Complications - Laparoscopic colectomy with ileorectostomy

• 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 Complications from trocar insertion

Insertion of the trocars, especially the first trocar, may result in injury to hollow viscera and vessels, which in many cases, requires rapid conversion to laparotomy for safe assessment and management of the injury. While it should be possible to manage accidental bowel injury laparoscopically, the possibility of other intraabdominal injuries not apparent at first glance must also be considered.

1.3 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.

1.4. Organ specific complications

Staple line failure

Positive leak test: if the leak is small and easily accessible, oversew it and consider a diverting ileostomy. When in doubt, refashion the anastomosis.

Organ injury

• • Splenic injury: Bipolar RF coagulation: if necessary, apply hemostyptic agent or fibrin sealant. Laparotomy is needed only in exceptional cases.
  • Pancreatic injury: In case of bleeding, proceed akin to injuries to the spleen. In this case it may be advisable to place a drain to evacuate secretions from any pancreatic fistula.
  • Intestinal/duodenal injury: With adequate expertise, laparoscopic suturing is possible.
  • Thermal damage from bipolar scissors or ultrasonic dissector
  • Vascular injury: Most bleeding from smaller vessels can be stopped by bipolar energy devices or ultrasonic scissors and, if necessary, by clipping.
    Injury to one of the large vessels (e.g., aorta, vena cava) mandates immediate laparotomy.
  • Ureteral injury In case of partial transection, laparoscopic suturing is an option; otherwise conversion to laparotomy and open ureteral repair. Such injuries always require ureteral double-J splinting.
  • Vaginal injury: Iatrogenic trapping of the vagina when closing the stapler may result in rectovaginal fistula.

Staple line failure

Any deviation from the regular postoperative course should raise the suspicion of staple line failure. In case of reasonable suspicion, perform prompt (flexible) endoscopy and/or CT with rectal contrast. Small leaks without generalized peritonitis are treated by laparoscopic drainage and fashioning of a diverting ileostomy. In favorable cases detected early, the leak may also be oversewn laparoscopically.

In case of larger staple line failures with generalized peritonitis, relaparotomy with Hartmann procedure is indicated. Moreover, any peritonitis and sepsis require intensive medical care.

Intraabdominal abscess

Minor abscess without clinical signs of infection, diagnosed as incidental finding, should be monitored in its course and in general does not require surgical or interventional treatment. However, intraabdominal abscess may be an indirect sign of staple line failure. Therefore, if intra-abdominal abscess is confirmed, staple line leakage must be ruled out.

In signs of infection interventional abscess drainage is the modality of choice. Depending on location and expertise, this may be accomplished under ultrasound or CT guidance.

In progressive sepsis, supportive treatment (intensive care unit, antibiotic regimen) should be complemented by surgical management of the focus, if possible.

Bleeding

There may be postoperative perianal discharge of small amounts of old blood. With increasing perianal discharge of fresh blood, bleeding from the anastomosis is possible. Most anastomotic bleeders can be controlled quite well endoscopically (e.g., by clipping). Revision surgery is needed only in exceptional cases. Close monitoring of plasma hemoglobin (Hb level) and coagulation status is mandatory.

In case of bloody secretions from the inserted target drain, hemoglobin and coagulation status must also be monitored. Depending on the extent of bleeding, clinical condition, and hemoglobin level, RBC transfusion or surgical revision may be indicated.

Anastomotic stricture

First, attempt endoscopic dilation; if unsuccessful, a new anastomosis must be fashioned.

Incisional or trocar-site hernia

Surgical repair after 6 months at the earliest; trocar-site hernias can be closed with direct suture, mesh hernioplasty is needed for true incisional hernias.