Neurologic Injury in Laparoscopic Surgery
The incidence of nerve injury associated with laparoscopy is more common in obese patient, but has been estimated at 0.5 per 1000 cases. Peripheral neurologic injury is usually related either to inappropriate positioning of the patient or occurs secondary to pressure exerted by the surgeon or assistants. During laparoscopy, nerve injury may happen rarely as a result of the surgical dissection.
In the lower extremity, the trauma may be direct, such as compression of the perineal nerve against stirrups. Alternatively, the femoral nerve or the sciatic nerve or its branches may be overstretched and damaged by inappropriate positioning of the hip or the knee joint.
Brachial plexus injuries may occur secondary to the surgeon or assistants leaning against the abducted arm during the procedure. Alternatively, if the patient is placed in steep Trendelenburg’s position, the brachial plexus may be damaged because of the pressure exerted on the shoulder joint.
Diagnosis
If nerve is damaged in most instances, the patient is found to have sensory and/ or motor deficit as they emerge from the effects of the anesthesia. The diagnosis can usually be suspected by clinical examination. Injuries to the perineal nerve will be reflected by loss of sensation in the lateral aspect of the leg and foot together with a foot drop. Brachial plexus injuries may be variable, but usually involve damage to the C-5, 6 roots manifesting in loss of flexion of the elbow and adduction of the shoulder. Electromyography can be used to further define the extent and location of the lesion by testing nerve conduction and recording the electrical potential for various muscles. This evaluation should be delayed for three weeks to allow for complete degeneration of injured nerves.
Prevention
During laparoscopic procedure if nerve injury has to be prevented then surgeon should must achieve a good ergonomics of patient. The incidence of brachial plexus injury can be reduced by placing the arms in an adducted position, which also facilitates the performance of pelvic surgery by allowing the surgeon to stand in a more comfortable position. Should it be necessary to leave the arm in an abducted position, adequate padding and support of the arms and shoulders are necessary and can be facilitated with the use of shoulder supports, preventing the slippage of the patient up the table when placed in Trendelenburg’s position. Furthermore, in such a position, the surgeon may not lean on the patient’s arm.
Sciatic and perineal nerve injury is minimized with the use of appropriate stirrups and careful positioning protocols. Those stirrups that combine both knee and foot support are probably best. Additional measures include simultaneous raising and lowering of the legs, flexion of the knees before flexion of the hips, and limitation of external rotation of the hip. Assistants should be admonished to avoid placing undue pressure on the inner thighs.
Injury to the obturator and genitofemoral nerves is uncommon but will likely increase as greater numbers of retroperitoneal dissections are performed. In such cases, it will be important to clearly understand the anatomy, maintain hemostasis, and to exert the utmost care in performing the dissections, carefully identifying the neural structures as they are encountered.
Management
Most injuries to peripheral nerves recover spontaneously. The time to recovery depends upon the site and severity of the lesion. For most peripheral injuries, full sensorineural recovery occurs in three to six months. Recovery may be facilitated with physical therapy, appropriate braces, and electrical stimulation of the affected muscles. Transection of major intrapelvic nerves will require open microsurgical repair.
Dissection and Thermal Injury
Recognition
Diagnosis of injury to the bowel incurred during the course of dissection may be more straightforward. Any length of dissected bowel should be carefully examined prior to proceeding further with the procedure. This is, if anything, more important during laparoscopic operations in comparison to those performed via laparotomy, for comprehensive “running” of the bowel near the end of the case is far more difficult under endoscopic guidance.
There has been confusion in the past regarding the frequency of thermal injury to bowel following the use of electrical energy. Formerly, many injuries actually caused by mechanical trauma were erroneously attributed to electrosurgical accidents.
Thermal injury to bowel may be more difficult to diagnose intraoperatively, particularly if created with electrical or laser energy, a feature that makes careful adherence to safety protocols a surgeon’s imperative. Even if thermal injury is recognized, it is difficult to estimate the extent of the damage by visual inspection, as the zone of desiccation may exceed the area of visual damage. An understanding of the differing impacts of the various types of electrical current is essential for estimation of the extent of injury. In some instances, diagnosis is delayed until the development of peritonitis and fever, usually a few days later, but occasionally not for several weeks.
