Evidence - diagnostic laparoscopy for adhesion zone, lavage cytology, biopsy sampling, second look operation

The complication rate in laparoscopic procedures is generally low. In the field of gynecological laparoscopy, the following complication rates can be observed:

• 0.2 to 18 percent of all laparoscopic procedures are associated with a complication. This includes both minor and major issues.
• 0.6 to 14.6 percent of procedures result in major complications that require further treatment or an additional procedure.
• The mortality rate is 0.02 percent (0.01 to 0.03 percent), which is 1 to 3 deaths per 10,000 procedures, mostly due to vascular or gastrointestinal injuries from the insertion of trocars or Veress needles.

Vascular Injuries

are a significant complication in laparoscopic procedures and the second most common cause of death after anesthesia complications in these surgeries.

• The rate of vascular injuries in laparoscopies is between 0.1 to 6.4 per 1000 procedures.
• About 50 to 83 percent of vascular injuries occur during access to the abdominal cavity.
• Larger retroperitoneal vessels 0.4 to 4 in 1000 procedures, such as the right iliac artery and vein, the aorta, and the vena cava are most commonly affected.

In the direct comparison of the Veress needle technique and the open access technique (Hasson technique), there is insufficient evidence to clearly determine whether there are differences in the rate of vascular injuries between the two techniques. Both methods have their advantages and disadvantages, but the existing studies do not provide clear results that identify one of the techniques as significantly safer in terms of the risk of vascular injuries.

Bowel Injuries

are the third most common cause of death after anesthesia and major vascular injuries in laparoscopic procedures. Gastrointestinal tract injury occurs in 0.03 to 0.65 percent of patients undergoing laparoscopy, and 41 to 50 percent of accidental bowel injuries occur during abdominal access.

Access-associated bowel injuries:

• The small intestine is the most commonly affected structure, but the stomach, liver, and colon can also be affected, especially with subcostal access techniques.
• Preventive measures: Gastric decompression with a nasogastric tube can reduce the risk of accidental stomach injury.
• Treatment: Iatrogenic small and large bowel injuries should be treated according to the degree of injury. Most access-induced injuries require a simple primary suture of the bowel wall defect. In rare cases, a colostomy is necessary.

Dissection-related bowel injuries:

• Injuries can occur during dissection or manipulation of the bowel, particularly through the use of electrosurgery.
• About 25 to 33 percent of injuries are caused by electrosurgery. These injuries should be treated by inversion and suture or resection with a safety margin, as the visible thermal injury is often smaller than the actual injury.

Unrecognized bowel injuries:

• 30 to 50 percent of bowel injuries are not recognized intraoperatively. These injuries can lead to postoperative complications, often after the patient is discharged.
• Symptoms: Typical symptoms of an unrecognized injury appear within 12 to 36 hours but can also occur later (up to 5 to 7 days) and include persistent abdominal pain, tachycardia, and fever. Imaging diagnostics may show free air in the abdomen, with the amount of air gradually decreasing after surgery.
• Emergency care: A missed bowel injury is a surgical emergency and should be treated surgically as soon as possible.

Prognosis:

• The overall mortality in laparoscopic bowel injuries is 0.8 percent, but increases to 3.2 to 3.6 percent with delayed diagnosis

Urinary Tract Injuries

Urinary tract injuries frequently occur in laparoscopic gynecological, urological, and colorectal surgeries, with an incidence of 0.5% (range: 0.03% to 1.7%) in gynecological procedures.

Access-related bladder injuries

• 36% of all urinary tract injuries occur during the initial access.
• A bladder puncture often occurs when a suprapubic trocar is inserted into an overdistended bladder. Therefore, a Foley catheter should be inserted before surgery to decompress the bladder, as this is safer than immediate bladder emptying of the patient. Gas accumulation in the catheter bag and bloody urine are signs of an injury.
• Management based on injury size:
  • <2 mm: Usually does not require repair.
  • <10 mm: Typically resolves spontaneously with bladder decompression.
  • Larger or irregular defects: Require suture closure with absorbable sutures, with a Foley catheter left in place for up to two weeks.

