How to ID and treat intraoperative complications Part 2 Stapler misfire, ischemic segment, bladder invasion, small bowel invasion, intraoperative bleeding Morris E. Franklin Jr MD. F.A.C.S. Director Texas Endosurgery Institute Karla Russek, MD. Research Fellow MISS meeting 2010

Industry relationships W.L. Gore & Associates Grant/research support, consultant and speaker bureau Covidien Striker Consultant, advisory board Ethicon Consultant and speaker bureau Atrium Consultant Aesculap KCI The Authors do not have financial interest with the above mentioned companies

The pessimist sees difficulty in every opportunity The pessimist sees difficulty in every opportunity. The optimist sees the opportunity in every difficulty. Winston Churchill

Laparoscopic Colectomy Conversion rate of 23.5% Unclear anatomy Actually….. Stapler misfire Are all these still Bleeding reasons for Cystostomy conversion???? Enterostomy Adhesions Adjacent organ invasion Indications for Conversion to Laparotomy S Pandya, MD; JJ. Murray, MD; JA. Coller, MD; LC. Rusin, MD Arch Surg. 1999;134:471-475

Adjacent Organ invasion

Peritoneum (parietal and visceral) Possible invasion to: * Bladder * Small intestine Peritoneum (parietal and visceral) Uterus, ovaries Stomach Omentum Pancreas Abdominal wall

Statistics Until 50 years ago, colorectal carcinoma infiltrating surrounding tissue was considered nonresectable Most of the time the diagnosis is made in the OR

Tumor subsite location and adjacent organ invasion Multivisceral resection for locally advanced primary colon and rectal cancer. Thomas Lehnert, Mascha Methner, Andreas Pollok. Annals of Surgery, 2002

Transection of tumor and spreading of tumor cells must be avoided whenever possible The removal of all carcinoma-bearing tissue, including the regional lymph nodes, is ideal Multivisceral resection for colon carcinoma. Roland Croner, Susanne Merkel, Thomas Papadopoulos, et al. Dis Col & Rectum, Aug 2009

Bladder invasion

Abdominal wall invasion

Abdominal wall invasion

Intraoperative bleeding

Intraoperative bleeding Vascular injury Tamponade with pressure Irrigate Inform anesthesia team

Intraoperative bleeding Slow to open if controllable with pressure Venous injury may bleed more while converting to open if there is no intraabdominal pressure Always think of gas embolism

Intraoperative bleeding Keep calm Make sure the anesthesiologist is aware of the problem Ask for help

Some tips to prevent it: Know the anatomy other than Netter!!! If possible, dissect the artery from the vein

Vascular control

Stapler Misfire

Colonoscopy and anastomosis leak test Intestinal clamps Liberal use of colonoscope

Colonoscopy and anastomosis leak test Anastomosis Air leak test ID Bleeding Integrity

The Use of Bioabsorbable Staple Line Reinforcement for Circular Stapler (BSG “Seamguard”) In Colorectal Surgery. Initial Experience. “We consider these first 5 cases using bioabsorbable Seamguard for circular stapler reinforcement an initial experience perhaps helping to alleviate the most devastating complication of gastrointestinal surgery. Longer follow up and a larger number of patients are obviously needed; however the initial data is very promising and has encouraged us to continue using this device on further patients “ Franklin Jr, M.E. MD, FACS; Portillo G. MD; Surg Laparosc Endosc Percutan Tech;2006;16:411-415

Ischemic segment

Loose anastomosis

“You can not depend on your eyes when your imagination is out of focus” Morris E. Franklin Jr.

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