How to deal with How to deal with ACCESS INJURY: ACCESS INJURY:

digestive and vasculardigestive and vascular

George S. Ferzli MD, FACSGeorge S. Ferzli MD, FACSProfessor of SurgeryProfessor of Surgery

SUNY HSC, Brooklyn, NYSUNY HSC, Brooklyn, NY

PREVENTIONPREVENTION

is the best way to deal with access injury.is the best way to deal with access injury.

Laparoscopic access varies on Laparoscopic access varies on an individual patient basis.an individual patient basis.

Entry into abdomenEntry into abdomenPatient considerations:Patient considerations:

Thin skin?

Child?

Pregnant, or pelvic mass?

Ventral hernia, or bowel distension?

Previous surgery or PID ?

Obese?

Abdominal wallAbdominal wall• Epigastric vessels

• Nerves

• Bladder

Epigastric vessels - Epigastric vessels - InjuryInjury

• Injury to abdominal wall blood vessels • Incidence of 0.2–2.0%

• May see blood externally around port site or drip internally at peritoneal entry site

• Injury may be unrecognized secondary to tamponade by trocar / pneumo-peritoneum

• Transillumination may not identify deep epigastic vessels, especially in obese patients

Epigastric vessels – Epigastric vessels – PreventionPrevention

• Place trocars in midline or lateral to rectus muscles

• At completion of case, examine port sites after trocar removal to assess for unrecognized bleeding

Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

Epigastric vessels-Epigastric vessels-ManagementManagement

Cautery / ligation from within the peritoneal cavity

Cautery / suture-ligation via cutdown over the trocar site

Suture-ligation through the abdominal wall with Keith needle / endoscopic suture passer

Anatomic distribution of nerves across Anatomic distribution of nerves across anterior abdominal wallanterior abdominal wallIlioinguinal nerve Iliohypogastric nerve

(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)

Incision line/trocar sites vs. nerve distributionIncision line/trocar sites vs. nerve distribution

Iliohypogastric n.

Ilioinguinal n.

Epigastric a.

Trocar sitePfannenstiel incision

(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.)

Bladder injury-Bladder injury-• Incidence of laparoscopic bladder injury

0.02%-8.3%*

• The bladder can be injured upon entry into abdomen or during laparoscopic procedure

• Bladder injury may go un-recognized until end of surgery

• Signs of possibly bladder injury- Urine leak from port site

(extra- or intra-abdominally)- Blood or gas in foley bag

• Risk factors for injury• Adhesions, endometriosis, prior

radiation, bladder diverticulum

Nehzat C et al. Laparoscopic management of intentional and unintentional cystostomy. Jnl Urol 1996;156:1400 Armenakas N et al. Iatrogenic bladder perforations. JACS 2004; 198:78

Bladder injury-Bladder injury-ManagementManagement• Mobilize the bladder around injury

- Expose / inspect bladder wall, ureteral orifices, bladder neck- Allows for tension-free repair

• One or two layer repair using absorbable sutures- Avoid staples or non-absorbable sutures- Nidus for calculi, granulomas, recurrent UTI, etc

• Foley catheter drainage post-op for 7-10 days

Tools:Tools:Laparoscopic entry systemsLaparoscopic entry systems

Hassan

Veress

• BLIND NON-VISUAL ENTRY

Insufflated entryClosed conventional trocarHigh pressure trocar entryRadially expanding trocar entry

Non-InsufflatedDirect sharp trocar entryOpen Hasson’s trocar entryGassless laparoscopy

Ternamian, Artin, MD, FRCSC. Laparoscopic Entry Safety.

Tools:Tools:Laparoscopic entry systemsLaparoscopic entry systems

Optiview

• VISUAL ENTRYOptical trocarEndopath OptiviewVISIPORTVisual cannulaENDOTIP Endoscopic Threaded Imaging PortOptical Veress mini-laparoscope

Ternamian, Artin, MD, FRCSC. Laparoscopic Entry Safety.