Dissection-related urinary tract injuries

• Electrosurgical devices: Responsible for 45% of bladder and 33-48% of ureteral injuries.
• Bladder injury: Common in pelvic surgeries; management ranges from catheterization to laparotomy, depending on the severity of the injury.
• Ureteral injury: Occurs in less than 2% of pelvic surgeries, often during pelvic preparation or due to thermal injuries. Prophylactic placement of ureteral stents can help identify the ureters.

Detection and Diagnosis

• Intraoperative diagnosis: 45-85% of bladder injuries and only 3-12% of ureteral injuries are recognized during surgery.
• Routine cystoscopy: Increases the intraoperative detection rate of urinary tract injuries, but does not significantly impact postoperative detection.

Surgical Wound Infection

Wound infections are less common after laparoscopic procedures than after open procedures, but can cause significant morbidity.

Trocar Hernia/ Incisional Hernias

The incidence of trocar hernia after laparoscopic surgeries is a median of 0.5% (range: 0% to 5.2%). The likelihood depends on the size of the defect. In laparoscopic gastrointestinal or gynecological procedures, inguinal hernias can occur at the extraction site. The risk factor for hernia formation at the extraction site depends on the size and location of the incision. In one study, the incidence of extraction site hernias was 7.2%.

Trocar Metastases

Metastases refer to the growth of cancer cells at the site of a trocar incision after laparoscopic tumor resection. Incidence is 0.4% to 2.3%

Peripheral Nerve Injuries

The Trendelenburg position most commonly leads to upper extremity injuries, while the lithotomy position is often associated with lower extremity injuries.

Complications Related to Pneumoperitoneum

Subcutaneous Emphysema

Postoperative Shoulder Pain: postoperative shoulder pain can be expected in 50 to 80 percent of patients after laparoscopic procedures and is associated with irritation of the phrenic nerve and stretching of the parietal peritoneum and liver capsule by CO₂. These pains usually last one to three days, but can occasionally persist for up to seven days.

Thromboembolic Events: Longer operation times and increased intra-abdominal pressures can also lead to venous thrombotic or thromboembolic events.

Gas Embolism: A minimal amount of carbon dioxide diffused into the capillary system during laparoscopy is clinically irrelevant. A gas embolism through an open large retroperitoneal vessel or liver vein is a rare complication (0.15 percent), but can cause severe morbidity or mortality.

Reference:

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2. Fuller J, Ashar BS, Carey-Corrado J. Trocar-associated injuries and fatalities: an analysis of 1399 reports to the FDA. J Minim Invasive Gynecol 2005; 12:302.
3. Magrina JF. Complications of laparoscopic surgery. Clin Obstet Gynecol 2002; 45:469.
4. Vilos GA, Vilos AG, Abu-Rafea B, et al. Three simple steps during closed laparoscopic entry may minimize major injuries. Surg Endosc 2009; 23:758.
5. King NR, Lin E, Yeh C, et al. Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review. Obstet Gynecol 2021; 137:434.
6. Ahmad G, Baker J, Finnerty J, et al. Laparoscopic entry techniques. Cochrane Database Syst Rev 2019; 1:CD006583.
7. Magrina JF. Complications of laparoscopic surgery. Clin Obstet Gynecol 2002; 45:469.
8. Schwartz MJ, Faiena I, Cinman N, et al. Laparoscopic bowel injury in retroperitoneal surgery: current incidence and outcomes. J Urol 2010; 184:589.
9. Eisner IS, Wadhwa RK, Downing KT, Singhal PK. Prevention and management of bowel injury during gynecologic laparoscopy: an update. Curr Opin Obstet Gynecol 2019; 31:245.
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11. Llarena NC, Shah AB, Milad MP. Bowel injury in gynecologic laparoscopy: a systematic review. Obstet Gynecol 2015; 125:1407.
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There are various access techniques for laparoscopic procedures:

• Closed technique (classic or Veress needle)
• Open technique (Hasson technique)
• Direct trocar insertion method

Current evidence, however, indicates that no technique has proven to be significantly superior to the others. There is no clear gold standard in technique recommendation.

The literature shows that about 50% of laparoscopic complications occur during access to the abdominal cavity. The most common are iatrogenic injuries such as bowel or vascular injuries.

The ISGE points out that intraperitoneal pressure is the only reliable indicator for the correct positioning of the Veress needle. A pressure of ≤ 8 mmHg is considered a safe indication, other methods such as the "double click" or the "hanging drop" were considered unnecessary or risky.

