Complications - Hybrid-NOTES - Sigmaresektion - general and visceral surgery

1.1 Position-induced complications

To improve organ exposure in laparoscopic surgery, patients are often brought into extreme positions which may compromise long superficial nerves. Nerves particularly at risk include:

• • Peroneal nerve
  • Femoral nerve
  • Ulnar nerve
  • Brachial plexus

Prevention

• • Padded shoulder rests if Trendelenburg position is expected
  • In lithotomy position, the stirrups at the level of the head of the fibula should be padded with additional gel cushions
  • When the arms are adducted, the elbow areas should be positioned on additional padding and loosely secured to the body pronated
  • Abducted arms should always be positioned on padded supports and never abducted beyond 90°

1.2 Pneumoperitoneum-induced complications

Pneumoperitoneum may trigger a variety of pathologic changes in hemodynamics, the lungs, kidneys, and endocrine organs. Depending on the intraabdominal pressure, type of anesthesia, ventilation technique, and underlying disease, the following severe complications may arise:

Cardiovascular complications

• • Arrhythmia
  • Cardiac arrest
  • Pneumopericardium
  • Hypotension/hypertension

Pulmonary complications

• • Pulmonary edema
  • Atelectasis
  • Air embolism
  • Barotrauma
  • Hypoxemia
  • Pneumothorax/pneumomediastinum

Immediate action

• • Deflate the pneumoperitoneum
  • If the anesthesiologist cannot manage the complication, consider conversion to open surgery or terminate the operation

Extreme subcutaneous emphysema

Up to 3% of all laparoscopies are complicated by collar skin emphysema; if left untreated it may threaten compression of the airways with secondary pneumothorax and pneumomediastinum and require CO2 deflation via a collar incision. If CO2 pneumothorax does not result in ventilation problems, watchful waiting is one possible option because the CO2 within the chest is rapidly absorbed. A chest tube is indicated in ventilation problems or extensive pneumothorax. Due to their flaccid tissue, elderly patients are particularly at risk.

1.3 Specific complications in transvaginal access
Injury to the rectum/bladder/adnexa when inserting the trocars. These complications can be avoided under direct vision through the transabdominal laparoscope. 

1.4 Staple line failure

Positive leak test: If there is only minor leakage from the staple line, oversewing may be attempted. In this case, consider a diverting ileostomy. When in doubt, refashion the anastomosis.

1.5 Intraabdominal or retroperitoneal organ injury

Bowel injury:

• • The initial trocar placement is a risk factor!
  • Prevent through open trocar placement and making the incision outside scars.
  • Grasp bowel only with atraumatic forceps under direct vision. With the instruments grasp only in the region of the taenia and omental appendices. Avoid traction on the bowel. Dissect and coagulate only under direct vision.
  • Adhesiolysis increases the risk! Injuries range from serosal defects through transmural openings to complete division and mesenteric tears causing ischemia of the affected bowel segment.
  • Thermal injury can be easily missed. Thermal injury by bipolar scissors or ultrasonic dissector is particularly common near the left flexure.
  • Measures: Carefully inspect the abdomen before closing the abdominal wall. Oversew minor lesions; sparing resection technique with primary anastomosis, if needed.

Splenic injury

Spleen-sparing management should always be attempted because emergency splenectomy is associated with high morbidity and mortality.

Superficial capsule defects are easy to treat with electrocautery, hemostatic patches and compression. If necessary, apply continuous external compression through splenorrhaphy in which the spleen is packed inside an absorbable synthetic mesh which is tightened.

Pancreatic injury

Place a drain to evacuate secretions from any pancreatic fistula.

Vascular injuries

Injury to the epigastric vessels from trocar placement (abdominal wall bleeding in obese patients is difficult to detect!)

Management: Place mattress sutures superior and inferior to the trocar insertion site, alternatively extend the incision site and suture ligate directly.

In intraabdominal bleeding, identify the source of bleeding.

Obtain primary hemostasis through compression/clamping and decide whether the bleeding can be stopped laparoscopically. Well-founded indication for conversion laparotomy; if necessary, consult a vascular surgeon. Ready vascular tray and packed RBCs. Obtain anatomical overview with exposure of the injured vessel. Ligate or repair the vascular defect with direct suture or resection with interposition.

Ureter injury

Ureteral injury is followed by a sharp rise in serious complications (kidney failure, staple line failure, bleeding).

Prevention through definitive intraoperative visualization; if necessary, preoperative splinting to facilitate intraoperative identification.

Management: Insert a double J catheter; if necessary, direct suture, diversion, implantation on the opposite side, psoas hitch.

Vaginal injury

Iatrogenic trapping of the vagina when closing the stapler may result in rectovaginal fistula!