MISADVENTURES IN MISADVENTURES IN ENDOSCOPIC ENDOSCOPIC

SURGERYSURGERY

Dr. Rabinarayan Dr. Rabinarayan SatapathySatapathy

Asst. ProfessorAsst. Professor

Dept. of Obst.& GynaeDept. of Obst.& Gynae

S.C.B. Medical S.C.B. Medical College,CuttackCollege,Cuttack

Complications : Complications :

** Related to endoscopy itselfRelated to endoscopy itself

** Related to anaesthesiaRelated to anaesthesia

** Related to any surgical procedureRelated to any surgical procedure

** Related to the experience of the Related to the experience of the surgeonsurgeon

• Reported complication rate of 3.2/1000( French Reported complication rate of 3.2/1000( French multicentric, collaborative study of 15,521cases)multicentric, collaborative study of 15,521cases)

• Nezhat et al reported complication rate of 3.08% of Nezhat et al reported complication rate of 3.08% of 6949 advanced endoscopic surgeries6949 advanced endoscopic surgeries

• Complication rate ↑ to 5 .2/1000 for advanced Complication rate ↑ to 5 .2/1000 for advanced interventionsinterventions

• Complication rateComplication rate↓↓ by almost 50 % since 1972 (6.8 vs by almost 50 % since 1972 (6.8 vs 3.2/1000)3.2/1000)

ANAESTHETIC ANAESTHETIC COMPLICATIONSCOMPLICATIONS

Rare Rare

HypoventilationHypoventilation

Inadvertent endobronchial intubation (as Inadvertent endobronchial intubation (as hilum hilum

of lung displaced upwards in deep of lung displaced upwards in deep Trendelenburg position)Trendelenburg position)

↑ ↑ risk of regurgitation of gastric contentsrisk of regurgitation of gastric contents

Adverse cardiorespiratory effectsAdverse cardiorespiratory effects

Minimizing Minimizing ComplicationsComplications

Use cuffed endotracheal tubeUse cuffed endotracheal tube

Use nasogastric drainageUse nasogastric drainage

Avoid overforceful mask ventilationAvoid overforceful mask ventilation

Use complete muscle paralysisUse complete muscle paralysis

Complications of Complications of PneumoperitoneumPneumoperitoneum

Associated with Veress needleAssociated with Veress needle : : * * Preperitoneal & omental emphysemaPreperitoneal & omental emphysema

* * Injury to blood vesselInjury to blood vessel

**Injury to intestinal tractInjury to intestinal tract

**Injury to bladderInjury to bladder

**Gas embolismGas embolism

Minimizing complications Minimizing complications of Pneumoperitoneumof Pneumoperitoneum

• Percuss left upper quadrant to detect gastric Percuss left upper quadrant to detect gastric distensiondistension

• Test spring mechanism before insertionTest spring mechanism before insertion

• Leave valve openLeave valve open

• Direct towards hollow of sacrumDirect towards hollow of sacrum

• Advance only 2-3mm after piercing parietal Advance only 2-3mm after piercing parietal peritoneumperitoneum

……contdcontd• Perform safety testsPerform safety tests : :

**hissing phenomenonhissing phenomenon

**aspiration testaspiration test

**hanging drop methodhanging drop method

**monitoring intra-abd pressuremonitoring intra-abd pressure

• Do not insufflate at more than 1L/min initiallyDo not insufflate at more than 1L/min initially

• If no obliteration of liver dullness, suspect If no obliteration of liver dullness, suspect extravasationextravasation

• Avoid over-insufflation of peritoneal cavityAvoid over-insufflation of peritoneal cavity

Extraperitoneal Extraperitoneal InsufflationInsufflation

• Usually pre-peritoneal

• Recognized by abnormal high insufflation pressure & palpation of abdomen

• Remove needle, allow gas to escape, then re-introduce

• Complications include mediastinal emphysema & compromised cardiac function

• Pneumo-omentum harmless & rare (2%)

Complications due to Complications due to TrocarsTrocars

♦♦ Major injuries due to adherent bowel or low Major injuries due to adherent bowel or low intraperitoneal pressure at time of introductionintraperitoneal pressure at time of introduction

( wait for intraperitoneal pressure of 15 mm Hg)( wait for intraperitoneal pressure of 15 mm Hg)

