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Complications of Laparoscopic Colectomy

Gustavo Plasencia MD FACS, FASCRS Clinical Professor of Surgery Florida International University College of Medicine. Complications of Laparoscopic Colectomy. Complications of laparoscopic colorectal surgery. Best treatment for complications. Prevent them. Learning. LAPAROSCOPIC COLECTOMY.

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Complications of Laparoscopic Colectomy

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

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

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

  4. LAPAROSCOPICCOLECTOMY Learning Curve Relationship between volume and results 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 Bennett Ch, et al. Arch Surg 1997.

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

  11. 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 Larger injuries or late recognition

  12. Defects in the 2nd portion of the duodenum should be patched with a vascularized jejunal graft. Major Injuries • 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. Bowel Injury • 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% Philips PA et al.,J Am Coll Surg 200119:525-536 Van der Voort M et al.,Br J Surg2004;91:1253-1258

  16. Location No. of injuries (407) Stomach 16 (3.9%) Small intestine 227 (55.8%) Large intestine 157 (38.6%) Unknown 7 (1.7%) Location of Laparoscopy/induced Bowel Injuries 29,521 operations 0.22 % Bowel Injuries Van der Voort M et al.,Br J Surg2004;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. Bowel Injury -Prevention • 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

  21. Bowel Injury - Management • 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

  22. Management of Laparoscopy-Induced Bowel Injury 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 SurgeryUreters • 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

  31. ID Ureters

  32. ID Ureters Lightened Stents

  33. Double ureter

  34. UreterUreter 1

  35. Bleeding Related Injuries

  36. Bleeding Related Injuries • 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

  37. 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

  38. Vascular Injuries • 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

  39. 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.

  40. Major Vascular InjuryRisk Factors • Inexperienced or unskilled surgeon (Forceful thrust) • Failure to sharpen trocar • Failure to elevate or stabilize the abdominal wall • Lateral deviation of needle or trocar • Inadequate pneumoperitoneum • Failure to note anatomic landmarks • Inadequate skin incision

  41. Major vascular InjuryManagement • 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

  42. Major Vascular InjuryManagement • 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

  43. Video Iliac Artery Injury

  44. 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

  45. Vascular Control • If coagulation devices fails…

  46. If a major vessel is bleeding!!

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

  48. 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

  49. 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

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