Laparoscopy complications veress

Complications of induction Complications of induction of pneumoperitoneum by of pneumoperitoneum by

“veress needle” “veress needle”

Dr . Sumeet ShahMBBS (MAMC), MS, DNB, MNAMS, FIAGES,

Fellowship (MAS)

Laparoscopic & Bariatric Surgeon

Max Healthcare, New Delhi

[email protected]

Extraperitoneal insuffalation of gasExtraperitoneal insuffalation of gas Injury to gastro intestinal tractInjury to gastro intestinal tractBladder injuryBladder injuryBlood vessel injuryBlood vessel injuryPuncture of liver & spleenPuncture of liver & spleenGas embolismGas embolism

Complications of Closed (Veress) Complications of Closed (Veress) AccessAccess

1. Extra-peritoneal gas 1. Extra-peritoneal gas insufflation insufflation

Failure to introduce the Failure to introduce the Veress' needleVeress' needle into the into the peritoneal cavity may peritoneal cavity may produce produce extra-peritoneal extra-peritoneal emphysemaemphysema. .

This occurs in about This occurs in about 2%2% of of cases. cases.

The The diagnosis diagnosis is made by is made by palpation of palpation of crepituscrepitus caused by caused by bubbles of Cbubbles of CÓÓ2 under the skin.. 2 under the skin..

If this is recognized earlyIf this is recognized early, the , the gas may be allowed to escape gas may be allowed to escape and the needle re-introduced and the needle re-introduced through the same or another through the same or another site. site.

1. Extra-peritoneal gas 1. Extra-peritoneal gas insufflation insufflation

If the complication is If the complication is not recognized not recognized during the introduction of gasduring the introduction of gas, the typical , the typical appearance of extra-peritoneal gas may be appearance of extra-peritoneal gas may be recognized when an attempt is made to recognized when an attempt is made to introduce the telescope. introduce the telescope.

It is always essential to It is always essential to view through the view through the telescope during its insertiontelescope during its insertion through its through its cannula. cannula.

11 . .Extra-peritoneal gas Extra-peritoneal gas insufflationinsufflation

The typical The typical spider-webspider-web appearance caused by pre-appearance caused by pre-

peritoneal insufflation will be seen peritoneal insufflation will be seen when the telescope reaches the end when the telescope reaches the end

of the cannula and of the cannula and further further stripping of the peritoneum by the stripping of the peritoneum by the

tip of the telescope tip of the telescope avoidedavoided..


The The laparoscope should be withdrawnlaparoscope should be withdrawn and attempts made to express the gas. and attempts made to express the gas.

The The needle may then be re-introducedneedle may then be re-introduced through the same or another site. through the same or another site.

Alternatively the trocar and cannula Alternatively the trocar and cannula may be introduced by may be introduced by 'open laparoscopy'open laparoscopy'. '.


The The aspiration test and the aspiration test and the high insufflation pressurehigh insufflation pressure

will make it obvious that will make it obvious that the needle is sited incorrectly the needle is sited incorrectly

in which case it should be in which case it should be withdrawn and re-sitedwithdrawn and re-sited..


2. Injury to gastro-intestinal 2. Injury to gastro-intestinal tracttract

Certain conditions may predispose Certain conditions may predispose to injury by the Veress' needle. to injury by the Veress' needle.

These include :These include :1.1. Distension of the gastro-intestinal Distension of the gastro-intestinal

tract or tract or 2.2. Adhesions of bowel to the Adhesions of bowel to the

abdominal wall. abdominal wall.

Penetration of the stomachPenetration of the stomach may occur when an upper may occur when an upper abdominal site of insertion abdominal site of insertion is chosen or the stomach is is chosen or the stomach is distended during induction distended during induction

of anesthesia.of anesthesia.


Gastric distensionGastric distension may also occur if may also occur if anesthesia is maintained with a mask anesthesia is maintained with a mask and should be suspected if there is and should be suspected if there is upper abdominal distension or upper abdominal distension or increased tympanism. increased tympanism.

In this case the In this case the stomach should be stomach should be aspirated with a naso -gastric tubeaspirated with a naso -gastric tube..


The diagnosis of The diagnosis of gastric gastric perforation by the Veress' perforation by the Veress' needleneedle may be made when may be made when the patient belches gas. the patient belches gas.

The laparoscope should be The laparoscope should be introduced and the stomach introduced and the stomach inspected carefully. inspected carefully.


Provided the Provided the stomach wall has not stomach wall has not been tornbeen torn, no surgical treatment is , no surgical treatment is necessary but a broad spectrum necessary but a broad spectrum antibiotic should be given. antibiotic should be given.

