2. Laparoscopic Complications

3. Complications related to laparoscopy in gynecologic patients: 0
Complications related to laparoscopy in gynecologic patients: 0.1 to 10%
Over 50% occurred at entry
20 to 25% not recognize until the postoperative period.

4. studies One survey between 1980 and 1999:
The incidence of entry access injury:5 to 30 per 10,000 procedures.
Bowel and retroperitoneal vascular injuries:76% of all injuries
The type and proportion of organ injury during entry: small bowel (25%), iliac artery (19%), colon (12%), iliac or other retroperitoneal vein (9%), secondary branches of a mesenteric vessel (7%), aorta (6%), inferior vena cava (4%), abdominal wall vessels (4%), bladder (3%), liver (2%)

5. A review of procedures from 1975 to 2002:
Entry-related visceral lesions: 0.3 to 1.3 per procedures
Entry-related vascular lesions:0.07 to 4.7 per procedures
The open technique was not associated with fewer complications than the closed technique

6. Nerve Injury
Most nerve injuries: neurapraxia or nerve contusion, usually resolve within 6 weeks
Neurotmesis, or complete division of the nerve: the most severe injury, often resulting in permanent disability.
Proper patient positioning & knowledge of risk factors associated with neuropathies are important
Femoral neuropathy: associates with excessive hip flexion or abduction, or long operating times

7. Nerve Injury Obturator neuropathy:
Radical pelvic surgery or lymph adenectomy (most common)
Excessive hip flexion (in the obturator foramen, the nerve lies directly against bone)
Retropubic dissection (paravaginal repair of lateral defects of the anterior vaginal wall)
Iliohypogastric and ilioinguinal nerves: lateral trocars (suture ligature and fibrotic entrapment): avoid extreme lateral trocar placement
Injury to the ilioinguinal and iliohypogastric nerves can be avoided by placing incisions above the anterior superior iliac spine.

8. Nerve Injury
Sciatic neuropathy: result of nerve stretching. It is reported in procedures lasting as short as 35 minutes in free-hanging stirrups
Peroneal nerve: division of sciatic, under the least amount of tension when the knee and hip are flexed (the nerve is fixed at the sciatic notch and the fibular head). Tension along the nerve is increased with hip flexion when the knee joint becomes straightened or externally rotated.

9. Nerve Injury
Patients at increased risk of sciatic nerve injury: long-legged, obese, or short in stature.
In hanging-type stirrups, long-legged or obese patients have a tendency for external hip rotation, and shorter patients have less flexion at the knee.
In such cases, stirrups that support the ankle and calf are more appropriate.

10. Vascular Injuries The most life threatening
Usually laceration of the mesenteric vessels during insertion of the primary trocar or Veress needle
Injury to the great vessels requires immediate laparotomy
Injury to smaller vessels: usually hemostasis
Injury to the inferior epigastric vessels:
Bipolar forceps through the contra lateral port  coagulation
Endoscopic fascial closure devices  suture passing through the fascia and peritoneum
A 30-cc Foley catheter through the trocar site with the aid of an 8-inch clamp, inflating the balloon: tamponade
Enlarging the trocar site: visualize, clamp, and ligate the vessel

11. Gastrointestinal Injury
The most lethal injury associated with laparoscopy (mortality rate: 3.6%)
The golden rule of laparoscopic surgery is that patients gradually get better following the operation. If a patient continues to have pain, especially tachycardia or fever, bowel injury must be suspected
Ileus after laparoscopy is not normal

12. BOWEL INJURY 
The demonstration of free intra-abdominal air on an upright abdominal radiograph (to diagnose a ruptured intraperitoneal viscus): This radiographic sign is generally NOT helpful after laparoscopic surgery (40% of patients will have >2 cm of free air at 24 hours postlaparoscopy)
Patients who present after several days have experienced either delayed necrosis of damaged bowel, or had a leak which temporarily sealed off.

13. BOWEL INJURY 
Free air may be seen up to a week postoperatively, but the volume should gradually decrease.
Increasing amounts of intraabdominal air indicates ruptured viscus until proven otherwise  Laparotomy is indicated
Patients may have fecal contamination of the abdominal cavity and still have bowel movements, be ambulatory and not display peritonitis.
Symptoms from penetrating trauma generally manifest within 12 to 36 hours, but may occur up to 5 or 7 days

14. Gastrointestinal Injury
As a general rule: Veres needle injury needs no repair as long as the puncture is not associated with bleeding
Colonic puncture without tearing: non operative management with antibiotics, copious irrigation and suction
Stomach perforation: 1 in 3,000 cases, Risk factors: history of upper abdominal surgery and difficult induction (gas-distension).
Trocar injury to the stomach requires repair by laparoscopy or laparotomy, and the abdominal cavity should be irrigated and suctioned. NG Tube maintain postoperatively until normal bowel peristalsis

