Complications - Resection rectopexy, laparoscopic

  1. Prevention and management of intraoperative complications

    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

    Prophylaxis

    • 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 a padded support and never abducted beyond 90°
    1.2 Trocar insertion complications

    Insertion of the trocars, particularly the first trocar, may injure hollow viscera and vessels; in many cases safe assessment and management of the injury will require speedy conversion to laparotomy. Laparoscopic assessment of retroperitoneal vascular injuries is almost impossible. Even if accidental intestinal injury could be managed laparoscopically, the possibility must be considered that there might be additional intra-abdominal injuries not evident at first glance.

    1.3 Pneumoperitoneum-induced complications

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

    Cardiovascular complications

    • Arrhythmia
    • Cardiac arrest
    • Pneumopericardium
    • Hypotension/hypertension

    Pulmonary complications

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

    Emergency procedure

    • 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

    Anastomotic failure
    Positive leak test: If the insufficiency is small and easily accessible, oversewing it can be attempted. In this case, consider a diverting ileostomy. When in doubt, reconstruct the anastomosis.

    Organ injury

    • Splenic injury: Use bipolar coagulation with bipolar current, ultrasonic scissors; if necessary hemostatic agent or fibrin sealant. Laparotomy is reserved for special cases.
    • Pancreatic injury: In pancreatic bleeding proceed as in injury to the spleen. If necessary, we recommend placement of an Easy-Flow drain which will evacuate any secretions in case of pancreatic fistula.
    • Bowel injuries: Laparoscopic suturing is possible with adequate expertise.
    • Thermal injury using bipolar scissors or ultrasonic dissector
    • Vascular injury: Bleeding from smaller vessels can usually be stopped with bipolar diathermy or ultrasonic scissors and, if necessary, clipping.
    • Immediate laparotomy is indicated for injuries to large vessels (e.g., aorta, vena cava).
    • Ureteral injuries: Laparoscopic suture can be attempted in superficial injuries; otherwise we recommend a small laparotomy in direct projection onto the site of the injury to openly suture the ureter under direct view. Insertion of a ureteral splint is always indicated.
    • Vaginal injuries: Iatrogenic inclusion of the vagina when closing the stapler may result in the formation of rectovaginal fistula.

    Laparotomy is indicated in situations with insufficient anatomical view and/or with an uncertain management of an iatrogenic organ lesion.

    Note: Conversion is not a crime!

Prevention and management of intraoperative complications

Anastomotic failure Any deviation from the regular postoperative course should raise the suspicion

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