1. 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

2. 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

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

5. 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:

6. Adjacent Organ invasion

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

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

9. 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

10. 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

11. Bladder invasion

12. Abdominal wall invasion

13. Abdominal wall invasion

14. Intraoperative bleeding

15. Intraoperative bleeding
Vascular injury
Tamponade with pressure
Irrigate
Inform anesthesia team

16. 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

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

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

19. Vascular control

20. Stapler Misfire

21. Colonoscopy and anastomosis leak test
Intestinal clamps Liberal use of colonoscope

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

23. 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:

24. Ischemic segment

25. Loose anastomosis

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