♦♦ Injury to hollow viscera or blood vessels Injury to hollow viscera or blood vessels → due to → due to uncontrolled entry or improper directionuncontrolled entry or improper direction

↓↓ Laparotomy and vascular repair

Injury to epigastric vessels:Injury to epigastric vessels:

Transillumination of abdominal wall is Transillumination of abdominal wall is

preventivepreventive

Transparietal suturesTransparietal sutures

BBipolar laparoscopic coagulationipolar laparoscopic coagulation

Compression by Foley’s catheter at Compression by Foley’s catheter at involved involved

site by introduction through 5 mm site by introduction through 5 mm trocar trocar

sleevesleeve

Minimizing complications Minimizing complications with Trocarwith Trocar

* * Place finger guard to within 3cm of trocar tip Place finger guard to within 3cm of trocar tip

** Use controlled twisting motion Use controlled twisting motion

* * Direct trocar tip towards sacral hollow Direct trocar tip towards sacral hollow

** Advance no more than 2cm beyond parietal Advance no more than 2cm beyond parietal

peritoneumperitoneum

** Replace laparoscope into trocar sheath first Replace laparoscope into trocar sheath first

during withdrawalduring withdrawal

Minimizing Minimizing complicationscomplications

** Transilluminate for epigastric vessels Transilluminate for epigastric vessels

** Place trocars as high above symphysis pubis Place trocars as high above symphysis pubis as cosmetically possible ( never less than 3cm)as cosmetically possible ( never less than 3cm)

** Insert ancillary trocar under direct lap vision Insert ancillary trocar under direct lap vision

** Direct downward, not laterally Direct downward, not laterally

Injuries during Operative Injuries during Operative ProcedureProcedure

Injury to bladder Due to: * dissection * electrocoagulation * laser use Predisposing factors include previous CS,

endometriosis Detection by noting presence of blood & gas in urobag. Confirmation by infusion of methylene

blue dye into bladder Small injury – heals spontaneously with indwelling

catheter Large injury – suture by laparotomy or laparoscopy

Injuries during Operative Injuries during Operative Procedure… Procedure… contd.contd.

Injury to ureterInjury to ureter **Due to:Due to: - - sharp dissectionsharp dissection - - electrosurgeryelectrosurgery - - laserlaser - - during isolation of uterosacral ligamentduring isolation of uterosacral ligament - - improper evaluation of anatomyimproper evaluation of anatomy - - adhesions, myomas, endometriosisadhesions, myomas, endometriosis* * Diagnosis madeDiagnosis made 48-72 hrs after surgery48-72 hrs after surgery * * Confirm by IVPConfirm by IVP* * Treatment is reanastomosisTreatment is reanastomosis

Injuries during Operative Injuries during Operative Procedure… Procedure… contd.contd.

Injury to small bowelInjury to small bowel

* Occurs during surgery for adhesions

* Electro or laser surgery causes occult thermal lesions- apparent after 48-72 hrs.

* Frank bowel perforation warrants laparotomy for transverse suture or resection-anastomosis

Injuries during Operative Injuries during Operative Procedure… Procedure… contd.contd.

Vascular injuryVascular injury * Occurs mainly during lap hysterectomy * Careful isolation and coagulation of uterine

arteries by bipolar electrosurgery is the key * Beware of improper haemostasis * Other sites are tubal, ovarian or vaginal

vessels * Should be managed laparoscopically * Ensure haemostasis before withdrawing

scope

Other ComplicationsOther Complications Haemorrhage & shockHaemorrhage & shock

InfectionInfection

Incisional herniaIncisional hernia

Peritoneal fistula formationPeritoneal fistula formation

Accidental burnsAccidental burns

Minimizing complications Minimizing complications of Endoscopic Surgeryof Endoscopic Surgery

