1. Gustavo Plasencia MD FACS, FASCRS Clinical Professor of Surgery Florida International University College of Medicine Complications of Laparoscopic Colectomy

2. Best treatment for complications Prevent them Learning Complications of laparoscopic colorectal surgery

3. Variables associated with complications Age Age Obesity Obesity Previous surgeries Previous surgeries Type of surgery Type of surgery LAPAROSCOPIC COLECTOMY Experience (learning curve) Experience (learning curve)

4. Learning Curve Surgeons with > 40 cases have lower rates of intraoperative and postoperative complications than surgeons with < 40 cases. 114 surgeons, 1194 patients Intraoperative – 3.7% vs. 6.3%, p<0.1 Postoperative - 10% vs. 19%, p<0.001 Relationship between volume and results Bennett Ch, et al. Arch Surg 1997. LAPAROSCOPIC COLECTOMY

5. Complications of laparoscopic colorectal surgery Analysis and comparison of early vs. later experience 195 laparoscopic colorectal procedures in a 5 year period divides in "early" and "late" Conversion for iatrogenic injuries: 7.3% fell to 1.4% over time Conversion rate: –13.8% laparoscopic related complication in early group –2.8% in the late group Larach S. et al. Dis Colon Rectum 1997 (40):592-6

6. Complications of Laparoscopic Colorectal Surgery Complications during laparoscopic Colorectal Surgery: –Disease related complications –Surgical procedure related complications Most of the complications diminish as the experience of the surgeon increases

7. Complications of Access Techniques Visceral injury Incidence –Small bowel most commonly injured –Have been reported for all techniques Management –Laparoscopic management of most injuries –Abortion or modification of procedure if there is prosthetic material involved Surg Endosc. 2004; 18: 1778-1781.

8. Complications of Access Techniques Vascular injury Incidence –Particularly common with mid-line access techniques –Distal aorta and right common iliac particularly vulnerable –Have been reported for all techniques Management –Can attempt laparoscopic repair –Major injuries may need laparotomy Surg Endosc. 2004; 18: 1778-1781.

9. Duodenal injuries Although uncommon duodenal injuries still occur specially in lap choles Most are due to thermal in origin with cautery. Prompt recognition in the OR is crucial to decrease the morbidity and mortality

10. Small injury Small injury recognized in OR –Primary repair with omental patch –+/- external drainage with T-tube Running single-layer suture of 3-0 monofilament

11. Larger injuries or late recognition Extensive injuries of the first portion of the duodenum (proximal to the duct of Santorini) can be repaired by débridement and end-to- end anastomosis because of the mobility and rich blood supply of the distal gastric atrium and pylorus Large lacerations found at laparotomy If patient is septic pyloric exclusion, with T-tube drainage Duodeno-jejunostomy is an alternative

12. Major Injuries Defects in the 2 nd portion of the duodenum should be patched with a vascularized jejunal graft. Suture repair using an end-to-end anastomosis in the second portion often results in an unacceptably narrow lumen.

13. Pyloric exclusion

14. Small Bowel Injuries

15. It is an uncommon but serious complication (usually under reported) Third most common cause of death during laparoscopy Incidence  bowel injury 0.13%  bowel perforation 0.22% Bowel Injury Van der Voort M et al., Br J Surg 2004;91:1253-1258 Philips PA et al., J Am Coll Surg 200119:525-536

16. Location of Laparoscopy/induced Bowel Injuries 7 (1.7%)Unknown 157 (38.6%)Large intestine 227 (55.8%)Small intestine 16 (3.9%)Stomach No. of injuries (407) Location 29,521 operations 0.22 % Bowel Injuries Van der Voort M et al., Br J Surg 2004;91:1253-1258

17. Intestinal injuries It is more frequent during laparoscopic approach rather than open surgery –Loss of tactile sensation –Instrument (angulations, grabbing the bowel, etc) –Thermal injuries It may happen any moment during the procedure Bishoff JT. Et al.. Laparoscopic bowel injury: incidence and clinical presentation J Urol 1999;161(3): 887-890

18. Diathermy injury Most go unnoticed Off camera injury Electrical arch discharge injury Usually present 3 to 7 day post-op with fever, distention, and abdominal pain Harmonic/Ultrasicion scalpel may help reduce incidence by minimizing collateral damage

19. Intestinal injuries - Prevention Avoid use any source of energy close to the bowel The hot part of any source of energy should be maintain in the vision field Vancaillie TG. Surg Endosc. 1998; 12(8):1009-1012.

