How to ID and treat intraoperative complications

Part 2Stapler misfire, ischemic segment, bladder invasion, small

bowel invasion, intraoperative bleeding

How to ID and treat intraoperative complications

Part 2Stapler 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

Morris E. Franklin Jr MD. F.A.C.S.

Director Texas Endosurgery Institute

Karla Russek, MD.

Research Fellow

MISS meeting 2010MISS meeting 2010

• W.L. Gore & AssociatesW.L. Gore & Associates– Grant/research support, consultant and speaker bureauGrant/research support, consultant and speaker bureau

• CovidienCovidien– Grant/research support, consultant and speaker bureauGrant/research support, consultant and speaker bureau

• StrikerStriker– Consultant, advisory boardConsultant, advisory board

• EthiconEthicon– Consultant and speaker bureauConsultant and speaker bureau

• AtriumAtrium– ConsultantConsultant

• AesculapAesculap– ConsultantConsultant

• KCIKCI– ConsultantConsultant

The Authors do not have financial interestThe Authors do not have financial interestwith the above mentioned companieswith the above mentioned companies

Industry relationshipsIndustry relationships

The pessimist sees difficulty in every opportunity. The optimist

sees the opportunity in every difficulty.

Winston Churchill

The pessimist sees difficulty in every opportunity. The optimist

sees the opportunity in every difficulty.

Winston Churchill

• Conversion rate of 23.5%Conversion rate of 23.5%

• Unclear anatomyUnclear anatomy Actually…..Actually…..• Stapler misfireStapler misfire Are all these stillAre all these still• BleedingBleeding reasons forreasons for• CystostomyCystostomy conversion????conversion????• EnterostomyEnterostomy• AdhesionsAdhesions• Adjacent organ invasionAdjacent organ invasion

Indications for Conversion to LaparotomyS Pandya, MD; JJ. Murray, MD; JA. Coller, MD; LC. Rusin, MDArch Surg. 1999;134:471-475

Laparoscopic ColectomyLaparoscopic Colectomy

Adjacent Organ invasion

Possible invasion to:

* Bladder* Small intestine

•Peritoneum (parietal and

visceral)•Uterus, ovaries

•Stomach•Omentum•Pancreas

•Abdominal wall

StatisticsStatisticsStatisticsStatistics

• Until 50 years ago, colorectal carcinoma infiltrating surrounding tissue was considered nonresectable

• Most of the time the diagnosis is made in the OR

• 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 Tumor subsite location and adjacent organ invasionadjacent organ invasion

Tumor subsite location and Tumor subsite location and adjacent organ invasionadjacent organ invasion

Multivisceral resection for locally advanced primary colon and rectal cancer. Thomas Lehnert, Mascha Methner, Andreas Pollok. Annals of Surgery, 2002Multivisceral 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

• 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 2009Multivisceral 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

• 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

Intraoperative bleeding

• Know the anatomy Know the anatomy other than Netter!!!other than Netter!!!

• If possible, dissect the If possible, dissect the artery from the veinartery from the vein

Some tips to prevent it:

Vascular control

Stapler Misfire

Colonoscopy and anastomosis leak test

Intestinal clamps

Liberal use of colonoscope

Colonoscopy and anastomosis leak test

AnastomosisAir leak test

IDBleedingIntegrity

The Use of Bioabsorbable Staple Line Reinforcement for Circular Stapler (BSG “Seamguard”) In Colorectal

Surgery. Initial Experience.

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 “

“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”

“You can not depend on your eyes when your imagination is

out of focus”

Morris E. Franklin Jr.Morris E. Franklin Jr.

www.texasendosurgery.comwww.texasendosurgery.com