PREVENZIONE DELLE

COMPLICANZE

Massimo Luerti

U.O. Ostetricia Ginecologia 1

A.O. della Provincia di Lodi

massimo.luerti@ao.lodi.it

www.massimoluerti.com

INCIDENCEIT IS DIFFICULT TO COMPARE THE VARIOUS

PUBLISHED SERIES

– HETEROGENEOUS POPULATIONS

– MIXTURE OF DIAGNOSTIC PROBLEMS

– DIFFERENT LEVELS OF OPERATIVE LPS

QUERLEU 1.08 - 5.23 ‰

NEZHAT 3.08 - 6.949 ‰

MAJOR COMPLICATIONS PER 1000

OPERATIVE LAPAROSCOSCOPIES

By Site of Injury

•Vessels/bleeding 2.6-11.0 ‰

•Bowel 0.6-2.0 ‰

•Genitourinary 0.6-1.6 ‰

•Nerve 6.1 ‰

•Uterine perforation 3.7 ‰

Complicanze gravi da accesso in laparoscopia

N Casi D Intest D Vascolari

Mintz 1977 99204 0.3 ‰ 0.5 ‰

Loffer 1975 32719 0.7 ‰ -

Berqvist 1987 75035 - 0.07 ‰

Querleu 1993 17521 0.4 ‰ 0.2 ‰

Chapron 1998 29966 0.5 ‰ 0.2 ‰

Harkki-Siren 1999 102812 0.3 ‰ 0.1 ‰

Totale 357257 0.4 ‰ 0.2 ‰

Danni intestinali

N Casi N %

Laparotomia 5700 48 8.4/1000

Chir Vaginale 965 7 7.3/1000

Laparoscopia 3710 11 3/1000

RCU 7575 11 1.5/1000

Krebs Am J Ob Gyn 1986;15:509-14

MAJOR COMPLICATIONS PER 1000

OPERATIVE LAPAROSCOSCOPIES

By instrument

•Veress needle 2.7 ‰

•Large trocar 2.4-2.7 ‰

•Accessory trocar 2.5-6.0 ‰

•Electrosurgery 0.5-2.8 ‰

•Pneumoperitoneum 7.4 ‰

STRUMENTI CAUSA DI DANNI VASCOLARI IN

47 PROCEDIMENTI MEDICO-LEGALI

Ago di Veress 4

Trocar Principale 24

Riutilizzabile 10

Monouso 11

“Open Laparoscopy” 3

Trocar accessorio 4

Forbici 4

Suturatrici 2

Bisturi 3

Elettrobisturi monop. 5

R Soderstrom J of AAGL May 97

POSIZIONE DELLA PAZIENTE

• Compressione del nervo peroneale

• Stiramento del nervo otturatorio

• Stiramento del plesso brachiale

• Lacerazione o rottura di dita e mani

RISCHI!!!

POSIZIONE DELLA PAZIENTE

•Paziente supina con gambe divaricate, leggermente flesse, mantenute da specifici supporti

•Natiche a livello del bordo del tavolo operatorio

•Braccio sinistro lungo il corpo

•Vescica vuota

•Assenza di separazione tra l’operatore e l’anestesista

•Reggispalle posizionati

PATIENT POSITIONING• Don’t flex the hips beyond a 90 degree angle

• Avoid pressure over the head of the fibula

• Pay attention to the abduction of the thighs

• Tuck the arms by the patient’s sides, rather than allowing

them to remain outstretched on the armboards

• Tuck the arms only after the legs have been properly

positioned and the bottom part of the operating table

has been dropped down

• Replace the arms on the armboards before the bottom

of the table is brought up into the horizontal position

PERFORAZIONE DA ELEVATORE

L’inserimento dell’ago di Veress e

del trocar ombelicale sono i

momenti più critici della

laparoscopia.

Oltre il 50% delle complicanze più

gravi occorrono in questa fase.

