Page 41 - Journal of Laparoscopic Surgery - WALS Journal

WJOLS

Entry Techniques for creating Pneumoperitoneum
intraoperative complications associated with laparoscopy laser ablative endometriosis surgery or laparoscopic-
occur at the time of surgical entry. The most devastating assisted vaginal hysterectomy. There are reports of
among these is major vascular injury, and half of all bowel ureteral injuries during laparoscopic tubal ligation,
injuries occur during entry, with the small intestine at adnexectomy, and lap uterosacral ligament ablation.
highest risk. Ureteral injuries were identified with incidence rates
ranging from 0.025 to 2%. 6,7
Bowel Injury
RECOMMENDATIONS FOR SAFE ENTRY
Bowel injury during MAS is a rare but serious complica-
tion. A cautery injury to the bowel can cause delayed • In case of a patient with history or presence of peri-
perforation of the viscus, thus increasing the possibility of umbilical hernia, periumbilical adhesions, three failed
a preventable morbidity. Patients presenting with features insufflation attempts at the umbilicus, left upper
of perforation peritonitis within 24 hours and up to 2 to 3 quadrant point known as Palmer’s point should be
8
weeks after laparoscopic Bovie injury to the bowel have considered for entry. Other sites that can be used are
been reported in the literature. transuterine, trans cul-de-sac, 9th or 10th intercostal
Cautery injury to the bowel has a hidden depth, space.
causing a slow transmural tissue necrosis, and it might • Waggling of Veress needle from side to side must be
also impair local healing and eventually lead to perfora- avoided as this can enlarge a small puncture injury
tion. Thus, the patient may present later than the usual to a bigger one. 9
period for wound healing and remodeling as previously • Various Veress needle tests can be done, though these
reported. Given the disastrous consequence, it is impera- provide very little information on the placement of
tive to perform a good surgical repair of even a minor needle.
cautery injury to the bowel. 3 • Attach the carbon dioxide source to the Veress needle
The small intestine was most frequently injured on entry as Veress intraperitoneal pressure is a reliable
(55.8%), followed by the large intestine (38.6%). In most of indicator of correct intraperitoneal placement of
these cases the diagnosis was made during the laparoscopy Veress needle.
or within 24 hours thereafter. Laparoscopy-induced bowel • The angle of the Veress needle insertion should vary
injury is associated with a high mortality rate of 3.6%. 4 according to the body mass index of the patient, from
45° in nonobese women to 90° in obese women. 10
Vascular Injury • Adequate pneumoperitoneum should be determined
by a pressure of 20 to 30 mm Hg and not by predeter-
Vascular injuries are usually induced by the insertion mined CO volume.
2
of the Veress needle or the first/primary trocar, because • Hasson’s method of entry can be used as an alterna-
both are usually introduced blindly. The insertion of tive to Veress needle technique, although there is no
the secondary trocars has a lesser risk, because they are evidence that the open entry technique is superior
placed under direct vision. During access into abdominal to or inferior to the other entry techniques currently
cavity the most dangerous complications of entry are available.
to great vessels like aorta, vena cava, and common iliac • Direct insertion of the trocar is associated with less
vessels. Vascular injury is one of the major causes of insufflation-related complications, e.g., gas embolism
mortality from laparoscopy, with a reported mortality and its insertion without prior pneumoperitoneum
of 15%. The reason of these injuries is the close proximity is considered as a safe alternative to Veress needle
of anterior abdominal wall to the retroperitoneal vascular technique.
structures. The most common minor vascular injury is • Shielded trocars may be used in an effort to decrease
to the inferior epigastric vessels and superior epigastric entry-related injuries. 11,12
vessels occurring in up to 2.5% of lap hernia repairs. 5 • After introduction of the telescope, the bowel should
be inspected for obvious injury and abdomen
Urological Injuries visualized for presence of adherent bowel around the
umbilicus.
The incidence of bladder injury during laparoscopic
procedures ranged from 0.02 to 8.3% as is evident from
various studied articles. Most frequently, these injuries CONCLUSION
occurred during laparoscopic-assisted vaginal hysterec- Any surgical procedure whether open/conventional
tomy. Sharp electrosurgical dissection was the leading or laparoscopic has its respective risks and associated
instrument causing injury. Ureteral injuries during lapa- complications. Complications can occur even at the best
roscopic gynecological surgeries typically occur during of hands and it is vital that these are recognized promptly
World Journal of Laparoscopic Surgery, January-April 2016;9(1):38-40 39