** Minimize use of unipolar electrocauteryMinimize use of unipolar electrocautery ** Disconnect all electrosurgical units when not in useDisconnect all electrosurgical units when not in use ** Identify ureters before ant surgery of pelvic side Identify ureters before ant surgery of pelvic side

wallwall ** Use traction/countertraction to identify tissue Use traction/countertraction to identify tissue

planesplanes * * Minimize forceful blunt dissectionMinimize forceful blunt dissection ** Spread jaw of scissors to develop tissue planesSpread jaw of scissors to develop tissue planes ** Cauterize vessels before transectionCauterize vessels before transection ** Avoid scissor action between instruments to avoid Avoid scissor action between instruments to avoid pinching of bowel or omentumpinching of bowel or omentum ** Do not cut any tissue before identifying its anatomyDo not cut any tissue before identifying its anatomy

Complications of Complications of HysteroscopyHysteroscopy

* * TraumaTrauma

* * HaemorrhageHaemorrhage

** Complications related to distension mediaComplications related to distension media

** Infection Infection

** Thermal damageThermal damage

** CO2 & air embolismCO2 & air embolism

TraumaTrauma * Cervical & Uterine perforationCervical & Uterine perforation

** Occurs during insertion of manipulators, Occurs during insertion of manipulators,

dilators, hysteroscope or during surgerydilators, hysteroscope or during surgery

** Hysteroscopic surgery suspended due to gas Hysteroscopic surgery suspended due to gas

or fluid leakageor fluid leakage

** Small, mechanical perforations – observation Small, mechanical perforations – observation

onlyonly

Trauma…Trauma…contdcontd..

* * Lateral wall injury or broad ligament Lateral wall injury or broad ligament

haematoma- concurrent use of laparoscope haematoma- concurrent use of laparoscope usefuluseful

** Perforation due to electrosurgical electrode – Perforation due to electrosurgical electrode – laparotomy warrantedlaparotomy warranted

** Uterine perforations avoided by gentle Uterine perforations avoided by gentle

insertion of hysteroscope under direct visioninsertion of hysteroscope under direct vision

** In difficult cases, do concomitant laparoscopy In difficult cases, do concomitant laparoscopy

HaemorrhageHaemorrhage

** Occurs during surgery for submucus Occurs during surgery for submucus

myoma/TCREmyoma/TCRE

** Usually possible to control with Usually possible to control with

electrocauteryelectrocautery

* * Post opereative tamponade with Foley’s Post opereative tamponade with Foley’s

catheter usefulcatheter useful

* * If field of vision obscured, stop operationIf field of vision obscured, stop operation

Complications related to distension mediaComplications related to distension media ** Distension media used: Distension media used: CO2CO2 Dextran-70Dextran-70 5% dextrose5% dextrose Glycine, Sorbitol, MannitolGlycine, Sorbitol, Mannitol

* * Should be non-conductive in hysteroscopic surgeryShould be non-conductive in hysteroscopic surgery ** Dangers: Dangers: Dextran - anaphylaxis, DIC, ARDS, non-cardiogenic Dextran - anaphylaxis, DIC, ARDS, non-cardiogenic pulmonary oedemapulmonary oedema 5% dext - hyperglycaemia, hyponatraemia5% dext - hyperglycaemia, hyponatraemia CO2 – Fatal gas embolismCO2 – Fatal gas embolism

FLUID OVERLOADFLUID OVERLOAD

~ Monitor fluid intake & output carefully. Look out for +ve fluid balance

~ Length of hysteroscopic procedure and the amount of raw uterine surface created are important factors.

~ Dilutional hyponatraemia causes cerebral oedema , convulsions and even death

+ ve fluid balance+ ve fluid balance RemarksRemarks

1000ml 1000ml AlertAlert

1500m 1500m Finish Finish surgery surgery

quicklyquickly

2000ml 2000ml STOP STOP SURGERY!!SURGERY!!

Give diureticsGive diuretics

CONCLUSIONCONCLUSION ** Complications of endoscopic surgery are Complications of endoscopic surgery are directly related to the skill of the surgeondirectly related to the skill of the surgeon

** Availability of appropriate instruments is an Availability of appropriate instruments is an important factorimportant factor

* * Prevention of complications should be the Prevention of complications should be the aimaim

** Early detection of complications is essentialEarly detection of complications is essential

FOREWARNED IS FOREARMEDFOREWARNED IS FOREARMED

MISADVENTUREMISADVENTURE

↓↓ ADVENTUREADVENTURE

ENDOSCOPIC SURGERY IS SAFE!!ENDOSCOPIC SURGERY IS SAFE!!