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Complications of Laparoscopic cholecysectomy

Complications of Laparoscopic cholecysectomy. By 醫六 黃昌逢、 張凱閔. Brief history. This is a 45 y/o woman suffered from acute cholecystitis and laparoscopic cholecystectomy was planned. The known preop data included: ASA class II BW:45kg Hb:12.5.

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Complications of Laparoscopic cholecysectomy

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  1. Complications of Laparoscopic cholecysectomy By 醫六 黃昌逢、 張凱閔

  2. Brief history • This is a 45 y/o woman suffered from acute cholecystitis and laparoscopic cholecystectomy was planned. • The known preop data included: ASA class II BW:45kg Hb:12.5

  3. Brief history • Drops both in SpO2 and ETCO2 were noted when creation of pneumoperitoneum was attempted. • The management include: resumption of trandelenburg position and pumping air out of abdomen • Operation was resumed and the course was smooth hereafter.

  4. Treatment of acute cholecystitis • Medical: NPO, NG suction, IV fluid, analgesia, and antibiotics. • Surgical: open (OC), laparoscopic (LC) and minimal invasive (MC) cholecystectomy

  5. Comparison between LC, and OC • 1. No evidence of symptomatic outcome between LC, and OC. • 2. Weak evidence that mortality and complication rates were lower after LC than OC. • 3.Weak evidence that biliary tract complication were more common in LC. The Lancet 349(9052) p 631-635 1 March 1997

  6. Comparison between LC, and OC • 4. Strong evidence that LC causes less deterioration in pulmonary function than OC. • 5. Strong evidence that postoperative pain after LC is less than after OC. The Lancet 349(9052) p 631-635 1 March 1997

  7. Results of Laparoscopic Cholecystectomy NEJM 330(6):409-19, 1994 Feb 10.

  8. Indication for open cholecystectomy • 1. Poor cardiopulmonary function • 2. Previous abdominal surgery • 3. Severe adhesion • 4. Massive hemorrhage or structure unclear • 5. Malignancy

  9. Methods of creating pneumoperitoneum • 1. USE OF THE VERESS NEEDLE AND PRIMARY TROCAR • 2. DIRECT TROCAR INSERTION • 3. OPEN LAPAROSCOPY • 4. TRANSFUNDAL/TRANSFORNICEAL • 5. GASLESS LAPAROSCOPY Obstetrical & Gynecological Survey. 53(3):167-74, 1998 Mar.

  10. 1. USE OF THE VERESS NEEDLE AND TROCAR • Procedure: Veress needle insertion, gas insufflation and trocar insertion • Test for correct placement of the needle. • Presence of flatus, abdominal wall crepitus, or blood returning via Veress needle indicate the incorrect placement. • Blind insertion: source of complications

  11. 2. DIRECT TROCAR INSERTION • Is pneumoperitoneum before trocar insertion absolutely necessary ? • Distended abdomen may contribute to bowel and major vascular injury. • Procedure: infraumbilical skin incision and trocar insertion and creation of pneumoperitoneum after correct placement checked by laparoscope

  12. 3. OPEN LAPAROSCOPY • Procedure: skin incision and dissection to expose peritoneum, trocar placement and wound closure • The technique was supposed to guarantee pneumoperitoneum and to avoid the dangers of blind insertion esp. in high risk patients.

  13. 4. TRANSFUNDAL/ TRANSFORNICEAL • Procedure: transfundal or transforniceal approach of abdominal insufflation and blind insertion of trocar • It is a useful esp. in patients who are obese or not suitable for abdominal approach. • Potential complication: persistent bleeding from uterus, perforation of the bladder or the broad ligament

  14. 5. GASLESS LAPAROSCOPY • Procedure: cutdown and insertion of the lifting device either within the peritoneal cavity or in the preperitoneal space and creating the space • Benefits: 1. preperitoneal insertion to avoid interference with adhesions 2.the more planar shape of abdominal wall bringing the operative field more close to surgeon 3. no pneumoperitoneum

  15. Complication of laparoscopic cholecysectomy 1、trocar insertion 2、trendelenburg position and reverse trendelenburg position 3、pneumoperitoneum creation ]

  16. 1.Trocar insertion • A .Bleeding abdominal wall vessel intra-abdominal vessel Aorta iliac arteries inferior venal cava

  17. B.hepatic 、splenic tears • C.gastrointestinal trauma perforation avulsion of adhesion omental disruption • D. herniation

  18. 2、Trendelenburg position • Trendelenburg position during pneumoperitoneum: 10 to 20 degree head down position to increase cardiac output • Reverse Trendelenburg position during dissection of gallbladder: prevent bowel injury and provide optimal exposure

  19. Physiological effect of Trendelenburg position Cardiovascular change: • 1、Healthy pt:↑cardiac index；CVP、 、PCWP、HR、SVR remain unchanged • 2、normotensive but CAD pt: ↑ CVP、 PCWP；↓cardiac index；possibility of cerebral congestion

  20. Physiological effect of Trendelenburg position Respiratory change • 1. Associated with pt age,preop lung function,head-down degree degree…. • 2. Reduce lung vital capacity due to abdominal visera on diaphragm • 3. Increase work of breathing • 4. associated disease:COPD,asthma • 5.compensatory increase in respiratory rate in health pt

  21. Physiological effect of Trendelenburg position Endotracheal tube site change • The endotracheal tube,firmly secured at its proximal end,dose not always move cephalad with the trachea as diaphragm presses upwards and displaces the lung and carina.

