Port related injury in laparoscopic surgery

Dr Krishan kantDNB(MAS), M.S, DNB, MNAMS

FIAGES, FMAS, FICLS

Advanced Laparoscopic and Bariatric surgeon at Central Railway Hospital

(Jabalpur)

Dr Kurt Semm-Therapeutic laparoscopy 1970s-Ovarian cyst enucleation1971-Laparoscopic appendectmy in1981 germany

Statistics in laparoscopy

- 50% of the trocar-related injuries to the bowel and vasculature are during the initial entry.

-30-50% of the bowel injuries and 15-50% of the vascular injuries are not diagnosed at the time of injury.4

-delay contributed to mortality rates of 3-30% for bowel and vascular injuries

WHY COMPLICATIONS?

Experience: 4 fold if > 100 cases

Complexity: 9 fold if more complex

Patient risk: As ASA increases so does

risk of complications.

(Fahlenkamp, D. et al.: J. Urol. 162: 765, 1999 – 2,407 cases) (Parsons, J. et al.: Urology: 63: 27, 2004 – 894 cases)

COMPLICATIONS

1. Entry

2. Pneumoperitoneum

3. Intraoperative

4. Postoperative

a. Early

b. Late

ABDOMINAL ACCESS INSTRUMENTS

Open Technique Closed

Technique

Hasson Cannula Veress Needle

Trocar

Sheath

Assemblies

Opti trocar

ENTRY

A good beginning is essential:“More than one half of the complications related to laparoscopy are related to the entry technique.”

Incidence: 0.3 – 1.0%

(Magrina, J. F.: Clin. Ob. and Gyn. 45: 469, 2002)(meta-analysis: 1,549,360 laparoscopic cases)

ENTRY INJURIES

Veress or Open?

Veress Open

Vascular injury: 0.08% 0.0%*

Bowel injury: 0.08% 0.05%

Gas embolism: 0.001% 0.0%

Death: 0.003% 0.0%

*p < .05; (Bonjer, H: Br. J. Surg. 84: 599, 1997) (N.B.: other prospective studies showed no difference!)

(n= 12,444) (n= 489,335)

Access Related Complications (0.03 – 1%)

• Extraperitoneal insertion • Vascular injury

– Abdominal wall vessels– Retroperitoneal vessels– Mesenteric vessels

• Visceral injury– Stomach, bowel, liver, spleen, bladder

1.VERESS NEEDLE

• The operator should feel or sense the needle passing through two distinct planes.

• The needle is advanced and withdrawn several times. If this is done easily and without obstruction, the tip is in proper position.

Veress placement

TRANSPERITONEAL STANDARD ENTRY

Veress needle:• Test needle prior to

placement.• Aspirate, irrigate, aspirate

(then irrigate)…drop test and advancement test. Needle rotation.

• “If in doubt, pull it out.” (High pressure and low flow, remove needle.)

Tip: Increase abdominal pressure to 15 mm Hg for initial trocar placement.

Insufflation

Set pressure cut off to at least 20-25mmHgStart at low flow (1L/min)Check gas entering at low pressure (<8mmHg)After 0.5L flow rate can be increasedInsufflate to pressure cut off (20-25mmHg)

1. Veress cont.....

The greater the gas bubble & abdominal wall tension the less the risk of bowel injury

Abdominal pressure= 8mmHg Abdominal pressure= > 15 mmHg

2.Primary trocar

2. Primary port cont....

Commonest problem - failed entry

Insertion of subumbilical Veress needle

Closed entry can still cause bowel injury, especially if adhesions are present

2. Primary port cont....

• An intra-abdominal pressure of >15mmHg should be achieved before inserting the primary trocar

• The distension pressure should be reduced to 12–15 mmHg once the insertion of the trocars is complete

Green-top Guideline. No. 49 May 2008(RCOG)

• The primary trocar should be inserted at 90 degrees to the skin, through the incision at the base of the umbilicus

• Once the laparoscope has been introduced it should be rotated through 360 degrees to check for any adherent bowel

Green-top Guideline. No. 49 May 2008(RCOG)

Trocar placement

Secondary ports are inserted under direct vision - an inadvertent injury from a secondary port could be considered negligent”

Principles

Avoid inferior epigastric vesselsAvoid bowel/vascular injuryMinimise hernia risk

3. Secondary ports

Round ligament

Obliterated umbilical artery

Rectus muscles

Mid-line

3. Secondary ports - Anatomy

• Secondary ports inserted under direct vision at right angles to the skin at 12-15 mmHg pneumoperitoneum

• Inferior epigastric vessels should be visualised laparoscopically prior to secondary port placement

• Once the trocar has pierced the peritoneum it should be angled towards the anterior pelvis

Green-top Guideline. No. 49 May 2008

Alternatives to closed umbilical entry considered:

If there is risk of umbilical adhesions - previous (midline) laparotomy

In very slim or morbidly obese womenFailed saline test or Veress insertion x2

Unsatisfactory closed Veress insufflation

Alternatives include:

Open entry – variations of Hassan technique Palmer’s point closed entry

4. Primary port – Alternatives

WHERE’S THE BEST PLACE?

