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 Univ Consultant Urology, King Faisal Specialist Hospital, Jeddah

Major Complications of Transperitoneal Abdominal Laparoscopic Surgery Urology 2004; J Urol Abdominal Total Procedures 13.2%Overall complications 5.7% 7.5% Intraoperative/ postoperative 0.2%Deaths 2.8%Vascular injury 1.1%Bowel injury 1.1%Adjacent organ injury 1.7%Conversion rate

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 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 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/m 2 Obese = 30 to 34.9kg/m 2 30 to 34.9 kg/m 2 Morbid obesity= > 35 kg/m 2 > 35 kg/m 2

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, 2005

Sites for verse needle Upper 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 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, 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, 2005

Ralph V. Clayman, J of urol. Pg 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 40 mm Hg20 mm Hg10 mm Hg5 mm HgEffects Cardiovascular ↓↑↑↑Heart rate ↑↑↑↑Mean arterial pressure ↑↑↑↑Systemic vascular resistance ↓↓↑ →/↓Venous return ↓→/↓→/↑→/↓Cardiac output Renal ↓↓ ↓→Glomerular filtration rate ↓↓ ↓→Urine output Respiratory ↑→/↑ →End-tidal CO 2 ↑↑↑→PCO 2 ↓↓→/↓→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

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 Clayman. J of Urol, Dec 2005

WOUND COMPLICATIONS AFTER HALS MONTGOMERY, et al. J of Uro, Dec 2005

WOUND COMPLICATIONS AFTER HALS MONTGOMERY, et al. J of Uro, Dec 2005