MAJOR ENTRY COMPLICATIONS

INCLUDE BOWEL AND MAJOR

VESSEL INJURY AT

FREQUENCIES OF 0.04% TO 0.5%

AND 0.01% TO 1.0%,

RESPECTIVELY

Vilos G.A., Laparoscopic bowel injuries: Forty litigated gynecological cases in Canada, J Obstet Gynecol Can, Volume: 24, (2002), pp. 224--230

Jansen F.W., Kolkman W., Bakkum E.A., de Kroon C.D., Trimbos-Kemper T.C.M., Trimbos J.B., Complications of laparoscopy: An inquiry about

closed-versus open-entry technique, Am J Obstet Gynecol, Volume: 190, (2004), pp. 634--638

Fuller J., Scott W., Ashar B., Corrado J., Laparoscopic trocar injuries: a report from a U.S. Food and Drug Administration (FDA) Center for Devices

and Radiological Health (CDRH) Systematic Technology Assessment of Medical Products (STAMP) Committee. 1-14, (2005),

CLASSIFICAZIONE DELLE LESIONI

DA ACCESSO IN LAPAROSCOPIA

• Tipo 1 Lesioni su organi in posizione normale

• Tipo 2 Lesioni su organi aderenti alla parete

addominale

A Consensus Document Concerning laparoscopic entry techniques:

Middlesbrough UK, March 19-20 1999

Risk factors for Veress needle

and trocar insertion

• Previous abdominopelvic surgery

• High or low body weight

• Very large uterus

• Large pelvic masses

RISK OF ADHESIONS IN PATIENTS WITH

PREVIOUS ABDOMINOPELVIC SURGERY

– Adhesions to Anterior Abdominal Wall

• Previous Incision

– 27% Pfannenstiel

– 55% midline below umbilicus

– 67% midline above umbilicus

• Hx – Pelvic/Abdominal Infection

– Abscess, Ruptured Appendix

Brill, Ob/Gyn, 1995

RISK OF ADHESIONS IN PATIENTS WITH

PREVIOUS ABDOMINOPELVIC SURGERY

• Patients with multiple abdominal incision have moreadhesions than patients with Pfannestiel incision

• Patients with multiple abdominal incision have notmore adhesions than patients with a single incision

• Patients with Pfannestiel incision for gynecologicsurgery have more adhesions than patients with thesame incision for obstetric surgery

• Patients with longitudinal incision have not moreadhesions than patients with Pfannestiel incision if thesurgery is obstetric

COMPLICATIONS OF THE INDUCTION

OF PNEUMOPERITONEUM

1. Extra-peritoneal gas insufflation

2. Subcutaneous, pre-peritoneal and mediastinal

emphysema

3. Pneumothorax

4. Pneumo-omentum

5. Injury to gastro-intestinal tract

6. Bladder injury

7. Blood vessel injury

8. Gas embolism

9. Puncture of liver or spleen

I° passo: Aspirazione, che non deve produrre aria o liquido,

accertando l’assenza di perforazione vascolare, urinaria, intestinale

II° passo: Iniezione di 20 cc di aria o liquido. Non si dovrebbe

percepire resistenza e non dovrebbe essere possibile aspirare il

liquido. E’ un metodo semplice per confermare che non c’è contatto

con visceri intraaddominali o aderenze

III° passo: Tentativo di riaspirare l’aria o il liquido iniettato. Se il

Veress è nello spazio preperitoneale o nelle fibre muscolari del

muscolo retto, il tentativo può avere successo

CONTROLLI DURANTE LA CREAZIONE

DEL PNEUMOPERITONEO

• Osservare la pressione intraddominale e gli indici di

resistenza sui display dell’insufflatore elettronico

• Verificare con la percussione la scomparsa

dell’ottusità epatica (dopo circa 0,5-1 l. di CO2), la

diffusione dell’onda sulla parete addominale e il

corretto sviluppo del pneumoperitoneo

• Mappare la profondita della falda di gas aspirando

gas attraverso un ago da spinale 18 G, connesso ad

una siringa contenente 5-10 cc di soluzione fisiologica

GAS EMBOLISM

CARBON DIOXIDE INTRODUCED INTO LARGE VEIN

WITH VERESS (rare) -> RIGHT VENTRICLE ->

PULMONARY ARTERY -> COLLAPSE ->CYANOSIS

• RECOGNITION :