Prevention
Total prevention of dissection or thermal injury is impossible, but the incidence of penetrating or energy based enteric complications may be reduced with patience, prudence, and meticulous technique. A sound understanding of the principles of electrosurgery is critical to reducing the incidence of electrical trauma.
When dissecting, exposure of the operative field must be accomplished with a combination of good visualization and adequate traction and, if necessary, countertraction applied by forceps. In many instances, it will be necessary to enlist the aid of a competent assistant. Dissection close to bowel should be performed mechanically, using sharp scissors, not with electrical or laser energy sources. Occlusion of blood vessels near to bowel is preferably accomplished with clips, but may be performed with bipolar current provided that there is an adequate margin of tissue, a circumstance that usually requires skeletonization of the vessel.
There is no certainty about the proper distance to maintain between the electrode and the bowel serosa. Animal histological studies, using the rather large caliber Kleppinger forceps, have demonstrated that desiccation injury begins to affect bowel serosa and muscularis between 5 and 10 mm away. It is likely that the zone of safety is less for instruments that compress tissue well or that use electrodes with a smaller surface area. Regardless, if the difficulty of the dissection makes the surgeon uncomfortable, alternative methods for hemostasis should be used. If this is not feasible, the aid of more experienced colleagues should be sought the procedure abandoned, or converted into an open case.
Management
The treatment of mechanical bowel trauma recognized during the dissection follows the principles described above for trocar injury. If the diagnosis is delayed until the postoperative recognition of peritonitis, surgical consultation should be obtained and laparotomy arranged.
Thermal injury may be handled expectantly, if the lesion is superficial and confined. It is possible to estimate the degree of tissue injury if the nature of the current and other parameters is known, such as the wattage, current density, and duration of contact with tissue. For example, fulguration current, arcing to bowel, is unlikely to cause thermal injury more than 1 mm deep, even with rather prolonged exposure. On the other hand, the high power density provided by a sharp electrode will quickly cause penetrating injury of the bowel. Such lesions will have relatively little collateral thermal injury and may be repaired as if they were created by mechanical means. This is a circumstance vastly different from that occurring when there is direct, and even relatively short, duration of contact (seconds) with a low power density electrode. The significant thermal injury that results will often mandate wide excision of the lesion or local resection of the injured segment of bowel.
The incidence of nerve injury associated with laparoscopy is more common in obese patient, but has been estimated at 0.5 per 1000 cases. Peripheral neurologic injury is usually related either to inappropriate positioning of the patient or occurs secondary to pressure exerted by the surgeon or assistants. During laparoscopy, nerve injury may happen rarely as a result of the surgical dissection.
In the lower extremity, the trauma may be direct, such as compression of the perineal nerve against stirrups. Alternatively, the femoral nerve or the sciatic nerve or its branches may be overstretched and damaged by inappropriate positioning of the hip or the knee joint.
Brachial plexus injuries may occur secondary to the surgeon or assistants leaning against the abducted arm during the procedure. Alternatively, if the patient is placed in steep Trendelenburg’s position, the brachial plexus may be damaged because of the pressure exerted on the shoulder joint.
Diagnosis
If nerve is damaged in most instances, the patient is found to have sensory and/ or motor deficit as they emerge from the effects of the anesthesia. The diagnosis can usually be suspected by clinical examination. Injuries to the perineal nerve will be reflected by loss of sensation in the lateral aspect of the leg and foot together with a foot drop. Brachial plexus injuries may be variable, but usually involve damage to the C-5, 6 roots manifesting in loss of flexion of the elbow and adduction of the shoulder. Electromyography can be used to further define the extent and location of the lesion by testing nerve conduction and recording the electrical potential for various muscles. This evaluation should be delayed for three weeks to allow for complete degeneration of injured nerves.
Prevention
During laparoscopic procedure if nerve injury has to be prevented then surgeon should must achieve a good ergonomics of patient. The incidence of brachial plexus injury can be reduced by placing the arms in an adducted position, which also facilitates the performance of pelvic surgery by allowing the surgeon to stand in a more comfortable position. Should it be necessary to leave the arm in an abducted position, adequate padding and support of the arms and shoulders are necessary and can be facilitated with the use of shoulder supports, preventing the slippage of the patient up the table when placed in Trendelenburg’s position. Furthermore, in such a position, the surgeon may not lean on the patient’s arm.
