Page 4 - World Journal of Laparoscopic Surgery

Nonbiliary Complications of Laparoscopic Cholecystectomy
Table 1: Trocar-related injuries
Presumed mechanism
No. Site of injury Age and sex of injury Presentation Interval surgery Type of surgery Outcome
1 Transverse colon 50 male Direct injury-trocar Intraoperative Immediate Laparotomy, Repair Survived
of perforation
2 Transverse colon 44 female Direct injury-trocar Intraoperative Immediate Laparotomy, Repair Survived
of perforation
3 Inferior vena cava 38 male Direct injury-trocar Intraoperative Immediate by Laparotomy + Death POD10
primary surgeon hemostatic suturing
reexploration
after 24 hours
Table 2: Dissection-related injuries
Presumed mechanism
No. Site of injury Age and sex of injury Presentation Interval surgery Type of surgery Outcome
1 Duodenum 45 male Dissection and Intraoperative Immediate Duodenorrhaphy Survived
adhesiolysis with omental patch
2 Duodenum 48 male Electrocautery Septicemia 10 days Tube duodenostomy Death POD10
peritonitis, duodenal feeding jejunostomy
fistula
3 Duodenum 58 female Electrocautery Septic shock, perito- 3 days Duodenorrhaphy Death POD4
nitis, biliary fistula with omental patch
4 Duodenum 65 male Electrocautery Septicemia, 7 days Duodenorrhaphy Death POD4
peritonitis with omental patch
5 Duodenum 57 female Dissection and Septic shock, biliary 4 days Duodenorrhaphy Death POD1
adhesiolysis fistula with omental patch
6 Ileum 55 female Electrocautery Peritonitis 5 days Ileal resection and Death POD10
adhesiolysis exteriorization
Inferior Vena Cava Injury Ileal Injury
A 38 years old male underwent laparoscopic cholecystectomy in a A 55-year-old female was taken up for laparoscopic cholecystectomy
peripheral rural hospital. He sustained injury to inferior vena cava in our unit. She had past h/o laparotomy, preoperatively there were
during primary insertion of trocar. Immediate laparotomy and repair small bowel adhesions to parietal wall. Laparoscopic adhesiolysis
of injury was done by primary surgeon, however he continued of small bowel was done to access gallbladder, followed by
to have low blood pressure despite on table repair and multiple laparoscopic cholecystectomy. On postoperative day 5, she
transfusion and was referred to our hospital after 14 hours for further developed diffuse abdominal pain, voluntary guarding and rigidity.
management. At the time of admission, he was hemodynamically Ultrasound abdomen revealed free fluid. Immediate exploration
unstable. After further resuscitation with blood and fresh frozen showed perforation of bowel from site of adhesiolysis, probably
plasma he was reexplored. Preoperatively active bleeding from thermal injury. Resection and exteriorization of bowel was done.
sutured IVC was detected, hemostatic suturing was done. However, However patient developed multiorgan dysfunction and died on
patient continued to be in shock, disseminated intravascular postoperative day 10 (Table 2).
coagulopathy and died on postoperative day 10 (Table 1). dIscussIon
Dissection-related Injuries Laparoscopic cholecystectomy is the standard operation for gall-
Duodenal injury stone disease. In comparison to open cholecystectomy laparoscopic
A total of five cases were of duodenal injury. In two cases duodenal approach has nearly two fold higher risk of major biliary, vascular
2
injury was recognized intraoperatively by the primary surgeon. Of and bowel complications. The approximate incidence of major bile
3,4
these two cases, one case was dealt with by primary surgeon with duct injury following laparoscopic cholecystectomy is 0.4–0.86%.
laparoscopic suturing. She developed duodenal fistula, septicemia The incidence of major retroperitoneal vascular injury such as
and multiorgan failure and was referred to us with septicemia abdominal aorta, inferior vena cava, iliac vessels is reported to be
5
shock on day 3. She could not survive despite resuscitation and 0.05%. The incidence of bowel injury has been reported to be
exploratory laparotomy. In second case, our team was called for between 0.06% and 0.32%. 6,7
intraoperative consult. In this patient duodenal repair was done In our study we have categorized nonbiliary injuries in two
after converting to laparotomy. Patient had uneventful outcome. In categories: (1) access-related injury, (2) dissection-related injury. The
another three patients, it was difficult laparoscopic cholecystectomy insertion of first trocar in laparoscopic cholecystectomy is dangerous
due to adhesions in Calot’s triangle, duodenal injury was not step with potential of bowel and vascular complication. Secondary
recognized intraoperatively. All of these three patients underwent ports being placed under vision have lower risk of complications.
delayed repair of duodenal perforation with duodenorrhaphy The faulty technique, surgeon’s inexperience, forceful thrust,
and omentopexy. However, all patients succumbed to persistent obesity, extreme thinness, previous abdominal surgery are the
8,9
septicemia and multiorgan failure (Table 1). predisposing factors for access-related complications. In our case
50 World Journal of Laparoscopic Surgery, Volume 12 Issue 2 (May–August 2019)