– BLOOD ON THE VERESS

– CARBON DIOXIDE CONCENTRATIONS

• MANAGEMENT

– STOP INSUFFLATION

– DON’T REMOVE VERESS

– RESUSCITATION

INSERZIONE TROCAR

Evitare la posizione di Trendelemburg

COMPLICANZE DA INTRODUZIONE DEL

TROCAR PRINCIPALE

• Sanguinamento della parete

addominale

• Perforazione di un viscere

• Lacerazione di un vaso

• Danni epatici o splenici

No randomised studies confirm that

disposable trocars are safer than the

reusable ones

Easy insertion of the former may cause

vascular or intestinal injuries, if

excessive strength is used

• Tecnica classica 0.3‰

• Open Laparoscopy 0.4‰

• La open laparoscopy elimina solo

le lesioni di tipo 1

LESIONI INTESTINALE DA ACCESSO

OPEN vs CLOSED• The Swiss Association for Laparoscopic and

Thoracic Surgeons : In contrast to general surgery publications the OPEN access method used in the current series failed to show any superiority over the Closed method

• The european Ass for endoscopic surg: there are similar bowel injuries but no major vascular injuries with the open technique

• AJOG 2004 : the number of entry-related complications in the OPEN technique was significantly higher than the CLOSED

COMPLICANZE VASCOLARI

•Incidenza 0,05%

•Mortalità 8-17%

PREVENTION OF VASCULAR INJURIES• Adequate skin incision

• Feel with fingers the position of aortic bifurcation remembering that in 80% of cases it is situated 1,25 cm from the level of iliac crest

• Position of umbilicus variable

• Manually elevate abdominal wall,

mainly in thin women: avoid Bachaus

• The trocar must have a sharp tip

• Stay in midline

– Thin: 45 degrees

– Obese: 90 degrees

• No Trendelenburg

• Pressure at insertion

– Higher (15-18 mm) is better ?

MIDLINE

VASCULAR INJURY

Large retroperitoneal vessels

• PRESENTATION:

– PERITONEAL OR RETROPERITONEAL BLEEDING OR

HAEMATOMA

– DROP OF BLOOD PRESSURE

• MANAGEMENT:

– DON’T REMOVE VERESS/TROCAR

– DO NOT OPEN PERITONEUM

– MIDLINE LPT

– APPLY A PRESSURE OVER THE SITE OF DEFECT

– VASCULAR SURGEONS/ANAESTHETIC STAFF

INSERZIONE DEI TROCAR ACCESSORI

• Transilluminazione della parete addominale

• Premere col dito nella sede di inserzione

• Inserzione sotto controllo della vista nel “triangolo di sicurezza”

• Identificazione con la pressione digitale della zona avascolare lateralmente ai vasi epigastrici

• Inserzione dei trocars sotto controllo visivo, perpendicolarmente alla parete, fino al peritoneo, e quindi in direzione del Douglas

• Usare trocars a punta conica?

Anatomia laparoscopica

COMPLICANZE LEGATE

ALL’ALTO FLUSSO DI CO 2In un trocar di 10 mm di diametro, senza strumenti all’interno, il flusso massimo di gas sarà di circa 6.5 (+/- 0.5) litri/min.

E’ inutile usare flussi superiori ai 10 l/min.

Se il flusso supera 3 litri / min., la pressione istantanea della macchina diventa significativamente più alta della pressione media del pneumoperitoneo.

Queste alte pressioni di insufflazione sono implicate in:

• enfisema sottocutaneo

• ipercapnia

• rischio di embolia gassosa.

L’alto flusso non dovrebbe essere utilizzato che in particolari condizioni (laser, cambio di trocar etc.)