20. No more than 3 attempts at insertion Alternative sites may be used, such as Palmer's point It is usually free of adhesions With this technique severe adhesions with a potential risk of bowel injury were detected in  7% of patients with a previous horizontal  31% with a midline laparotomy J. Neudecker et al., Surg Endosc 2002;16 (12):1121-1143 Bowel Injury - Prevention

21. Management should be individualized according to: –Time of diagnosis –Location and extension of injury –Severity of complication –Surgeon´s skills Van der Voort M et al., British J Of Surgery 2004; 91:1253-1258 Bowel Injury - Management

22. Management of Laparoscopy- Induced Bowel Injury Injuries (n=359) % Laparoscopy 27 (7.5) Laparotomy 282 (78.6) Conservative 25 (7.0) Serosal patch 1 (0.3) Unspecified* 24 (6.7) Van der Voort M et al., British J Of Surgery 2004; 91:1253-1258

23. Mortality Meta-analysis study; 450 patients whose laparoscopy was complicated by bowel injury –Overall mortality: 3.6% Delayed diagnosis of bowel injury is a mayor cause of sepsis and mortality The combined Dutch and ISGE surveys reported 14 cases (18%) of delayed diagnosis with mortality rate of 21% Van der Voort M et al., British J Of Surgery 2004; 91:1253-1258 Jansen et al. Br J Obstet Gynaecol 1997; 104: 595-600

24. Small Bowel injuries

25. Ureter Injuries

26. Complications: Laparoscopic Colon Surgery Ureters Must always identify ureters Highest risk dividing vascular pedicle Risk increased when the dissection plane is extended too far laterally Medial mesenteric exploration may help identify ureter

27. Ureters Injuries Division of the ureter, most common Diathermic injury Devascularization

28. Identification Ureter ? In conventional surgery, imperative to identify left ureter During laparoscopic surgery, if you operate from medial to lateral the ureter will remain always behind the plane of retroperitoneum

29. ID Ureters ID lateral to medial ID medial to lateral Anatomic variations Use of stents Lightened stents

30. ID Ureters

33. ID Ureters Lightened Stents

34. Double ureter

35. Ureter Ureter 1

36. Bleeding Related Injuries

37. In the early experience uncontrolled bleeding was the first cause for conversion With the new energy source devices this complication is less frequent The devascularization is more efficient done in the base of the mesentery to avoid branches of the main trunks

38. Bleeding Related Injuries Most common bleeding source is the mesenteric vessels Usually associated with blunt injury during dissection or inappropriate firing of the vascular stapler Obesity

39. -Second most common cause of death during laparoscopy -Accounts for 30-50% of surgical trauma during laparoscopy Chapron C, et al., Gynecol Obstet Biol Reprod 1992;21(2):207-13. Dixon M, et al., Surg Endosc 1999;13(12):1230-1233 Vascular Injuries

40. Major Vascular Injury Major retroperitoneal vessels - Aorta - IVC - Common iliac arteries Rare but life threatening injury - Prevalence of MVI of 0.05% - Mortality ranging from 9% to 17% Roviaro GC et al., Surg Endosc 2002 Aug;16(8):1192-6.

41. 1.Inexperienced or unskilled surgeon (Forceful thrust) 2.Failure to sharpen trocar 3.Failure to elevate or stabilize the abdominal wall 4.Lateral deviation of needle or trocar 5.Inadequate pneumoperitoneum 6.Failure to note anatomic landmarks 7.Inadequate skin incision Major Vascular Injury Risk Factors

42. Major vascular Injury Management -Treatment is individualized depending on the specific vessel involved -If the diagnosis is delayed, mortality may reach 33% Nordestgaard AG et al., Am J Surg 1995; 169:543-5

43. Venous ligation should be avoided It is better to perform a venorrhaphy even at the risk of subsequent thrombosis, than to ligate Ligation of the external or common iliac vein compromise the vascular function of the pelvis Baadsgaard SE et al. Acta Obstet Gynecol Scand. 1989:68(3):283-5 Major Vascular Injury Management

44. Video Iliac Artery Injury

45. Bleeding - Prevention Complete dissection and visualization of vascular pedicles before clipping and cutting Adequate use of sources of energy (time, release tension) Adequate surgical technique

46. Vascular Control If coagulation devices fails…

47. If a major vessel is bleeding!!

48. Vascular Control Do not panic Maintain pressure Tell the anesthesiologist Suck and clean

49. Conclusions Before undertaking a laparoscopic colectomy, the surgeon and its team should be well coached in laparoscopic surgery. Should be selective with the first patients The majority of the complications associated with the laparoscopic surgery of colon are preventable Adequate technical of surgery, management of the intestine, knowledge of the anatomy, and attention to the details will reduce enormously the possibility of problems

50. Conclusions The basis for avoiding the intraoperative accident during laparoscopic colorectal surgery is the security of good visual field and the thorough hemostasis during the operation

51. MUCHAS GRACIAS