1.

Background
2. Complication of Gynecology Laparoscopy
2.1 The Anaesthetic
2.1.1 The use of Steep Trendelenburg position and distention of abdomen
2.1.2 Local Anaesthetic
2.2 The induction of pneumoperitoneum
2.2.1 Extra-peritoneal gas insufflations
2.2.2 Mediastinal emphysema
2.2.3 Pneumothorax
2.2.4 Pneumo-omentum
2.3 Insertion of primary and secondary trocars ( entry stage)
2.3.1 Major Vascular Injury
2.3.2 Nerve Injury
2.3.3 Mechanical instruments injury
2.3.3.1 Injury to gastro-intestinal tract
2.3.3.2 Urinary tract injury
2.3.3.3 Blood vessel injury
2.3.3.4 Gas embolism
2.3.3.5 Puncture of liver or spleen
2.3.3.6 Complications from distension medium
2.4 Electrothermal injury
2.4.1 Direct application
2.4.2 Stray current
2.4.3 Direct coupling
2.4.4 Capacitive coupling
2.4.5 Return electrode or alternative site burns
2.5 Other associated conditions
2.5.1 Cervical laceration
2.5.2 Uterine perforation
2.5.3 Shoulder pain
2.5.4 Pelvic inflammatory disease
2.5.5 Omental and Richter’s herniation
2.5.6 Injuries from the operating table
2.5.7 Foreign bodies
3. The Postoperative complications
3.1 Intestinal perforation
3.2 Retroperitoneal hematome
3.3 Hernia formation in trocar region
3.4 Postoperative air embolism
 CHAPTER I
BACKGROUND

It is known that the incidence of major intraoperative complications is less than 1%,
with mortality ranging between 4 and 8 per 100.000 cases. There are various publications on
personal experiences with the laparoscopic technique, systematically analyzing data collected
from series of case histories presented with incidence rates and types of complications
(Mencaglia, L., et al., 2014).
In case of complications derived from the surgical technique, we can include:
hemorrhage, vascular injury, retroperitoneal hematoma, bile leak, bile duct injury, bile
peritonitis (with or without a bile duct injury). Postoperative complications include: intestinal
perforation, bile leak, retroperitoneal hematoma, pancreatitis, subhepatic abscess and
postoperative air embolism (Belena & Nunez, 2014).
The relevance of a surgeons experience in preventing the occurrence of MVI is mixed
among published reports. Many studies consider experience to be an important factor for
preventing MVI, which occur more frequently during a surgeon’s first 100 laparoscopic
operations. However, otherstudies claim that MVI occursporadically, even throughout the
careers of experienced laparoscopic surgeons. Therefore, care should be taken to avoid MVI,
regardless of experience. (Nezhat et a.l, 2008).
 CHAPTER II
COMPLICATIONS OF LAPAROSCOPY

Laparoscopic surgery requires the use of standardized tehcniques and manuevers

under visual control through a laparsocope that show the anatomy, whereas introduction of
the first trocar is not under direct visual control but is performed blindly, thus constituting a
risk factor.

Classification of the complications

There are various classsifications of laparoscopic complications; however, that

published by Querleu and Chapron in 1993 is distinguished by its practicality and logical
structure. Under the title “ complications of gynecologic laparasocopic surgery”, thses
authors proceed to a further classificaiton into potentially lethal and non-lethal; they are also
divided into intraoperative and postoperative, and minor and major complications
(Mencaglia, L., et al., 2014).

The aim of this phase-based classification is to promote a culture of risk management

based on the development of strategies to improve patient safety and outcome, the underlying
principles of which can be remembered by the acronym of ACT: (Lam et al, 2009)
  Awareness that a complication can occur at any time before the patient enters the
operating room through to the postoperative phase.
 Communication and counseling skills are essential in preventing and dealing with
complications.
 Teamwork and training are important risk management principles in protecting and
ensuring patient safety from harm, particularly in laparoscopic surgery due to the
frequent introduction of new technologies or techniques.

Let us now see how the ACT risk-management principles can be applied to prevent
and deal with complications which may occur during the various phases of laparoscopic
surgery (Lam et al, 2009).

 Phase I – Patient identification

It is the responsibility of the surgical team to go through the routine of
checking the patient identity, consent form, listed procedure, site of surgery and
whether a patient has an allergy before the patient is anaesthetised. Failure to
complete this basic step may cause grievous harm and complications in laparoscopic
surgery before an incision is made.

 Phase II – Anaesthesia and positioning

Laparoscopic surgery presents unique anaesthetic challenges which are not
seen in open surgery. These include the effects of pneumoperitoneum, patient
positioning, extraperitoneal gas insufflations and venous gas embolism.

