Complications - Hybrid-NOTES - Sigmoid Resection

1.1 Complications Due to Positioning

To improve organ exposure, patients undergoing laparoscopic procedures are often placed in extreme positions, which can compromise superficially running, long nerves during positioning. Particularly at risk are:

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

Prophylaxis

• Padded shoulder supports in anticipation of a head-down position.
• In lithotomy position, the leg supports 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 Pneumoperitoneum

Pneumoperitoneum can trigger numerous pathological changes on hemodynamic, pulmonary, renal, and endocrine levels. Depending on the 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, consider switching to an open procedure or aborting 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 no ventilation problems exist with a CO2 pneumothorax, observation may be initially considered, as CO2 is rapidly absorbed in the thorax; in case of ventilation problems or extensive capnothorax, a chest drain is indicated. Older patients are particularly affected due to lax tissue.

1.3 Specific Complications Due to Transvaginal Access
Injury to rectum/bladder/adnexa when introducing trocars. These complications can be avoided with good visibility via transabdominal optics. 

1.4 Anastomotic Leak

If the water test is positive, an attempt can be made to oversew a small and easily accessible insufficiency. In this case, the creation of a protective ileostomy should be considered. In case of doubt, a new anastomosis should be created.

1.5 Injury to Intra-abdominal or Retroperitoneal Organs

Bowel Injury:

• Risk factor is the first trocar placement!
• Prevention through open insertion and placement of the incision outside of scars.
• Grasping the bowel only with atraumatic forceps under vision. Instruments are used only in the area of the taeniae and appendices epiploicae. Avoid pulling on the bowel. Dissection and coagulation only under vision.
• An adhesiolysis increases the risk! Injury patterns range from serosal defects to transmural openings to complete transections, as well as mesenteric tears with consequent ischemia of the dependent bowel segment.
• Thermal lesions are particularly easy to overlook. Thermal damage using bipolar scissors or ultrasonic dissector occurs mainly in the area of the left flexure.
• Measures: Before closing the abdominal wall, perform a careful inspection again. Smaller lesions are oversewn, possibly with sparing resection with primary anastomosis.

Splenic Injury

A spleen-preserving therapy should always be aimed for, as emergency splenectomy is associated with increased morbidity and mortality.

Superficial capsule defects are treated with electrocoagulation, hemostatic patches, and compression. If necessary, permanent external compression through splenorrhaphy, where the spleen is placed in a resorbable synthetic mesh.

Pancreatic Injury

Placement of a drain to allow drainage of secretions in case of a pancreatic fistula.

Vascular Injuries

Injury to the epigastric vessels due to trocar placement (recognition of abdominal wall bleeding is difficult in obesity!).

Therapy: U-sutures above and below the trocar insertion site, alternatively enlargement of the incision site and direct oversewing.

In case of intra-abdominal bleeding, recognition and localization of the bleeding.

Primary bleeding control through compression/clamping and decision whether the bleeding can be stopped laparoscopically. Generous indication for conversion laparotomy, possibly involving a vascular surgeon. Provision of vascular tray and blood products. Creation of anatomical overview with exposure of the injured vessel. Ligation or repair of the vessel defect through direct suture or resection with interposition graft.

Ureteral Injury

After ureteral injuries, the rate of serious complications increases (renal failure, anastomotic leakage, bleeding).

Prevention through secure intraoperative visualization, possibly preoperative stenting to facilitate intraoperative identification.

Therapy: Placement of a double-J catheter, possibly direct suture, diversion, contralateral implantation, Psoas hitch.

Vaginal Injury

Accidental entrapment of the vagina when using the stapling device can lead to the formation of rectovaginal fistulas!

2.1 Anastomotic Leak
Any deviation from the normal postoperative course should suggest an anastomotic leak. In cases of justified suspicion, timely diagnostic laparoscopy/laparotomy should be pursued. Small leaks without generalized peritonitis can be sutured laparoscopically. However, in this case, the creation of a protective ileostomy is mandatory.
In cases of large anastomotic leaks and already septic patients, discontinuity resection is indicated.

Prevention: Tension-free, well-perfused bowel ends brought together, restriction of perioperative intravenous fluid administration

2.2 Intraoperatively Overlooked Bowel Injury

Often insidious symptoms, often delayed diagnosis, noticeable drainage secretion (stool, pus, air).

Treatment depends on the timing of diagnosis and the extent of the lesion. Suturing or conservative resection possibly with the placement of a protective stoma. In any case, abdominal lavage and placement of a target drain are recommended.

2.3 Intraoperatively Overlooked Ureteral Injury

Abundant "clear" fluid drains while urine output is reduced. Verification by determining creatinine from the drainage secretion. If the ureter is obstructed by clips, ligatures, or scar strictures, urinary obstruction develops.

Further invasive urological diagnostics with retrograde ureteral probing and contrast imaging. Stenting, direct suturing, surgical reconstruction with anastomosis. In more extensive injuries, complex urological care (ureteroneocystostomy, psoas hitch, transureteroureterostomy)

2.4 Intra-abdominal Abscess

Smaller abscesses without signs of infection, diagnosed incidentally, should be monitored over time and do not necessarily require surgical or interventional therapy. However, intra-abdominal abscesses can be indirect signs of anastomotic leakage. Therefore, in the presence of intra-abdominal abscesses, an endoscopic exclusion of suture leakage is necessary.
In the presence of signs of infection, interventional percutaneous drainage of the abscess is the method of choice. This can be performed sonographically or CT-guided, depending on location and expertise.
In cases of progressive sepsis, in addition to supportive therapy (intensive care, antibiotic therapy), surgical source control should be pursued.

2.5 Postoperative Hemorrhage

The severity of postoperative hemorrhage determines further therapeutic action.

Acute hemorrhage with circulatory instability is a potentially life-threatening complication and usually requires immediate surgical re-exploration.

In hemodynamically stable patients, timely diagnostics to locate the bleeding (intra- versus extraluminal) and optimization of coagulation.

Intraluminal bleeding at anastomoses/stapler lines is treated endoscopically with adrenaline injection or clip application. If adequate hemostasis cannot be achieved, angiography with superselective embolization.
In cases of extraluminal bleeding (bloody secretion through the inserted drainage), depending on the extent of the bleeding, clinical condition, and hemoglobin level, transfusion of erythrocyte concentrates and surgical revision are indicated.

2.6 Postoperative Ileus

Insertion of a nasogastric tube in cases of recurrent vomiting to relieve the gastrointestinal tract and prevent aspiration. Balancing and compensating for fluid/electrolyte loss, possibly administering a parasympathomimetic (neostigmine).

Early enteral nutrition combined with rapid mobilization reduces the likelihood of postoperative bowel atony.

After 7 days of inadequate oral intake, parenteral nutrition (25-30 kcal/kg body weight) should be initiated to ensure sufficient caloric intake.

2.7 Anastomotic Stricture

Initially, an endoscopic dilation attempt, if unsuccessful, surgical re-creation is unavoidable.

2.8 Incisional or Trocar Hernia

Surgical repair no earlier than 6 months, a trocar hernia can be closed with direct suturing, while a true incisional hernia requires mesh repair.