1.1 Complications due to Positioning
To improve organ exposure, patients in laparoscopic procedures are often placed in extreme positions, which is why superficially running, long nerves can be compromised during positioning. Particularly at risk are:
- Peroneal nerve
- Femoral nerve
- Ulnar nerve
- Brachial plexus
Prophylaxis
- padded shoulder supports in case of expected head-down position
- in the lithotomy position, the leg holders in the area of the fibular heads should be additionally padded with gel cushions
- with arms positioned alongside the body, these should be additionally padded in the elbow area and loosely fixed to the body in pronation position
- arms positioned away from the body should be placed on a padded splint and not abducted more than 90°
1.2 Complications due to Trocar Insertion
The insertion of trocars, especially the first trocar, can lead to injuries to hollow organs and vessels, which in many cases results in a prompt conversion to laparotomy for safe assessment and treatment of the injury. In particular, the assessment of vascular injuries that occur retroperitoneally is hardly possible laparoscopically. Even if an accidental bowel injury should be manageable laparoscopically, the possibility of further intra-abdominal injuries that are not recognizable at first glance must also be considered.
1.3 Complications due to Pneumoperitoneum
The pneumoperitoneum can trigger numerous pathological changes at hemodynamic, pulmonary, renal, and endocrine levels. Depending on the intra-abdominal pressure, the type of anesthesia, the ventilation technique used, and underlying diseases, serious complications may occur as a result of inadequate anesthesia management.
Cardiovascular Complications
- Arrhythmias
- Cardiac arrest
- Pneumopericardium
- Hypo/Hypertension
Pulmonary Complications
- Pulmonary edema
- Atelectasis
- Gas embolism
- Barotrauma
- Hypoxemia
- Pneumothorax/-mediastinum
Immediate Measures
- Release the pneumoperitoneum
- If the complication cannot be managed by anesthesia: possibly convert to open procedure or abort the intervention
Extreme Subcutaneous Skin Emphysema
In up to 3% of all laparoscopies, collar-like skin emphysema occurs, which, if untreated, can lead to impending compression of the airways and secondarily to pneumothorax and pneumomediastinum, requiring a collar incision to release the CO2. If there are no ventilation problems with a CO2 pneumothorax, one can initially wait, as the CO2 in the thorax is quickly resorbed; in case of ventilation problems or an extensive capnothorax, thoracic drainage is indicated. Older patients are particularly affected due to loose tissue.
1.4. Organ-Specific Complications
Anastomotic Insufficiency
Positive leak test: for small and easily accessible insufficiency, oversewing can be attempted. In this case, the creation of a protective ileostomy must be considered. If in doubt, the anastomosis should be recreated.
Organ Injury
- Splenic injury: Coagulation with bipolar current, ultrasonic scalpel, possibly apply hemostyptic or fibrin glue. A laparotomy is only necessary in exceptional cases.
- Pancreatic injury: In case of bleeding, proceed similarly as with splenic injuries. Here, the placement of an easy-flow drainage is recommended if necessary, to drain the secretion in case of a possible pancreatic fistula.
- Injuries to the intestine: With appropriate expertise, laparoscopic oversewing is possible.
- Thermal damage using bipolar scissors or ultrasonic dissector
- Vascular injury: Bleeding from smaller vessels can usually be stopped using bipolar current or ultrasonic scalpel and possibly by clipping.
In case of injuries to large vessels (e.g., aorta, vena cava), immediate laparotomy is indicated. - Ureter injury: for superficial injuries, laparoscopic oversewing can be attempted; otherwise, a small laparotomy in direct projection to the injury site is recommended to suture the ureter openly under vision. In any case, the insertion 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.
In situations without sufficient anatomical overview and/or with uncertain management of an accidental organ lesion, a laparotomy is indicated.
Note: Conversion is not a crime!