Dr. Mahesh Patwardhan is famous gynechologist doctor in UK. He is good consultant providing on obstetrics and gynaecology in UK. He is best laproscopy surgen.

1. www.slh.nhs.uk
Complica)ons of laparoscopic
surgery
Mr Mahesh Patwardhan
M.D., F.R.C.O.G.
Consultant Laparoscopic Surgeon
South East London NHS Healthcare
London, U.K.

2. What is a complication?
l A Complication is a concurrence of various
causes and conditions in the course of surgical
procedure, which do not normally form part of it
and which usually make it more serious.
l Historical Evolution of the risks of complications
Period Laparoscopic
Surgery
Complications
’70 –
’85
Initial Period Due to Technique
’85-’90 Development Due to indications
’90- Globalisation Due to Surgeon

3. Patterns of Risk factors
l The use of incorrect or unfamiliar
instruments.
l First and subsequent access routes.
l Surgical Technique and alternative route.
l Electrosurgical applications.
l Level of proficiency of the surgical team.

4. Learning the correct technique –
the governance side!
l Successful results of laparoscopic surgery
are essentially accomplished by good
technique and application of ergonomic
principle.
l .

5. System in U.K.
l U.K. – Single standardising body
(R.C.O.G.)
l Advising bodies – B.S.G.E., NICE.
l Advanced and intermediate level
certification.
l Training period – Minimum number.
l Private sector – Practices have to be
consistent with NHS practice.
l Compulsory approved training courses.
l G.M.C.

6. Complications related to Access
entry
l Veress needle or
direct entry?
l Umbilical port or
Palmer’s point.
l Metal ports or newer
ports?
l Correct entry and
placement of the
second port.

7. Inferior Epigastric Artery
Landmarks

8. Inferior epigastric - Anatomy

9. Inferior epigastric artery

10. Phipp’s Needle

11. What to do?
l Phipp’s Needle.
l Endocatch.
l Deep Suture.
l Foley’s catheter.
l Suturing under direct
vision.

12. Injury due to port entry
l Injury to bowel –
serosal, complete,
small / large bowel.
l Injury to major vessel
such as aorta,
common iliac,
external iliac etc.
l Surgical emphysema.

13. What to do?
l Bowel Injury – Most important –
identification.
l Laparoscopic suturing only if proficient.
l Major Vessel Injury - call for help.
l Pressure to stop the loss.
l Always a multidisciplinary approach.
l Correct documentation and
communications.

14. Port Hernias
l Larger Ports –
Morcellator.
l What to do?
l Prevention – Phipp’s
Needle, Endocatch, J
Shaped Needle.
l If Recognised early, - Jet
wash to separate, check
viability
l Multidisciplinary approach

15. Complications due to
electrosurgery
l Grounded versus isolated
generators. Current
division and alternate site
burns
l Direct coupling
l Capacitive coupling
l Insulation failure
l Return electrode site
burns – Large area, low
impedance ( excess hair,
fatty tissue, bony
prominence, adhesive
failure, fluid invasion, scar
tissue)

16. ACTIVE SURGICAL TEMPERATURES
Vaporization
of water
dessicates
tissues
Eschar forms
when tissues
burn
Eschar
(oxidation)
Protein
Coagulation
Proteins
disorganize
to form a
coagulum
HARMONIC Electrosurgery/Laser Surgery
50º C 100º C 150º C 400º C+
Tissue
Dessication

17. Amaral JF, Chrostek CA. SAGES, 1995.
0
10
20
30
40
50
60
70
Time (sec)
Lateral
spread
(cc²)
Electrosurgery
UltraCision
0 1 2 3 4 5 6 7 8 9 10
LATERAL SPREAD OF COAGUALTION

18. What to do?
l Many of these are unrecognised at the
time.
l Awareness.
l Risk reporting.
l Use of disposable instruments wherever
possible.
l Knowledge of electrosurgical principles.

19. Unfamiliar tools in inexperienced
hands!
l Morcellator. – Paediatric
complication in Oxford.
l Lap Loop.
l Unnecessary use of
traumatic graspers
l Advanced laparoscopic
surgery – should it be
allowed without proper
training?

20. Complications due to procedure.
l Cauterisation of endometriosis – ureteric injuries.
l Adhesiolysis – Bowel injuries.
l Myomectomy – Bleeding
l Colposuspension – Bladder injuries.
l Laparoscopic Hysterectomy – Bleeding form the
uterine arteries, bladder injuries.
l Laparoscopic sacropexy, pelvic lymph node
dissection – Injury to major vessels, bowel,
ureter

21. Intra operative resolution of
complications
l Correct diagnosis
l Knowledge of the limits of laparoscopic
surgery – Avoiding cowboy approach!
l Maximum coordination of surgical team
l Appropriate complexity of the admitting
hospital
l Multidisciplinary approach.

22. Causing awareness!
l Those who do not
have complications
either do not operate
or they conceal them
and therefore do not
publish them!

23. Causing awareness
l The best way to treat
the complications is to
recognise them and
the best way to
recognise is to show it
to the medical
community.

24. Prevention
l Balance between indications, technical
abilities and instruments
l Team work
l Safety standards valid during surgery
l Awareness that the complications exist!
l Training and education.
l Informed consent and appropriate
documentation

25. Role of responsible bodies
l Standardisation
across the country.
l Certification.
l Mandatory training
courses.
l Regular auditing of
practices.
l Revalidation.

26. Thank you
… any questions?