1. COMPLICATION OF
LAPAROSCOPY
Khalid Sait
Professor
Director of Gynecological Oncology Unit

2. Laparoscopy surgery
• Often considered as minimally invasive
surgery but risk is not…….
• Complications 8.9% laparoscopy vs. 15.2%
laparotomy (meta-analysis)

3. Laparoscopy surgery
• Generally safe but does have mortality
(0.03%-0.49%)
• Generally more complex surgery/ earlier on
a learning curve will lead to more
complications

4. Laparoscopy surgery
• Are currently being increasingly used for
wider and wider application
• Complication rate can be expected to rise

5. • Know how equipment work before use it !

7. • “ If you have not had a complication during
surgery , you are not doing enough
surgery”

8. Types of complications
• Surgical
• Anesthesia

9. Surgical complications
• Immediate
• Delayed

10. Bowel injury
• INCIDENCE: 0.1-0.5%
• The incidence varies according to the type of surgery,
surgical history, the skill and experience of the surgeon
• High risk factors include previous abdominal and pelvic
surgery, history of peritonitis, endometriosis or bowel
surgery, and major surgical procedure

11. TYPES OF BOWEL INJURIES
• BY VERRES NEEDLE
• BY TROCAR
• BY GRASPERS AND SCISSORS
• BY ELECTROCOAGULATIOIN (50%)

12. Bowel injury by VERRES needle
• Recognition by:
• – Leakage of bowel content through the Veress
• – Aspiration of gastric or feculent material
• – Initial intra-abdominal pressure of > 8 mmHg
• – Absent second pop sound on inserting the Veress
needle
• – Restricted mobility of the needle after insertion

13. Bowel injury by VERRES needle
• In the majority of the cases conservative (observation and
antibiotics)
• If lacerations resulted or the intestinal wall is devitalized
repair should be made

14. BOWEL INJURY BY THE TROCAR

15. BOWEL INJURY BY THE INSTRUMENT

16. Bowel injury caused by electro-
coagulation
• 1. Delayed tissue necrosis after thermal injury is difficult to
diagnose.
• 2. It is responsible for the delay in diagnosis of bowel
injury (3-4 days after the procedure)
• 3. Peritonitis and high mortality (20%) due to late
diagnosis

17. Complica)ons:
Direct
Coupling

18. Complica)ons:
Direct
Coupling

19. Complica)ons:Capacitive coupling

20. Capacitive coupling
• Risk factors:
• Longer
instruments

21. Other electrosurgical complications
• Alternate site burns at the
dispersive site
• Partial detachment
• Manufacturing/quality defect
• Placement over moist skin,
bony prominence
• Caution with pacemakers
• Monopolar currents may
override/ reset pacemakers

22. GI Injury
• Biggest problem is delay in diagnosis
• 34-62% of injuries noted at time of surgery
• Average time to small bowel perf 3.3 days
• Average time with large bowel perf 2-10 days

23. Prevention of bowel injury
• Entry technique ( open is safe )
• Proper grounding of the patient
• Do not activate the monopolar energy unless in contact
with the tissue to be desiccated
• Do not use blunt dissection extensively
• Be careful with sharp excision in endometriosis if the
planes are not identified

24. Trocar Site Hernias
• Hernias are well reported
• Ports greater than 10 mm
• 21 per 100000 cases
• 17.9% despite fascial closure
• 86.3% with trocars greater than 10 mm
• Close port sites

25. Hernia Prevention “J” needle

26. Vascular Injuries
• Trauma to a large vessel
• Risk of major vessel injury 1/1000

27. • Umbilicus to
aortic bifurcation
changes with
BMI & positioning
• 0.4cm – normal
• 2.9cm – BMI
>30

28. IVC injury by VERRES needle

29. Iliac vessels injury

30. Measures to avoid deep vessel injury
• Avoid Trendlenburg position
• The angle of insertion should be 45% at the umbilicus
in thin patient and more vertical in obese patients
• Use disposable trocars or sharp instruments to avoid
use of unnecessary force during primary entry

31. ABDOMINAL WALL VESSEL INJURY
How to avoid?
• 1. Always stay lateral to the rectus
muscle
• 2. Avoid the inguinal region
• 3. Trans-illumination of the anterior
abdominal wall to avoid vessels.
• 4. Always insert perpendicular to the
skin.
• 5. Use the conical tipped 5 mm
trocar

32. Injury to inferior epigastric vein

33. Injury to inferior epigastric vessels

34. Neurologic
Injury
• Peripheral
Neurologic
Injury
• inappropriate
positioning
of
the
patient
• pressure
exerted
by
surgeon/
assistants
• rarely
happens
from
surgical
dissection
(exception
is
obturator
and
genitofemoral
nerve
injury
with
increasing
retroperitoneal
dissections)

35. Neurologic
Injury

36. Urinary Tract Injuries
• Bladder and ureters susceptible
• 0.2/1000
• Use foley or empty bladder

37. Urinary Tract Injury

38. Urinary Tract Injury
• Bladder injury noted at 1.1 days
• Ureteric injury at 29.4 days
• Be aware of low urine output
• Ascites / peritonitis
• Investigate with IVP cysto and retrograde

39. Ureteric injury

40. Diaphragm injury by instrument

41. Trocar liver injury

42. Port site mets
• Well recognised
• Increased with CO2 pneumoperitoneum
• Increased intra abdominal pressures
• Excessive manipulation
• Failure to use bags
• May occur in similar rates to open cases?

43. Other Complications
• Anaesthetic
• Increased CO2
• Problems with ventilation pressures
• Arrhythmias
• Pain
• Subcutaneous emphysema/ pneumomediastinum
• Wound infection

44. Conclusion
• Laparoscopic surgery does have
considerable advantages
• Need to be aware of all potential
complications and have methods available
to fix!