PREVENTION OF GASTRIC LESIONS

• Insert an oral gastric tube after anesthesia

induction, mainly in case of difficult

intubation or masked hyperventilation

• Elevate the abdomen and correctly insert

the needle

• Induce an adequate pneumoperitoneum

before insertion of trocar

TROCAR REMOVAL

• Also under direct vision

• Release pneumo-peritoneum

• Re-inspect trocar sites

• Inspect umbilical port

– On way out

INCISIONAL HERNIA

• RECOGNITION:– PAIN, TENDER SWELLING

– X-RAY, CT, US

– DD: HAEMATOMA

• MANAGEMENT– REDUCE AND REPAIR

• PREVENTION:– CLOSURE OF THE FASCIA >10mm

– TROCAR VALVE CLOSE

– SECONDARY REMOVED FIRST AT LOW INTRAABDOMINAL PRESSURE AND

UNDER DIRECT VIEW

– INSERT A SOUND INTO THE SLEEVE BEFORE REMOVING IT

– SLOWLY MOVE ABDOMINAL WALL AFTER THE EXTRACTION OF THE

INSTRUMENTS

RECOMMENDATIONS TO AVOID ELECTROSURGICAL COMPLICATIONS

• Inspect insulation carefully

• Use lowest possible power setting

• Use a low voltage waveform (cut)

• Use brief intermittent activation vs. prolonged activation

• Do not activate in close proximity or direct contact with another instrument

• Use bipolar electrosurgery when appropriate

• Select an all metal cannula system as the safest choice

• Do not use hybrid cannula systems that mix metal with plastic

• Utilize available technology, such as a tissue response generator

to reduce capacitive coupling or an active electrode monitoring system,

to eliminate concerns about insulation failure and capacitive coupling

CUT BLEND COAG

Type of Current

PREVENTION OF BLADDER INJURIES

• Insert indwelling or “in-out” catheter

• Alternatively ask the patient to void just

before the operation

• If the limits of the bladder are not clear-cut,

fill it with 300 ml saline

• Identify high risk patients (previous surgery,

mainly CS)

• Warning to the bladder dissection in LAVH

INJURY TO THE URINARY TRACT

• RECOGNITION:

– IMMEDIATE (rarely):INDIGO -CARMINE

I.V.

– DELAYED: NON-SPECIFIC SYPTOMS

• MANAGEMENT:

– STENT

– UROLOGICAL SURGEON

PREVENTION OF URETERAL INJURIES

• Identification

• Isolation the ureter in case of endometriosis, LUNA or other

risky procedures

• Injection of fluid in the retroperitoneal space

• Bipolar coagulation with continuos visualisation of the

coagulated tract and of the structures nearby and for a short time

• Catheterise the ureter ( ev. with transilluminated catheter)

BOWEL INJURYNOT RECOGNIZED

• CAUSATION:

– LACERATION (VERESS/TROCAR)

– THERMAL INJURY

• RECOGNITION:

– FOUL SMELLING GAS

– GREENISH FLUID

– BOWEL MUCOSA

INC

IDE

NC

E 1

.8/1

000

PREVENTION OF SURGICAL INJURIES OF SMALL BOWEL

• Direct mechanical injury is less frequent than thermalone

• If unipolar forceps are used, pay attention to insulationand leave the bowel outside the energy field

• If bipolar forceps are used, don’t touch the bowelneither during nor immediately after the activation

• In adhesions between bowel-adnexa or bowel-pelvicsidewall remain nearer to genital structures or tovaginal or abdominal wall

• Prevent bleeding or washing operating field to look foravascular planes avoiding uncontrolled gesture

PREVENTION OF INTRAOPERATIVE

LARGE INTESTINE INJURIES

• Avoid non controlled trocar insertion

• Avoid non controlled insertion of sharp instruments

• to the distortion of anatomy for endometriosis or

previous surgery

• to the dissection of Douglas in case of endometriosis

PAY ATTENTION!!!!!

LAPAROSCOPIARACCOMANDAZIONI POSTOPERATORIE

•Stendere una descrizione dettagliata dell’intervento

(comprendente il nome degli strumenti, le sorgenti di

energia, le potenze utilizzate).

•E’ utile aggiungere documentazione fotografica.

•Ricordare che il dolore dopo una laparoscopia

dovrebbe diminuire costantemente nel tempo.

L’aumento o il mantenimento del dolore è un segno di

pericolo.

GRAZIE PER

L’ATTENZIONE

www.massimoluerti.com