Sciatic and perineal nerve injury is minimized with the use of appropriate stirrups and careful positioning protocols. Those stirrups that combine both knee and foot support are probably best. Additional measures include simultaneous raising and lowering of the legs, flexion of the knees before flexion of the hips, and limitation of external rotation of the hip. Assistants should be admonished to avoid placing undue pressure on the inner thighs.
Injury to the obturator and genitofemoral nerves is uncommon but will likely increase as greater numbers of retroperitoneal dissections are performed. In such cases, it will be important to clearly understand the anatomy, maintain hemostasis, and to exert the utmost care in performing the dissections, carefully identifying the neural structures as they are encountered.
Management
Most injuries to peripheral nerves recover spontaneously. The time to recovery depends upon the site and severity of the lesion. For most peripheral injuries, full sensorineural recovery occurs in three to six months. Recovery may be facilitated with physical therapy, appropriate braces, and electrical stimulation of the affected muscles. Transection of major intrapelvic nerves will require open microsurgical repair.
Dissection and Thermal Injury
Recognition
Diagnosis of injury to the bowel incurred during the course of dissection may be more straightforward. Any length of dissected bowel should be carefully examined prior to proceeding further with the procedure. This is, if anything, more important during laparoscopic operations in comparison to those performed via laparotomy, for comprehensive “running” of the bowel near the end of the case is far more difficult under endoscopic guidance.
There has been confusion in the past regarding the frequency of thermal injury to bowel following the use of electrical energy. Formerly, many injuries actually caused by mechanical trauma were erroneously attributed to electrosurgical accidents.
Thermal injury to bowel may be more difficult to diagnose intraoperatively, particularly if created with electrical or laser energy, a feature that makes careful adherence to safety protocols a surgeon’s imperative. Even if thermal injury is recognized, it is difficult to estimate the extent of the damage by visual inspection, as the zone of desiccation may exceed the area of visual damage. An understanding of the differing impacts of the various types of electrical current is essential for estimation of the extent of injury. In some instances, diagnosis is delayed until the development of peritonitis and fever, usually a few days later, but occasionally not for several weeks.
Prevention
Total prevention of dissection or thermal injury is impossible, but the incidence of penetrating or energy based enteric complications may be reduced with patience, prudence, and meticulous technique. A sound understanding of the principles of electrosurgery is critical to reducing the incidence of electrical trauma.
When dissecting, exposure of the operative field must be accomplished with a combination of good visualization and adequate traction and, if necessary, countertraction applied by forceps. In many instances, it will be necessary to enlist the aid of a competent assistant. Dissection close to bowel should be performed mechanically, using sharp scissors, not with electrical or laser energy sources. Occlusion of blood vessels near to bowel is preferably accomplished with clips, but may be performed with bipolar current provided that there is an adequate margin of tissue, a circumstance that usually requires skeletonization of the vessel.
There is no certainty about the proper distance to maintain between the electrode and the bowel serosa. Animal histological studies, using the rather large caliber Kleppinger forceps, have demonstrated that desiccation injury begins to affect bowel serosa and muscularis between 5 and 10 mm away. It is likely that the zone of safety is less for instruments that compress tissue well or that use electrodes with a smaller surface area. Regardless, if the difficulty of the dissection makes the surgeon uncomfortable, alternative methods for hemostasis should be used. If this is not feasible, the aid of more experienced colleagues should be sought the procedure abandoned, or converted into an open case.
Management
The treatment of mechanical bowel trauma recognized during the dissection follows the principles described above for trocar injury. If the diagnosis is delayed until the postoperative recognition of peritonitis, surgical consultation should be obtained and laparotomy arranged.
Thermal injury may be handled expectantly, if the lesion is superficial and confined. It is possible to estimate the degree of tissue injury if the nature of the current and other parameters is known, such as the wattage, current density, and duration of contact with tissue. For example, fulguration current, arcing to bowel, is unlikely to cause thermal injury more than 1 mm deep, even with rather prolonged exposure. On the other hand, the high power density provided by a sharp electrode will quickly cause penetrating injury of the bowel. Such lesions will have relatively little collateral thermal injury and may be repaired as if they were created by mechanical means. This is a circumstance vastly different from that occurring when there is direct, and even relatively short, duration of contact (seconds) with a low power density electrode. The significant thermal injury that results will often mandate wide excision of the lesion or local resection of the injured segment of bowel.
