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How to ID and treat intraoperative complications Part 2
Stapler misfire, ischemic segment, bladder invasion, small bowel invasion, intraoperative bleeding Morris E. Franklin Jr MD. F.A.C.S. Director Texas Endosurgery Institute Karla Russek, MD. Research Fellow MISS meeting 2010
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Industry relationships
W.L. Gore & Associates Grant/research support, consultant and speaker bureau Covidien Striker Consultant, advisory board Ethicon Consultant and speaker bureau Atrium Consultant Aesculap KCI The Authors do not have financial interest with the above mentioned companies
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The pessimist sees difficulty in every opportunity
The pessimist sees difficulty in every opportunity. The optimist sees the opportunity in every difficulty. Winston Churchill
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Laparoscopic Colectomy
Conversion rate of 23.5% Unclear anatomy Actually….. Stapler misfire Are all these still Bleeding reasons for Cystostomy conversion???? Enterostomy Adhesions Adjacent organ invasion Indications for Conversion to Laparotomy S Pandya, MD; JJ. Murray, MD; JA. Coller, MD; LC. Rusin, MD Arch Surg. 1999;134:
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Adjacent Organ invasion
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Peritoneum (parietal and visceral)
Possible invasion to: * Bladder * Small intestine Peritoneum (parietal and visceral) Uterus, ovaries Stomach Omentum Pancreas Abdominal wall
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Statistics Until 50 years ago, colorectal carcinoma infiltrating surrounding tissue was considered nonresectable Most of the time the diagnosis is made in the OR
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Tumor subsite location and adjacent organ invasion
Multivisceral resection for locally advanced primary colon and rectal cancer. Thomas Lehnert, Mascha Methner, Andreas Pollok. Annals of Surgery, 2002
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Transection of tumor and spreading of tumor cells must be avoided whenever possible
The removal of all carcinoma-bearing tissue, including the regional lymph nodes, is ideal Multivisceral resection for colon carcinoma. Roland Croner, Susanne Merkel, Thomas Papadopoulos, et al. Dis Col & Rectum, Aug 2009
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Bladder invasion
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Abdominal wall invasion
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Abdominal wall invasion
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Intraoperative bleeding
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Intraoperative bleeding
Vascular injury Tamponade with pressure Irrigate Inform anesthesia team
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Intraoperative bleeding
Slow to open if controllable with pressure Venous injury may bleed more while converting to open if there is no intraabdominal pressure Always think of gas embolism
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Intraoperative bleeding
Keep calm Make sure the anesthesiologist is aware of the problem Ask for help
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Some tips to prevent it:
Know the anatomy other than Netter!!! If possible, dissect the artery from the vein
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Vascular control
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Stapler Misfire
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Colonoscopy and anastomosis leak test
Intestinal clamps Liberal use of colonoscope
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Colonoscopy and anastomosis leak test
Anastomosis Air leak test ID Bleeding Integrity
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The Use of Bioabsorbable Staple Line Reinforcement for Circular Stapler (BSG “Seamguard”) In Colorectal Surgery. Initial Experience. “We consider these first 5 cases using bioabsorbable Seamguard for circular stapler reinforcement an initial experience perhaps helping to alleviate the most devastating complication of gastrointestinal surgery. Longer follow up and a larger number of patients are obviously needed; however the initial data is very promising and has encouraged us to continue using this device on further patients “ Franklin Jr, M.E. MD, FACS; Portillo G. MD; Surg Laparosc Endosc Percutan Tech;2006;16:
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Ischemic segment
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Loose anastomosis
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“You can not depend on your eyes when your imagination is out of focus”
Morris E. Franklin Jr.
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