Dr John AC Thanakumar Senior Consultant Minimal Access, Bariatric and Gastrointestinal Surgery Global Hospital Chennai www.lapsurgeon.org

1. Complications in Minimal Access Surgery
Dr John AC Thanakumar
MS, MNAMS, FRCS, FRCS, FIAGES, Dip MIS
Senior Consultant in Minimal Access, Bariatric and GI Surgery
Global Hospital, Chennai.

2. Complications of Laparoscopy
 Those of any surgical operation and anesthesia
 Those only confined to laparoscopic surgery
Only the latter are discussed in this presentation

3. Limitations in Laparoscopy
 Only a 2-dimensional view
 Restricted vision
 Limited tactile feedback
 Increasing emphasis on technology
 Learning curve

4. Advantages of Laparoscopy
 Magnified views
 Exceptional resolution and views
 30 and 45 degree telescopes
 Flexible devices
 Laparoscopic ultrasounds

5. Complications of Needle and Trochar
 Vascular Injury
 Visceral Injury
• Stomach
• Colon
• Bladder

6. •Vascular Injury
• Visceral Injury
Stomach
Colon
Bladder
Complications of Needle and Trochar
 Life threatening large retroperitoneal vessel
 77604 lap choles, 36 -0.05%-Aorta,IVC, Iliac injury
 Mortality in these pts 8.8%
 In collected 16 major vascular injuries, mortality was 13%
Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC: Complications of
laparoscopic cholecystectomy: A national survey of 4@292 hospitals and an analysis of 77,604
cases. Am j Surg 165:9-14, 1993.
25. Baadsgaard SE, Bille S, Egeblad K: Major vascular injury during gynecologic laparoscopy:
Report of a case and review of published cases. Acta Obstet Gynecol Scand 68:283-285, 1989.

7. •Vascular Injury
• Visceral Injury:
Stomach Avoid
Colon
Complications of Needle and trochar
Bladder
 Aspirate needle, look for bright blood
 Convert early if injury is suspected
 Hemostatic instability- Conversion is a must

8. •Vascular Injury
• Visceral Injury:
Stomach
Colon Complications of Needle and trochar
Bladder
 Significant injury in 0.01-0.04%
 Undetected, sepsis,peritonitis, fistula, abscess
 75,000 laparoscopic cholecystectomies, 4.6 percent of patients with
gastrointestinal injuries died
Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC: Complications of
laparoscopic cholecystectomy: A national survey of 4@292 hospitals and an analysis
of 77,604 cases. Am j Surg 165:9-14, 1993.

9. •Vascular Injury
• Visceral Injury:
Stomach
Avoid
Colon Complications of Needle and trochar
Bladder
 Proper technique
 NG tube
 Controlled inflation
 Resonance of the abdomen
 Watch IAP

10. •Vascular Injury
• Visceral Injury:
Stomach
Colon Thermal Injury
Bladder
 Thermal injuries with Cautery/laser- severe-resect
 Injury with needle, trochar, instruments- observe, suture or resect
 Repair open or laparoscope- Experience

11. •Vascular Injury
• Visceral Injury:
Stomach
Colon Complications of Needle and trochar
Bladder
 Prevent by catheterization
 Needle injury- Catheter
 Trochar injury- Suture the defect

12. Complications of Pneumoperitoneum
o Acidosis
o Arrhythmias
o Extraperitoneal insufflation
o Pneumothorax
o Gas embolism

13. •Acidosis
•Arrhythmias
Complications of Pneumoperitoneum
•Extraperitoneal Insufflation
•Pneumothorax
•Gas embolism
 CO2 leads acidosis-arrhythmia
 Mechanical effects of IAP = >Cardiac output

14. •Acidosis
•Arrhythmias
•Extraperitoneal insufflation
•Pneumothorax Complications of Pneumoperitoneum
•Gas embolism
 Increased ventilatory pressures and arterial desaturation
 Chest tube

15. •Acidosis
•Arrhythmias
•Extraperitoneal insufflation
•Pneumothorax Complications of Pneumoperitoneum
•Gas embolism
 Incidence is 0.002-0.0016%
 Etiology is vein injury with increased IAP
 Wheel like murmur,wide QRS
 Head end down left side down,aspirate via central catheter and ext
massage

16. Wound
 Hernia
 Infection
 Tumor Recurrence

17. Wound
•Hernia
•Infection
•Tumor Recurrence Wound
o Hernia
o Infection
o Tumor Recurrence

18. Wound
•Hernia
•Infection
• Tumor Recurrence
Hernia
 Incidence 0.1-0.3%
 Higher the trochar, higher the hernia
 Infection
 Prevent- Suture facial 10 mm defect

19. Wound
•Hernia
•Infection
Infection
•Tumor Recurrence
 Incidence of diagnostic <0.1%
 Lap Cholecystectomy 1%
 Prevent by retrieval bag

20. Wound
•Hernia
•Infection
• Tumor Recurrence
Tumor Recurrence
 Retrieval bags
 Low threshold for enlarging incision

21. Lap Cholecystectomy Complications
 Incidence of bile duct injuries 0.25-6%
 Less after 13 operations/100in institutions
 Mortality of LC is 0.1%
 Mortality due to co morbids/ injuries

22. Prevent CBD injury
 Hug the GB at dissection
 Window between GB and bed of GB
 Demo the cystic duct to GB junction
 Clear Vision of Calot
 Use heat wisely

23. Conversion in LC
 Incidence is 3.6-6.9%
 Indications- Bleed, Unclear anatomy,CBD injury, acute GB, pancreatitis
 Selection decreases incidence to 2%

24. Lap Antireflux Surgery Complications
 Incidence is 4-16
 Perforation of esophagus, stomach,spleen, pneumo
 Dysphagia 22-57% . Needs dilatation 4-32%
 Prevent by loose, short, floppy wrap

25. Lap Hernia Complications
 Incidence is 6-31% after TAPP
 Bladder, Inf epigatric bleed, Cord injury
 1-2.9% hernia recurrence
 Mesh Infection-1 in 535 TAPPS
 Retension of urine in 3-7%

26. Lap Appendectomy Complications
 Lap shows no advantage over open
 In open wd infection= Intra abscess in Lap

27. Future
 Virtual training
 Robotics
 Special instruments for haptics
 Laparoscopy will improve

30. Any Queries?

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