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

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

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

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

5. 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

6. 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

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

8. 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

9. Establishing the Pneumoperitoneum
Hassan Cannula Technique
Consists of a 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)

10. Establishing the Pneumoperitoneum
Hassan Cannula Technique (cont.)

11. 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

12. 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.

13. 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

14. Clinical Aspects of Pneumoperitoneum

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

16. 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

17. 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

18. 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

19. 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

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

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

22. 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

23. 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

24. 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

25. 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

26. 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

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

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

29. 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

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

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

32. 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

33. 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

34. 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

35. Complications in Laparoscopy
Preoperative
Intraoperative
Postoperative

36. 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

37. 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

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

39. 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

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

41. Endovascular GIA Stapler Malfunction
Chan et al. J Urol
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)

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

43. Laparoscopic Bowel Injury
Bishoff, Kavoussi, Schroder. J Urol
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

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

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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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