Entry sites: 5! Umbilical

(Danger – IVC/Aorta)

(Palmer’s point) / Left MCL subcostal

(Danger – Liver or Liver/spleen)

Right AAL – 2 fingerbreadths above the iliac crest

(Danger – colon)(Don’t hesitate to go left when

you are operating right!)(McDonald, D., et al.: SLEPT 15:

325, 2005)

5.HALS and outcome

• principle of master slave manipulator.

• The da Vinci system

• The Zeus system

Complication-

• Not accurate precision

• Conversion take time.

6.Robotic Surgery

INTRAOPERATIVE COMPLICATIONSThe BIG 3:

1. Cardiac arrest

2. Vascular

3. Bowel

The others: Spleen, Liver, Pancreas, Bladder, Ureter, Diaphragm, Instrumentation, Oliguria

VASCULAR INJURY

Overview:

Incidence: 0.5 – 2.8%

Conversion: 50%

Mortality: 9-17%

Mechanism:

1. Veress needle: 38%

2. Trocar: 45%

3. Intraoperative: 17%

(Hashizume, M.: Japan. Surg. Endosc. 11: 1198, 1997; Chapron, C. M., J. Am. Coll. Surg. 185: 461, 1997; Mintz, M. :J. Reprod. Med. 18: 269, 1997; Yuzpe, A.: J. Reprod. Med. 35: 485, 1990; Magrina, J. : Clin. Obstet. and Gyn. 45 469, 2002; Parsons, J. et al.: Urology: 63: 27, 2004)

Complications

Vascular Injuries

Vessel Injury : • Larger vessels may be injured by trocar or veress

needle.• CO2 peritoneum may tamponade a large vessel

injury. • When pressure normalizes it starts bleeding. Management –( If veress injury) • Examine the course of large vessels. • Overlying peritoneum is opened with laproscopic

scissors or a CO2 laser. • Hematoma evacuated by alternate suction and

irrigation.(If Trocar injury) * Laprotomy is required if hematoma is expanding

or persistent bleeding.

TROCAR INJURY: ABDOMINAL WALLThe most common site is from the

inferior and superior epigastric vessels.

The overall incidence is 0.5%

Key point: Lateral ports should be at least 5.5-6 cm. off the midline to avoid the epigastric vessels.

(Hashizume, M.: Japan. Surg. Endosc. 11: 1198, 1997)

Epigastric Vessels injury –• Deep epigastric vessels most frequently injured in

laproscopic hysterectomy Management – By Tamponade – • Rotate second puncture sleave by 3600.• By Foley’s catheter• Bipolar cautery• Needle suturing • Small haemostate (Mosquito clamp)

Complications

Injury to Small Bowel :

Bowel - May be injured due to trocar or veress needle

If due to veress needle it is managed conservatively

Diagnosis - • The emanation of foul smelling gas through pneumo-peritoneal

needle is a helpful diagnostic sign.• There may be GI contents at the tip of needle.

Management – • Mini laprotomy and repair of perforation. • Laparoscopically it may be sutured of laparoscopic stapler (ENDO-

GIA) can be used. • Colostomy

Injury to Urinary Bladder :

Bladder - Injury caused by second puncture trocar usually .

Diagnosis : Appearance of gas and blood in Foley’s catheter bag.

Management – • Early detection is important. • Place an indwelling catheter for 7-10 days and

prophylactic antibiotics - If defect is larger.

Repaired by a figure of 8 suture through muscularis of bladder & second suture to close peritonium

* A water tight seal should be documented by filling bladder with indigo carmine dye solution.

Direct Coupling damage

Direct Coupling Damage

Exit techniques

Wound closure:

Proper closure of fascia within umbilical port site to prevent wound dehiscence or hernia

Avoid hernia risk by closing sheath:

- Midline port sites > 7mm

- Lateral port sites > 5 mm

Take home message

• 5.5-6 cm. off the midline to avoid the epigastric vessels*• “In order to operate fast, it is necessary to go slow.” G.

Vallancien • Think twice … cut once.• Liberal use of energy devices (harmonic, Ligasure)• Blunt ports• Abdominal inspection at 5 mm Hg: look for “rivulets –

red swirls”• Port removal under vision at 5 mm Hg • If bleeding is confined to the retroperitoneum, there may

be very little blood intraperitoneally or none at all (thus presenting as an expanding retroperitoneal hematoma)

• Usal et al, Surgical Endoscopy, 1998