  22. 3.Pneumoperitoneum creation • 1.technical difficulties • 2.cardiovascular effects • 3.respiratory function

  23. Technical difficulties • 1.method of creating pneumoperitoneum • 2.subcutaneous insufflation of CO2 -extensive surgical emphysema

  24. Cardiovascular effects of pneumoperitoneum • 1.low intra-abdominal pressure(less than25 mmHg):increase cardiac output due to hypercarbia- induced sympathetic activity • 2.high intra-abdominal pressure(greater than 40 mmHg):decrease cardiac output due to reduce venous return or IVC compression • 3.hemorrhage-due to trocar injury • 4.dysrhythmia-CO2 related • 5.myocadial depression-due to acidosis

  25. Respiratory effects of pneumoperitoneum Intraoperative hypoxemia • 1. Preexisting conditions: A.cardiopulmonary disease: asthma or COPD acute exacerbation acute myocardiac infarction B.morbid obesity

  26. 2.Hypovetilation • A.patient posture • B.pneumoperitoneum • C.ET tube obstruction • D.inadequate ventilation

  27. 3.intrapulmonary shunting • A.pneumothroax • B.bowel distension-N2O related • C.pulmonary aspiration of gastric content • D.CO2 venous embolism

  28. 4.reduce cardiac output • A.massive hemorrhage • B.IVC compression • C.dysrhythmia • D.myocadial depression

  29. CO2 venous embolism 1.Incidence Carbon dioxide embolism is a potentially lethal complication of laparoscopic procedures, although its incidence is low (15 of 113,253 gynecologic laparoscopies). From ANESTHESIOLOGY 1999:Probable Carbon Dioxide Embolism during Endoscopically Assisted Varicose Vein Stripping by Mladen I. Vidovich, M.D.; Edwin W. Lojeski, D.O.

  30. CO2 venous embolism 2.Pathophysiology: A. Rapid entry or large volumes of CO2 put a strain on the right ventricle because of the migration of the emboli to the pulmonary circulation. B. The pulmonary arterial pressure increases, and the increased resistance to right ventricular outflow causes diminished pulmonary venous return. C. Because of the diminished pulmonary venous return, there is decreased left ventricular preload, resulting in diminished cardiac output and, ultimately, systemic cardiovascular collapse.

  31. CO2 venous embolism 2.Pathophysiology: D.Tachyarrhythmias often develop, but bradycardias are possible as well. When large quantities of gas (over 50 ml) are injected abruptly, acute cor pulmonale, asystole, or both are likely to occur. E.The alteration in the resistance of the lung vessels and the mismatch between ventilation and perfusion cause intrapulmonary right-to-left shunting and increased alveolar dead space, leading to arterial hypoxia and hypercapnia. From NEJM Volume 17 Feb 2000Primary Care: Gas Embolism by Muth, Claus M.; Shank, Erik S

  32. CO2 venous embolism 3.clinic findings • A.decrease in end-tidal carbon dioxide and O2saturation • B. Cardiovascular collapse, hypotension, ,dysrhythmias ,pulmonary edema and right heart failure • C. mill-wheel heart murmur :a splashing auscultatory sound due to the presence of gas in the cardiac chambers

  33. CO2 venous embolism 4.Diagnosis • Transesophageal echocardiography is the most sensitive method of detection of carbon dioxide embolism, whereas changes in end-tidal carbon dioxide, pulmonary artery pressure, and precordial Doppler are less sensitive

  34. CO2 venous embolism 5.Treatment • A.change to horizontal position • B.desufflation and hyperventilation • C.insertion of a CVP to attempt aspiration • D.cardiopulmonary resuscitation

  35. CO2 venous embolism 1.The median lethal dose of carbon dioxide embolism in dogs is 25 ml/kg. 2. In pigs, the volume of carbon dioxide required to change end-tidal carbon dioxide is approximately 0.66 ml/kg. 3.Because carbon dioxide is highly soluble in blood, it is rapidly absorbed from the bloodstream, and if embolization does occur, it is less likely to be fatal than if air or oxygen is used for insufflation. From ANESTHESIOLOGY 1999:Probable Carbon Dioxide Embolism during Endoscopically Assisted Varicose Vein Stripping by Mladen I. Vidovich, M.D.; Edwin W. Lojeski, D.O.

  36. Thank you for your attention! By醫六 張凱閔,黃昌逢

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