Palmer's Point: 

Located 3 cm below the left costal margin in the midclavicular line.

Recommended use of access route:

• Patients with longitudinal peri- or infraumbilical laparotomy scars
• In obesity
• Very slender women with an android pelvis shape and prominent sacral promontory, where large vessels run less than 2 cm from the navel
• After three unsuccessful transumbilical access attempts
• Suitable for both the introduction of the Veress needle and the primary trocar after abdominal insufflation

Additional recommendations:

• Gastric decompression is recommended, especially after difficult endotracheal intubation

Contraindications for access:

• Splenomegaly, hepatomegaly, portal hypertension
• Presence of stomach or pancreatic tumors
• History of spleen or stomach surgery
• Existing or suspected adhesions in the left upper quadrant

Lee–Huang Point: 

Located on the midline between the navel and the tip of the sternum (xiphoid process).

Recommended application of access:

Veress needle and primary port placement over the Lee–Huang Point are safe and useful in patients with large pelvic masses (e.g., fibroids) or malignant tumors.

Contraindications for access:

Not recommended in patients with previous supraumbilical surgeries.

Open laparoscopic access: 

A mini-laparotomy at the level of the navel, allowing direct placement of a trocar, followed by CO₂ insufflation and laparoscope introduction.

Development of the technique:

• First described by Harrith Hasson in 1971.
• Variants of this method allow access without sharp instruments, except for a scalpel and a clamp that blindly perforate the parietal peritoneum.
• The trocar system is blunt and can be fixed to the anterior rectus sheath with holding sutures.

Comparison to Veress needle technique:

• The open technique is less popular among gynecologists than among general surgeons, which may be due to differences in training, biases, and patient groups.

Applications:

• Preferred method for patients with previous surgeries (suspected intra-abdominal adhesions).
• Also used in pregnant women, very slender patients, and children with a small anterior-posterior abdominal diameter.

Steps for performing the open entry technique:

1. The skin incision in the area of the navel is made transversely or longitudinally, depending on preference or clinical situation. The length should be sufficient to allow precise preparation of the subcutaneous tissue, incision of the fascia, and entry into the abdominal cavity under direct visualization of each layer of the abdominal wall.
2. Blunt or sharp opening of the parietal peritoneum. The correct position in the abdominal cavity is verified by palpation with the finger.
3. Insertion of a blunt trocar system, if necessary, fixation of the trocar to the rectus sheath to ensure an airtight seal. 
4. After insertion of the primary trocar, CO₂ is insufflated to create the pneumoperitoneum.
5. Further working trocars are placed under direct vision, as in the Veress needle technique.
6. After completion of the procedure, both the fascial defect and the skin are sutured.

Steps for performing the closed entry technique (Veress needle): 

1. The skin incision in the area of the navel is made transversely or longitudinally, depending on preference or clinical situation. The length should be sufficient to allow the insertion of the optical trocar.
2. Lifting of the anterior lower abdominal wall by hand during Veress needle placement.
3. Selection of an appropriate needle length, especially in obese women
4. Needle orientation depending on the patient's BMI, 45° in normal-weight women and 90° in obese patients.
5. Verification of needle position, with correct intraperitoneal position, the intraperitoneal pressure is ≤ 8 mmHg. Other verification methods (double click, hanging drop, hissing) are considered unnecessary, the "swinging needle test" is to be avoided.
6. Further working trocars are placed under direct vision.
7. After completion of the procedure, both the fascial defect and the skin are sutured.

Reference: 

1. Djokovic, D., Gupta, J., Thomas, V., Maher, P., Ternamian, A., & Vilos, G. et al. (2016). Principles for a safe laparoscopic entry. European Journal Of Obstetrics & Gynecology And Reproductive Biology, 201, 179-188. doi: 10.1016/j.ejogrb.2016.03.040
2. Ahmad, G., Baker, J., Finnerty, J., Phillips, K., & Watson, A. (2019). Laparoscopic entry techniques. Cochrane Database Of Systematic Reviews. doi: 10.1002/14651858.cd006583.pub5
3. Hasson HM. A modified instrument and method for laparoscopy. Am J Obstet Gynecol. 1971 Jul 15;110(6):886-7. doi: 10.1016/0002-9378(71)90593-x. PMID: 4254516.