Port related injury in
laparoscopic surgery
Dr Krishan kant
DNB(MAS), M.S, DNB, MNAMS
FIAGES, FMAS, FICLS
Advanced Laparos...
Dr Kurt Semm
-Therapeutic
laparoscopy
1970s
-Ovarian cyst
enucleation
1971
-Laparoscopic
appendectmy in
1981 germany
Statistics in laparoscopy
- 50% of the trocar-related injuries to the bowel
and vasculature are during the initial entry.
...
WHY COMPLICATIONS?
Experience: 4 fold if > 100 cases
Complexity: 9 fold if more complex
Patient risk: As ASA increases so ...
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 tr...
ENTRY
A good beginning is essential:
“More than one half of the complications related
to laparoscopy are related to the en...
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...
Access Related Complications (0.03 – 1%)
• Extraperitoneal insertion
• Vascular injury
– Abdominal wall vessels
– Retroper...
1.VERESS NEEDLE
• The operator should feel or sense the
needle passing through two distinct
planes.
• The needle is advanc...
Veress placement
TRANSPERITONEAL STANDARD
ENTRY
Veress needle:
• Test needle prior to
placement.
• Aspirate, irrigate, aspirate
(then irrig...
Insufflation
Set pressure cut off to at least 20-25mmHg
Start at low flow (1L/min)
Check gas entering at low pressure (<8m...
The greater the gas bubble & abdominal wall tension the less the risk
of bowel injury
Abdominal pressure= 8mmHg Abdominal ...
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 ...
• The primary trocar should be inserted at 90
degrees to the skin, through the incision at
the base of the umbilicus
• Onc...
Trocar placement
Secondary ports are inserted under direct vision - an inadvertent injury
from a secondary port could be considered neglige...
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 epiga...
Alternatives to closed umbilical entry considered:
If there is risk of umbilical adhesions - previous
(midline) laparotomy...
WHERE’S THE BEST
PLACE?
Entry sites: 5!
 Umbilical
(Danger – IVC/Aorta)
 (Palmer’s point) / Left
MCL subcostal
(Danger –...
5.HALS and outcome
• principle of master slave manipulator.
• The da Vinci system
• The Zeus system
Complication-
• Not accurate precision
• ...
INTRAOPERATIVE
COMPLICATIONS
The BIG 3:
1. Cardiac arrest
2. Vascular
3. Bowel
The others: Spleen, Liver, Pancreas, Bladde...
VASCULAR INJURY
Overview:
Incidence: 0.5 – 2.8%
Conversion: 50%
Mortality: 9-17%
Mechanism:
1. Veress needle: 38%
2. Troca...
Complications
Vascular Injuries
Vessel Injury :
• Larger vessels may be injured by trocar or veress
needle.
• CO2 peritoneum may tamponade a large vessel
...
TROCAR INJURY: ABDOMINAL
WALL
The most common site is from the
inferior and superior epigastric vessels.
The overall incid...
Epigastric Vessels injury –
• Deep epigastric vessels most frequently injured in
laproscopic hysterectomy
Management –
By ...
Complications
Injury to Small Bowel :
Bowel - May be injured due to trocar or veress needle
If due to veress needle it is managed conser...
Injury to Urinary Bladder :
Bladder - Injury caused by second puncture trocar
usually .
Diagnosis : Appearance of gas and ...
Direct Coupling damage
Direct Coupling Damage
Exit techniques
Wound closure:
Proper closure of fascia within umbilical
port site to prevent wound dehiscence or
hernia
A...
Take home message
• 5.5-6 cm. off the midline to avoid the epigastric vessels*
• “In order to operate fast, it is necessar...
Port related injury in laparoscopic surgery ppt
Port related injury in laparoscopic surgery ppt
Port related injury in laparoscopic surgery ppt
Port related injury in laparoscopic surgery ppt
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Port related injury in laparoscopic surgery ppt

Published on: Mar 4, 2016
Source: www.slideshare.net


Transcripts - Port related injury in laparoscopic surgery ppt

  • 1. Port related injury in laparoscopic surgery Dr Krishan kant DNB(MAS), M.S, DNB, MNAMS FIAGES, FMAS, FICLS Advanced Laparoscopic and Bariatric surgeon at Central Railway Hospital (Jabalpur)
  • 2. Dr Kurt Semm -Therapeutic laparoscopy 1970s -Ovarian cyst enucleation 1971 -Laparoscopic appendectmy in 1981 germany
  • 3. 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
  • 4. 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)
  • 5. COMPLICATIONS 1. Entry 2. Pneumoperitoneum 3. Intraoperative 4. Postoperative a. Early b. Late
  • 6. ABDOMINAL ACCESS INSTRUMENTS Open Technique Closed Technique Hasson Cannula Veress Needle Trocar Sheath Assemblies Opti trocar
  • 7. 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)
  • 8. 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)
  • 9. Access Related Complications (0.03 – 1%) • Extraperitoneal insertion • Vascular injury – Abdominal wall vessels – Retroperitoneal vessels – Mesenteric vessels • Visceral injury – Stomach, bowel, liver, spleen, bladder
  • 10. 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.
  • 11. Veress placement
  • 12. 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.
  • 13. Insufflation Set pressure cut off to at least 20-25mmHg Start at low flow (1L/min) Check gas entering at low pressure (<8mmHg) After 0.5L flow rate can be increased Insufflate to pressure cut off (20-25mmHg) 1. Veress cont.....
  • 14. 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
  • 15. 2. Primary port cont.... Commonest problem - failed entry Insertion of subumbilical Veress needle
  • 16. Closed entry can still cause bowel injury, especially if adhesions are present 2. Primary port cont....
  • 17. • 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)
  • 18. • 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)
  • 19. Trocar placement
  • 20. Secondary ports are inserted under direct vision - an inadvertent injury from a secondary port could be considered negligent” Principles Avoid inferior epigastric vessels Avoid bowel/vascular injury Minimise hernia risk 3. Secondary ports
  • 21. Round ligament Obliterated umbilical artery Rectus muscles Mid-line 3. Secondary ports - Anatomy
  • 22. • 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
  • 23. Alternatives to closed umbilical entry considered: If there is risk of umbilical adhesions - previous (midline) laparotomy In very slim or morbidly obese women Failed 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
  • 24. 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)
  • 25. 5.HALS and outcome
  • 26. • principle of master slave manipulator. • The da Vinci system • The Zeus system Complication- • Not accurate precision • Conversion take time. 6.Robotic Surgery
  • 27. INTRAOPERATIVE COMPLICATIONS The BIG 3: 1. Cardiac arrest 2. Vascular 3. Bowel The others: Spleen, Liver, Pancreas, Bladder, Ureter, Diaphragm, Instrumentation, Oliguria
  • 28. 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)
  • 29. Complications
  • 30. Vascular Injuries
  • 31. 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.
  • 32. TROCAR INJURY: ABDOMINAL WALL The 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)
  • 33. 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)
  • 34. Complications
  • 35. 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
  • 36. 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.
  • 37. Direct Coupling damage
  • 38. Direct Coupling Damage
  • 39. 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
  • 40. 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

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