If the stomach has been torn, If the stomach has been torn, surgical repairsurgical repair either by either by laparotomy or laparoscopy is laparotomy or laparoscopy is mandatory.mandatory.


AspirationAspiration following following initial insertion of the initial insertion of the needle should permit needle should permit early recognition of early recognition of

perforation of the bowel perforation of the bowel but it is not fool-proof. but it is not fool-proof.


Bowel penetrationBowel penetration should be should be suspected if there is suspected if there is

1.1.Asymmetric abdominal Asymmetric abdominal distension, distension,

2.2.Belching, Belching,

3.3.Passing of flatus or a fecal Passing of flatus or a fecal odour.odour.


The induction of The induction of pneumoperitoneum should be pneumoperitoneum should be stopped and the needle re-stopped and the needle re-sited to introduce the sited to introduce the pneumoperitoneum correctly. pneumoperitoneum correctly.

The gastro-intestinal tract The gastro-intestinal tract should be examined carefully should be examined carefully for perforation. for perforation.


It is important that It is important that both both sides of the bowel be sides of the bowel be examinedexamined as the exit as the exit wound may be larger than the wound may be larger than the entry wound. entry wound.

Fecal soilingFecal soiling demands demands immediate laparotomy and immediate laparotomy and repair of the bowel. repair of the bowel.


A A simple needle simple needle penetrationpenetration requires requires no no

treatmenttreatment but the patient but the patient should be kept under should be kept under observation observation and given and given

broad spectrum broad spectrum antibioticsantibiotics..


33 . .Bladder injuryBladder injury

Routine Routine catheterizationcatheterization of the bladder and of the bladder and proper proper

sittingsitting of the needle of the needle should prevent bladder should prevent bladder

penetration.penetration.

If If pneumaturiapneumaturia is noted is noted the needle should be the needle should be

partially withdrawn and partially withdrawn and the creation of the creation of

pneumoperitoneum pneumoperitoneum continued. continued.


The bladder peritoneum should The bladder peritoneum should be carefully inspected to be carefully inspected to ensure that no significant ensure that no significant injury has been caused. injury has been caused.

The treatment of a The treatment of a simple simple puncturepuncture is is conservativeconservative with with postoperative bladder postoperative bladder drainage.drainage.


44 . .Blood vessel injuryBlood vessel injury

The Veress' needle may The Veress' needle may penetrate: penetrate:

1.1. omental or omental or 2.2. mesenteric vesselsmesenteric vessels or or 3.3. any of the any of the major major

abdominal or pelvic abdominal or pelvic arteries or veins. arteries or veins.

Minor vascular injuriesMinor vascular injuries involving involving the omental or mesenteric the omental or mesenteric

vessels are vessels are difficult to preventdifficult to prevent as it is impossible to as it is impossible to

ensure that the omentum is not ensure that the omentum is not close to the abdominal wall close to the abdominal wall during during blind insertion of the blind insertion of the

insufflating needle. insufflating needle.


Injury may be suspected if: Injury may be suspected if:

1.1. blood returns upblood returns up the open the open needle or if :needle or if :

2.2. free bloodfree blood is seen in the is seen in the peritoneal cavity after peritoneal cavity after insertion of the laparoscope. insertion of the laparoscope.


If blood returns up the needle and If blood returns up the needle and the patient's condition is the patient's condition is stablestable, , the site of injury may be the site of injury may be investigated laparoscopicallyinvestigated laparoscopically. .

The needle should be left in place The needle should be left in place and a and a 5 mm laparoscope5 mm laparoscope introduced through a introduced through a suprapubic suprapubic cannula. cannula.


Minimal bleedingMinimal bleeding may usually be may usually be controlled by controlled by bipolar coagulationbipolar coagulation or or a a laparoscopic suturelaparoscopic suture. .

LaparotomyLaparotomy is not usually necessary is not usually necessary except in the case of injury to the except in the case of injury to the superior mesenteric artery. superior mesenteric artery.

Such injury requires repair by a Such injury requires repair by a vascular surgeonvascular surgeon

4. Blood vessel injury4. Blood vessel injury

((Bassil et al, 1993Bassil et al, 1993))

Injury to the major vessels may be Injury to the major vessels may be prevented by:prevented by:

1.1. LiftingLifting the abdominal wall, the abdominal wall, 2.2. AnglingAngling the needle towards the pelvis the needle towards the pelvis

once the initial thrust through the once the initial thrust through the fascia has been made fascia has been made and and by by

3.3. InsertingInserting only as much of the needle only as much of the needle as necessary. as necessary.


Thin patients and childrenThin patients and children are are at particular risk of this injury. at particular risk of this injury.

Withdrawal Withdrawal of blood on aspiration of blood on aspiration following insertion of the needle following insertion of the needle should should allow early detectionallow early detection of of blood vessel injury. blood vessel injury.


