General risks posed by creation of the pneumoperitoneum and any adhesiolysis: Injuries to vessels and hollow viscera are possible from blind insertion of the Veress needle, but also from the optical trocar. In patients with prior surgery, however, the optical trocar is the device of choice.
During adhesiolysis, thermal injury to the intestinal wall must be respected and safely ruled out. If laparoscopic overview cannot be obtained, convert immediately to open surgery.
Always place additional working trocars under direct vision to avoid intra-abdominal injuries.
Bleeding:
- Beware of the epigastric vessels; bleeding from trocar insertion sites is preferably managed with U-sutures using suture-passing devices for fascial closure.
- Bleeding from the staple line → oversew or clip
- Bleeding from retroperitoneal vessels (vena cava or aorta)
- Bleeding from the omentum
- If laparoscopic overview cannot be obtained, convert immediately to open surgery. Adhesions increase the risk of injury to retroperitoneal vessels.
Injury to adjacent organs:
- Spleen: Compression, haemostatics (see Medical Equipment tab), thermal modalities, as a last resort → splenectomy
- Parenchymal laceration of the liver from the retractor → haemostasis with monopolar current, compression, haemostatics (see Medical Equipment tab)
- Injury to the pancreas → oversew, targeted drainage
- Injury to the oesophagus with the large-bore gastric tube → endoscopic management: Endo-clips combined with injection of epinephrine, targeted oversewing as necessary