2. Complications of laparoscopic surgery Fereshteh Daneshmand M.D.

3. Intraoperative or perioperative complications from laparoscopic gynecologic surgery are uncommon, with overall rate 0/1% to 10%. Over the half of these complications are related to the entry technique, and 20 to 25% of intraoperative complications were not detected intraoperatively

4. Risk factors Extremes of body weight Any patient characteristics that could potentially increase the risk associated with anesthesia, such as cardiopulmonary disease. Other factors that could potentially distort pelvic anatomy such as endometriosis, PID, pelvic adhesions.

5. Complications rate were found to be higher for operative or major laparoscopic procedures than for diagnostic or minor laparoscopic procedures, 0/1% to 18% versus 0/1% to 7% As expected, complication rates are also related to the surgeon’s experience, with one study demonstrating a three-fold to five-fold increase in inadequately trained surgeons compared with surgeons with more training. Finally faulty instrumentation like dull trocars

6. Complications Anesthetic considerations Neurologic Injury Vascular Injury Bowel Injury Urinary Tract Injury Port-Site Hernia

7. Anesthetic considerations The CO2 pneumoperitoneum and Trendelenburg position induce numerous physiologic responses that are generally well tolerated by young healthy patients but which may be hazardous to those with compromised cardiopulmonary function. All patients should be monitored. Managing fluid balance may be difficult.

8. The irrigating fluid should be warmed to prevent hypothermia. Hypothermia can predispose hypokalemia and respiratory depression. Intra-abdominal pressures above 15 mm Hg mar compress the Vena cava. Mechanical stretching of the peritoneum, as well as veress needle or trocar insertion may cause Vagal stimulation leading to bradycardia.

9. Two complications that impact anesthesia care are subcutaneous emphysema and CO2 embolism. Sub coetaneous emphysema results from preperitoneal insufflations. Increased CO2 absorption from the large surface area may result in significant hypercapnea and respiratory acidosis.

10. Neurologic Injury Neurologic complications during laparoscopic, surgery are uncommon, and primarily consist of peripheral nerve compression or stretch from improper positioning during the case. Risk factors are duration of surgery,BMI less than 20Kg/m and pre-existing systemic conditions such as diabetes.

12. Most neurologic injuries from compression or stretch mechanisms can be conservatively managed and will usually resolve with supportive care.

13. Vascular Injury The most frequent vascular injury is laceration of the superficial or inferior epigastric vessels during insertion of the lateral ancillary trocars.

15. Injury to major vessels-aorta,vena cava and iliac is approximately 0.8% based on large series, the mortality rate has been reported as high as 17% and need immediate laparotomy with a midline incision, blood transfusion and consult a vascular surgeon.

16. Bowel Injury Bowel injuries are uncommon during laparoscopy, occurring at estimated rates of 0% to 0.5% with approximately one third to one half of these injuries incurring at the time of trocar insertion. Injuries are more frequent in cases where the bowel is distended or there is a risk of bowel being adherent to the anterior abdominal wall such as after prior laparotomy or PID

17. Bowel injuries are one of the most common causes of postoperative mortality from gynecology laparoscopy because approximately two thirds of these injuries are unrecognized intraoperatively and there is often also a delay in postoperative diagnosis. Electrosurgical injuries will often not become evident for several days.

18. Signs and Symptoms Low-grade temperature elevations Abdominal distention Increasing abdominal pain Decreased or normal WBC May have normal bowel sounds with diarrhea

19. Urinary Tract Injury The incidence of damage to the urinary tract is estimated to `be 0.02% to 3%, with bladder injuries being more common than ureteral injuries. Approximately a third of these injuries are not identified intraoperarively. Bladder damage was more likely to be found intraoperatively, whereas ureteral injuries were more likely to be missed.

20. Signs and Symptoms Hematuria, oliguria, elevated BUN, Creatinine, and WBC, elevated temperatures, Abdominal pain distention with nausea and vomiting Imaging modalities such as CT Scan IVP sonography can be helpful. If bladder damage is suspected intraoperatively, retrograde filling of the bladder with indigo carmine and cystoscopy can performed.

21. Uretral Injury Ureteral injury are rare in minor laparoscopic cases, but cn be as high as 8% in cases of laparoscopic management of malignancy or of benign disease such as endometriosis where the pelvic anatomy is distorted and there is extensive fibrosis within the rectoperitoneal space. The most definitive method to avoid uretral injury is to directly observe and identify the entire course of the ureter within the operative field.

22. If the uretral injuries are not identified intraoperatively, these patients may have flank pain postoperatively and may present in a similar manner to patients with bladder injuries.

23. Portal-Site Hernia Midline ports may be placed at the umbilicus and suprapubically. Port-site hernias at these locations are uncommon. Omental herniation may occur at the umbilical site. It is recommended to close the fascia in midline ports that are greater than 8 cm

24. Conclusions Fortunately, complications of laparoscopic gynecologic surgery are uncommon, with most of the complications occurring at the time of the initial trocar insertion. The complication rates are directly related to the general medical condition of the patient, the complexity of the case, and the extent of anatomic distortion. Most complications are avoidable and / or can be recognized interaoperatively, allowing for immediate correction to avert further potential sever consequences.

25. Emphasis must be placed on prevention and intraoperative detection of complications. The key to preventing most neurologic injuries is proper patient positioning. The stomach should be decompressed Foley catheter placed in bladder prior to trocar insertion. Attention should be paid to anatomical landmarks to reduce vascular and neurological injuries when inserting trocar.

26. Placement of the initial trocar in the left upper quadrant should be considered when there is a risk of bowel adhesions to the anterior abdominal wall. Most laparoscopic complications may be treated immediately by laparoscopy including bladder, ureter, bowel, and minor vascular injuries.

27. One of the main advantages of laparoscopic surgery is a rapid postoperative recovery. There should be a high index of suspicion for an unrecognized complication if postoperative pain is getting worse or the patient has any problems with bladder or bowel function.