Page 21 - Textbook of Practical Laparoscopic Surgery by Dr. R. K. Mishra

20 SECTION 1: Essentials of Laparoscopy

Access Injuries to severe chronic obstructive pulmonary disease (COPD)
and cardiac disease may not be candidates for abdominal
The incidence of abdominal access injury was 5–30/10,000
procedures. Bowel and retroperitoneal vascular injuries insufflation given the physiologic changes related to
comprised 76% of all injuries, and almost 50% of small pneumoperitoneum. For patients with risk factors for
and large bowel injuries were unrecognized for at least complications, the laparoscopic approach and approach
24 hours. The overall reported rate of vascular injury to abdominal access need to be carefully planned; an open
arterial or venous injury ranges from 0.1 to 6.4/1,000 approach may be preferred. If possible, these patients
laparoscopies. Most injuries involve minor vessels; can be a candidate of gasless laparoscopic surgery. The
however, underreporting is common. Bladed disposable frequency of complications during access technique may
trocars with sharp blades are more likely to injure vessels be related to surgeon experience and the number of the
compared with smooth, pyramidal tip trocars that push specific procedures performed for some, but not all, types
the vessel out of the way. of minimal access surgical procedures.
The type and proportion of organ injury during abdominal Mild-to-Moderate Hypotension
access were as follows:
■ ■Small bowel (25%) In cases of moderate hypotension, the surgeon should
■ ■Iliac artery (19%) consider discontinuing gas insufflation immediately and
■ ■Colon (12%) reducing intra-abdominal pressure to 8.0 mm Hg. 360°
■ ■Iliac or another retroperitoneal vein (9%) scan of the abdominal cavity should be performed
■ ■Secondary branches of a mesenteric vessel (7%) immediately to rule out retroperitoneal bleeding. If
■ ■Aorta (6%) bleeding or expanding hematoma is seen, one should
■ ■Inferior vena cava (4%) proceed immediately to long midline laparotomy and
■ ■Abdominal wall vessels (4%) compression of the bleeding vessel. Blood should be
■ ■Bladder (3%) aspirated; bleeder is exposed, and bleeding should
■ ■Liver (2%) be controlled with vascular clamps. When necessary,
■ ■Other (<2%) operator should obtain assistance of a vascular surgeon.
Port-site metastasis refers to cancer growth at a port
incision site after laparoscopic tumor resection. Port-site Withdrawal of Instruments and Ports
metastasis occurs after 1–2% of laparoscopic procedures Once the surgery is finished, all the instrument should
performed in the presence of intraperitoneal malignancy, be removed carefully under vision. All the accessory port
which is equivalent to the rate of wound metastasis should be removed, and the gas is removed by releasing
after laparotomy performed under similar conditions. the valve of 10 mm cannulas. The primary port should be
Mechanism of metastasis includes hematogenous spread taken out in the end (Fig. 54).
or direct contamination by tumor cells, secondary effects If last port is suddenly withdrawn sudden suction
from pneumoperitoneum-related immune suppression, effect of cannula can pull the omentum or bowel inside the
and surgical technique. Although it is not clear whether
port-site metastases can be prevented, suggested measures
to minimize the risk of port-site metastases include the
use of wound protectors and specimen extraction bags,
instillation of agents to prevent tumor growth, and port-
site excision.
Access Injury Risk Factors
It is shown that patients who have had prior open surgery
for intra-abdominal or pelvic disease have a higher risk
of complications related to adhesions compared with
patients who do not have this history. Other conditions that
increase the risk of complications include extensive bowel
distention, very large abdominal or pelvic mass-like large
fibroid or abdominal cyst, and diaphragmatic hernia. In
addition, patients with poor cardiopulmonary reserve due Fig. 54: The tip of telescope should be introduced in and cannula is
pulled over telescope to prevent suction of omentum or bowel.