1.1 Complications Due to Positioning
To improve organ exposure, patients are often placed in extreme positions during laparoscopic procedures, which can compromise superficially running, long nerves. Particularly at risk are:
- Peroneal nerve
- Femoral nerve
- Ulnar nerve
- Brachial plexus
Prophylaxis
- Padded shoulder supports in anticipation of head-down position.
- In lithotomy position, the leg holders should be additionally padded with gel cushions at the fibular heads.
- Arms positioned alongside the body should be additionally padded at the elbow area and loosely fixed in a pronated position.
- Arms positioned away from the body should be placed on a padded arm board and not abducted more than 90°.
1.2 Complications Due to Trocar Insertion
Inserting trocars, especially the first trocar, can lead to injuries of hollow organs and vessels, often necessitating a quick conversion to laparotomy for safe assessment and management of the injury. Even if an accidental bowel injury can be managed laparoscopically, the possibility of other intra-abdominal injuries that are not immediately apparent must be considered.
1.3 Complications Due to Pneumoperitoneum
Pneumoperitoneum can trigger numerous pathological changes on hemodynamic, pulmonary, renal, and endocrine levels. Depending on intra-abdominal pressure, type of anesthesia, ventilation technique used, and underlying conditions, the following complications may occur.
Cardiovascular Complications
- Arrhythmias
- Cardiac arrest
- Pneumopericardium
- Hypo/Hypertension
Pulmonary Complications
- Pulmonary edema
- Atelectasis
- Gas embolism
- Barotrauma
- Hypoxemia
- Pneumothorax/-mediastinum
Immediate Measures
- Release of pneumoperitoneum
- If the complication cannot be managed anesthesiologically: possibly switch to open procedure or abort the operation.
Extreme Subcutaneous Emphysema
In up to 3% of all laparoscopies, a collar emphysema occurs, which in extreme cases can lead to threatening airway compression and secondarily to pneumothorax and pneumomediastinum, requiring a collar incision to release CO2. If there are no ventilation problems with a CO2 pneumothorax, observation can initially be considered, as CO2 in the thorax is rapidly absorbed; in case of ventilation problems or an extensive capnothorax, a chest drain is indicated. Older patients are particularly affected due to lax tissue.
1.4 Organ-Specific Complications
Anastomotic Leak
Positive leak test: in case of a small and easily accessible leak, oversewing should be performed. In this case, the creation of a protective ileostomy should be considered. In case of doubt, the re-creation of the anastomosis should be performed.
Organ Injury
- Spleen injury: Coagulation with bipolar current, if necessary, apply hemostatic agent or fibrin glue. Laparotomy is only necessary in exceptional cases.
- Pancreatic injury: In case of bleeding, proceed similarly to spleen injuries. It may be advisable to place a drain to manage potential pancreatic fistula secretion.
- Intestinal/Duodenal injuries: With appropriate expertise, laparoscopic oversewing is possible.
- Thermal damage using bipolar scissors or ultrasonic dissector
- Vascular injury: Bleeding from smaller vessels can usually be controlled using bipolar current or ultrasonic scissors and, if necessary, by clipping.
Injuries to large vessels (e.g., aorta, vena cava) require immediate laparotomy. - Ureteral injury: In case of partial transection, laparoscopic oversewing can be performed, otherwise laparotomy and open ureteral repair. In any case, placement of a ureteral stent is indicated.
- Vaginal injury: Accidental entrapment of the vagina when using the stapling device can lead to the formation of rectovaginal fistulas.