval entrapment (1), too much tissue (1), staples missing (1), ligation failure (2) Treatment Proximal stapler placement (3), clip (3), lap suturing (2), laparotomy (2)

Adjacent Organ Injuries Spleen Pancreas Duodenum Diaphragm Ptx caused by diaphragmatic injury

Laparoscopic Bowel Injury Bishoff, Kavoussi, Schroder. J Urol. 161. 1999 8 of 915 (0.8%) 2 perforations, 6 abrasions 6 identified intraoperatively, 5 repaired 4 cases undiagnosed (2 referrals) Symptoms: trocar site pain, distension, diarrhea, leukopenia, CV collapse 1.3/1000 in literature review 58% small bowel, 32% colon 50% cautery, 80% required open repair

Urinary Tract Injuries Bladder injuries Access related Foley for decompression Ureteral injuries Usually delayed presentation IVP, CT scan PCN and antegrade stent

Incisional Hernias 1-3% of cases Usually from 10-12mm port sites Endoscopic closure better In children, reports of omental herniation in 5mm ports

Exiting the Abdomen Exit with the same caution as entry Close port sites under endoscopic control Lower pneumoperitoneum and inspect surgical bed, renal hilum, adrenal bed

When using the linear stapling device, significant bleeding may result die to which of the following? Closing the stapling device over clips adjacent to the structure being divided Using the bowel stapling cartridge instead instead of the vascular load cartridge 1 and 2 Using the stapling device with the handle held upside down Using the stapling device with the end of the device reticulated at a 30 degree angle

If perforation in the diaphragm occurs during dissection of the lateral portion of the kidney when performing a radical nephrectomy, which of the following options should be attempted initially? Immediate thoracotomy and repair of diaphragmatic perforation Insertion of Heimlich valve in the thoracic cavity Immediate insertion of chest tube Repair of the diaphragmatic perforation using hand-assisted or laparoscopic suturing techniques Emergent laparotomy

Steps to avoid or manage tension pneumoperitoneum (sudden cardiovascular collapse owing to the increased intra-abdominal pressure of pneumoperitoneum include ALL BUT WHICH of the following? Keeping routine pneumoperitoneum pressure less than or equal to 20mmHg Adequate pre-operative hydration Use of slow flow on the insufflator (<3 liters per minute) Immediate desufflation if tension pneumoperitoneum is suspected Avoid leaning on the insufflated abdomen

Which of the following is true regarding laparoscopic complications in the morbidly obese? The complication rates are lower in the obese Open surgery is the better option in these cases The conversion rates are higher in the obese In experienced hands, the complication rates are higher in the obese In experienced hands, the complication rates are the same in the obese

During laparoscopic nephrectomy, dissection of the ureter: Is performed after dissection of the upper pole and the renal hilum Should be avoided since the ureter is fragile and may tear Is performed early in the procedure and the ureter divided soon after recognition Assists in the identification and dissection of the hilar blood vessels Is avoided in order to prevent bleeding from the gonadal vessels

Which of the following is NOT an appropriate management for venous gas embolism? Immediate desufflation Turning patient left side up and head down Hyperventilation with 100% oxygen Attempt at aspiration of gas in right ventricle General resuscitation maneuvers

You have applied and fired the stapler across the renal vein during a laparoscopic radical nephrectomy, but it misfires and you have venous bleeding on the caval side and the kidney remains attached. Most likely, you have: A stapler without staples You entrapped too much tissue You did not fire the vascular load, but the GI load The stapler was loaded incorrectly