Veress needleVeress needle• Trendelenburg• Elevation• Direction of needle• Manometry test• Hissing sound test• Palmer test• Aspiration test: bowel contents or urine (remove

Veress) blood (leave in place)• In out 5cc • Drop test – flow 1 liter per minute

Veress needleVeress needle• Palmer’s entry point (LUQ)

3cm below costal margin, midclavicular

• Do not waggle the Veress1.6mm - 1cm (II - 1A*)

• 45° angle in non-obese(umbilicus below aortic bifurcation)90° angle in obese (II - 2B*) (umbilicus above aortic bifurcation)

• Use short Veress to allow for better control and tactile sensation

Palmer’s entry point

Bifurcation variability.

45° 90°

* Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47

Open laparoscopyOpen laparoscopyHassonHasson

• Vascular injury less than bowel injury• Viscera unusually cling to the point of trocar

insertion• 0.061 bowel injury• Partial or through and through• Usually noticed immediately

Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47

GuidelinesGuidelines• Veress intraperitoneal pressure (VIP) is a reliable indicator (II-1A*)• Elevation of abdominal wall not routinely recommended (II-2B*)• No evidence that open entry technique is superior or inferior to other

entry techniques (II-2C*)• Radially expanding trocars are not recommended as being superior to

traditional trocars (1A*)• Visual entry trocars are non-superior to other trocars since they do not

avoid visceral and vascular injury (2B*)• Left upper quadrant (LUQ-Palmer’s) laparoscopic entry should be

considered in patients with umbilical hernia or periumbilical adhesions (II-2A*)

• There is no evidence that the use of shielded trocars results in fewer visceral and vascular injuries (2B*)

*Vilos GA, Ternamian, Dempster J and Laberge PY. Laparoscopic Entry : A review of techniques, technologies and complications. Obstet Gynaecol Can, 2007 May; (5) 433-47

Vascular injuryVascular injury

• Incidence 0.01%-0.05%; Mortality 8-17%• Incidence closed > open technique• Warning signs:

- Blood from Veress needle- Sudden hypotension- Hemoperitoneum open camera entry- Retroperitoneal hematoma

• Once recognized, majority of major vascular injuries require conversion

Harkki-Sirren P et al. Major Complications of laparoscopy: Follow-up Finnish study. Obst Gyned 1999; 94:95Deziel DJ et cl. Complications of laproscopic cholecystectomy. Am J Surg 1993; 165:9Saville L et al. Laparoscopy and major retroperitoneal vascular injuries. Surg Endosc 1995; 9:1096Chapron et al. Major vascular injuries during gynecologic laparoscopy. JACS 1997

Vascular injury-Vascular injury-ManagementManagement

• Early diagnosis is critical to minimize morbidity/mortality

• For most major vessel injuries, the rule is to convert to laparotomy

• Minor injuries (e.g. omental bleeding) may be managed laparoscopically

• Appropriate vascular principles apply to any repair

Bowel injuryBowel injury• Incidence of 0.1%-0.7%*

• Caused by Veress or trocarpuncture

• Penetrating injuries usually recognized intra-operatively

• Timely diagnosis / treatment requireshigh index of suspicion and minimizes morbidity / mortality

Schrenk P et al. Mechanism, management and prevention of laparoscopic bowel injuries. Gastroin Endosc 1996; 43:572Bishoff J et al. Laparoscopic bowel injury: Incidence and clinical presentation. J Urol 1999; 161:887

Management of injuries detected at initial accessManagement of injuries detected at initial access

TIPS:• Puncture injuries & serosal tears may be repaired with simple intra-corporeal suturing

avoiding need for conversion• Extensive injuries to colon or those requiring resection / reanastamosis may require

laparoscopic diverting ostomy• Endoloop bowel injury easy to find and reduces contamination

Veress injury

Fecal odor / aspiration test

Find another entry and excise site of injury

Sharp trocar injuries

Serosa (superficial)

No further treatment

Deep (through and through)

Close transversely(if <1/2 direction of bowel

Small bowelBrownish fluid Careful inspection

Segmentalresection if >1/2 mesenteric supply interrupted

Second trocar insertionSecond trocar insertion

• Use two hands

• Under direct vision ALWAYS

• Generous skin incision

• Use corkscrew motion rather than pushing

• Clear adhesions

Remember it is much harder to defend 2nd trocar injury.

After second trocar insertionAfter second trocar insertion

TIP:

• If there are doubts about a bleeding injury at the first incision site, switch the camera to the second site and inspect the first site visually.

• Hemodynamic instability – open immediately

ConclusionConclusionCautiousCautious

CarefulCareful

PreventivePreventive