If injury to a vessel such as If injury to a vessel such as the the aorta, inferior vena cava aorta, inferior vena cava

or common iliac vesselor common iliac vessel is suspected, is suspected, the needle should be left the needle should be left placeplace to mark the site of the to mark the site of the

injury and injury and laparotomylaparotomy performed through a mid-line performed through a mid-line

incision. incision.


There is usually a There is usually a large large haematomahaematoma which obscures the which obscures the site of the injury. site of the injury.

The The aorta aorta should be should be compressed with a clamp or compressed with a clamp or hand until a hand until a vascular surgeonvascular surgeon arrives to perform definitive arrives to perform definitive surgery.surgery.


Dramatic collapseDramatic collapse may result from may result from penetration of a penetration of a major vesselmajor vessel but the but the bleeding may not be immediately bleeding may not be immediately evident if it is evident if it is retro-peritonealretro-peritoneal. .

The loose areolar tissue anterior to The loose areolar tissue anterior to the aorta can allow accumulation of the aorta can allow accumulation of a a considerable amountconsiderable amount of blood of blood before frank intra-abdominal before frank intra-abdominal bleeding is seen. bleeding is seen.


A thorough search must be A thorough search must be made to determine the made to determine the extent of vessel damage. extent of vessel damage.

This includes retraction of This includes retraction of bowel to expose the bowel to expose the aorta aorta above the pelvic brimabove the pelvic brim which is the which is the most common most common site of perforation. site of perforation.


Failure to do search may Failure to do search may result in continued bleeding result in continued bleeding

and formation of a large and formation of a large haematoma leading to a haematoma leading to a second episode of second episode of

shockshock some hours later some hours later


66 . .Puncture of liver or spleenPuncture of liver or spleen

The liver or spleen may be The liver or spleen may be punctured by the Veresspunctured by the Veress

55 . .Gas embolismGas embolism

Intravascular insufflation of Intravascular insufflation of gas may lead to gas may lead to gas gas embolismembolism or even death. or even death.

This can only happen if the This can only happen if the penetration by the Veress' penetration by the Veress' needle goes unrecognized needle goes unrecognized and insufflation commences. and insufflation commences.

It should be prevented by It should be prevented by routine routine use of the aspiration test. use of the aspiration test.

The patient should be The patient should be turned on turned on to the left lateral positionto the left lateral position and, and,

If immediate recovery does not If immediate recovery does not take place, take place, cardiac puncturecardiac puncture performed to release the gas.performed to release the gas.

55 . .Gas embolismGas embolism

Open vs. Closed AccessOpen vs. Closed Access

Numerous studies have shown no Numerous studies have shown no clear benefit for one over the other clear benefit for one over the other

The incidence of bowel and The incidence of bowel and vascular injury for both are vascular injury for both are between 0.0 and 0.1%between 0.0 and 0.1%

Risk factors for both included Risk factors for both included previous surgery, thin habitus, previous surgery, thin habitus, distention, and obesitydistention, and obesity

JOGC 2007;193May:433-447

Safety and Closed Access Safety and Closed Access (Veress Needle)(Veress Needle)

Initial pressure > 10 mm HgInitial pressure > 10 mm Hg Access at Palmer’s Point with prior lower abdominal incisions Access at Palmer’s Point with prior lower abdominal incisions

(or use open technique) (or use open technique) When using Palmer’s Point, always decompress stomach When using Palmer’s Point, always decompress stomach

with OG tubewith OG tube Do not use Palmer’s Point in presence of upper abdominal Do not use Palmer’s Point in presence of upper abdominal

incisionsincisions Use Palmer’s Point for very thin and very obese patientsUse Palmer’s Point for very thin and very obese patients For thin patients and umbilical access, angle needle 45 For thin patients and umbilical access, angle needle 45

degrees caudal and for obese patients, introduce needle degrees caudal and for obese patients, introduce needle perpendicular to the skinperpendicular to the skin

Do not waggle needleDo not waggle needle Abort umbilical site after 3 failed attemptsAbort umbilical site after 3 failed attempts Use pressure instead of volume endpoint (20 mm Hg)Use pressure instead of volume endpoint (20 mm Hg) Check for access injuries upon entry and closureCheck for access injuries upon entry and closure

JOGC 2007;193May:433-447

Safety and Open Access Safety and Open Access (Hasson)(Hasson)

Avoid access through Avoid access through previous surgical scarprevious surgical scarUse more lateral access in Use more lateral access in such casessuch cases

Enter peritoneal cavity under Enter peritoneal cavity under direct visiondirect vision

Check for access injuries on Check for access injuries on entry and closureentry and closure

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