15. Gastrointestinal Injury
Veres needle and trocar injury to the small intestine: injury should be investigated when multiple anterior abdominal wall adhesions; A lower quadrant secondary port can be used to view the umbilical port site.
Full-thickness injury of ≥ 5 mm should be repaired in two layers with an interrupted layer of 3-0 delayed absorbable suture (mucosa and muscularis), and a serosal layer of 3-0 interrupted silk suture, perpendicular to the long axis of the intestine (avoid stricture formation)
Performing by laparoscopy, laparotomy or mini laparotomy at the umbilical site
Laceration ≥ one half of the luminal diameter  segmental resection

16. Gastrointestinal Injury
Trocar injury to the colon: 1 per 1,000 cases
Significant morbidity compared with small intestine and stomach
Broad-spectrum antibiotics
Consultation with a surgeon
Small rent with minimal soilage
The defect close in two layers with copious irrigation
Larger injury without bowel preparation, or injury involvement intestinal mesentery: colostomy

17. Gastrointestinal Injury
Delayed (postoperative) diagnosis: colostomy
Detection of injury to the rectosigmoid colon (flat tire test): filling the posterior cul-de-sac with normal saline and performing proctosigmoidoscopy, or injecting air into the rectum through a catheter-tipped bulb syringe and looking laparoscopically for bubbles
Thermal bowel injuries: require wide resection even though the bowel have a normal appearance

18. Gastrointestinal Injury
Electrosurgical injuries may not become symptomatic for several days.
Burn injuries require resection of 1 to 2 cm of viable tissue around the injury site.
The resected loop of bowel should be examined by the pathologist to ensure that all of the damaged tissue has been excised.

19. Trocar Site Hernia Frequency: 0.17%
The fascia should be closed if ≥ 10 mm
Risk factors: multiple ancillary ports, larger diameter ports, and operative instrumentation, (stapler), Increased operative times, greater tissue manipulation, fascial screws  fascial weakening
Closing the fascia may not entirely prevent hernia formation: 18% occurred despite fascial closure.
A defect is usually palpable over the trocar site incision with Valsalva, or a mass can be seen.

20. URINARY TRACT INJURY Bladder injury: 1 in 300 cases.
Injury usually occurs to the bladder during secondary trocar insertion.
Signs: bloody urine and gas in the urine bag
Higher injury rates with laparoscopic hysterectomy and bladder neck suspension.
No treatment required if the bladder is punctured with a pneumoperitoneum needle.
A perforation due to trocar injury should be sutured

21. Urinary Tract Injury
Risk factors for bladder injury: distended bladder during suprapubic trocar insertion; previous surgery & distortion to bladder anatomy; endometriosis obliterating the anterior cul-de-sac.
If the superior aspect of the bladder cannot be deciphered, filling the bladder with 300 mL of water or saline
Intraoperative signs of bladder injury: clear fluid in the operative field, visible bladder laceration, and gas distention of the Foley bag.
To adequate diagnosis: methylene blue or indigo carmine, diluted with 200 to 300 mL of sterile normal saline, instill through the Foley catheter.

22. Acute bladder injury
If the injury is small, uncomplicated, and isolated: catheter drainage, cystogram on the 10th day of drainage
Surgical repair: if the Foley catheter is unable to provide adequate drainage because of blood clots or persistent extravasation, or concomitant injury to the urethra or ureter.
Laparoscopic repair: if small injury with adequate exposure, as long as the ureters and bladder neck are not compromised.

23. ureteral injury
Overall complication rates for laparoscopy are decreasing, but ureteral injury has remained steady at 1%
The greatest risk: laparoscopic hysterectomy (LAVH is most association)
The usual time to diagnosis in post operation: between 2 and 7 days (is reported as late as 33 days after surgery)

24. ureteral injury
Symptoms: abdominal pain, fever, hematuria, flank pain, or peritonitis.
Leukocytosis is common
In the majority of cases: percutaneous or cystoscopic stenting
Laparotomy is usually performed for end-to- end anastomosis or reimplantation of the ureter into the bladder (in experienced hands, repair may be performed laparoscopically).

25. RISK FACTORS
prior surgeries, intraabdominal disease (endometriosis, pelvic inflammatory disease), extensive bowel distention, very large pelvic or abdominal masses, extensive pelvic/intraabdominal adhesions, cardiopulmonary disease, and diaphragmatic hernia.
Patients with these conditions are often better served with a nonlaparoscopic surgical approach.

26. WOUND Hematoma 
Clinical manifestations: swelling, pain, ecchymoses and external bleeding from the trocar site.
Hematomas which are stable on physical examination and by imaging: manage conservatively
The hematoma may drain spontaneously. No intervention is necessary.
Surgical intervention: if the hematoma is expanding or becomes abscessed
Delayed hematomas may present 2 or 3 days after surgery as purple discoloration of a portion of the abdominal wall and/or back.
They arise from delayed bleeding from vessels in the abdominal wall.
Observation and correction of anemia usually suffice.