 Phase III – Entry-related complications

Laparoscopy involves gaining entry into the abdomen for gas insufflation and
insertion of primary (most commonly at the umbilicus) and secondary trocars. It has
been estimated that more than 50% of all complications associated with laparoscopy
occur during the abdominal entry phase. The potential complications include vascular,
intestinal, urinary tract injury and gas embolism.

 Phase IV– Surgery-related complications

 Besides the general surgical risks associated with any intra-abdominal surgery,
there are specific risks to the type of surgery being performed and the type of
pathology for which it is being performed. For example, the main risk associated with
adhesiolysis is intestinal injury, for myomectomy it is haemorrhage, while the main
risk with hysterectomy and removal of an entrapped ovary is urinary tract injury.

 Phase V– Postoperative phase

Complications such as bowel, urinary tract injuries or secondary haemorrhage
may not present until the postoperative phase. Awareness and vigilance are critical as
delayed diagnosis and/or inappropriate intervention may result in serious morbidity or
even mortality.

 Phase VI – Communication and counselling

Communication and counselling are integral to the management of
complications associated with surgery in general, and with laparoscopic surgery in
particular because of the inherent perceived minimal invasive nature of this surgical
approach. Taking patient’s concerns seriously, acting on the concerns promptly,
explaining the circumstances surrounding the complication fully, answering any
questions related to the complication honestly, supporting the patient sympathetically
and keeping the patient’s relatives informed are important aspects in the management
of complications in laparoscopic surgery.

The specific aim of the module is to simplify data collection. It can also part of a
multicenter project for collecting data via the internet, in which individuals, teams,
institutions and scientific associations can participate. When the data have been collected to
this module, it will possible to have precise qualitative and quantitative consistency regarding
he incidence of complications according to time and place. (Mencaglia, L., et al., 2014).
2.1 The Anaesthetic
Pneumoperitoneum and patient positioning during laparoscopy induce certain
pathophysiologic changes. These must be understood for the anesthesiologist to provide the
best perioperative care, particularly for patients with coexisting medical problems. In this
chapter, the changes induced by raised CO2 pneumoperitoneum and head-down tilt are
reviewed. The complications of laparoscopy that are of immediate concern to the
anesthesiologist are discussed, followed by a brief description of anesthetic techniques and
postoperative management. Recent research involving anesthesia for nongynecologic
laparoscopy is included when relevant (Nezhat et al.,2008).
A patient who has undergone a preoperative bowel preparation and a prolonged fast
may be dehydrated on arrival in the operating room. Intraoperative blood loss may be
difficult to assess during laparoscopy because of dilution in large volumes of irrigation fluid.
Pulmonary edema has been described after the absorption of intra-abdominal irrigating fluid,
resulting in dyspnea and hypoxemia in the recovery room. Maintaining a careful record of
irrigating fluid balance intraoperatively will alert the anesthesiologist when large deficits are
accumulating (Nezhat et al.,2008).
Postoperative hypothermia has been associated with an increased incidence of wound
infection and prolonged hospital stay after laparotomy. In patients with cardiac risk factors,
perioperative myocardial events are increased in the presence of mild hypothermia.[35]
Peritoneal gas insufflation and the use of large volumes of peritoneal irrigation predispose a
patient to hypothermia during laparoscopy. Warming of insufflation gas has not proved
useful. Warming of irrigation fluids and the use of a forced-air warming blanket reduce the
incidence of the undesirable postoperative effects of hypothermia (Nezhat et al.,2008).

2.1.1 The use of Steep Trendelenburg position and distention of abdomen

The position of the patient on the operating table is also important. In patients of
medium height with an estimated distance of 6 cm between the skin and retroperitoneal
vascular structures, the Trendelenburg position causes an anterior rotation of the sacral
promontory, which shifts the aortic bifurcation nearer to the skin. Therefore, this shift should
be kept in mind when performing laparoscopy on patientswith this body habitus (Nezhat et
al.,2008).
The Trendelenburg position further impacts on the haemodynamic and pulmonary
consequences of pneumoperitoneum. While the head-down position may partially offset the
changes to venous return, SVR and CO, it may lead to a number of pulmonary effects such as
a decrease in vital lung capacity and increase in airway pressure caused by cephalad
movement of abdominal viscera onto the diaphragm. The endotracheal tube may slip into the
right bronchus with the cephalad shift of the trachea carina. Prolonged Trendelenburg
positioning may lead to a significant increase in central venous pressure and cause central and
cerebral venous congestion. To counter the cardiopulmonary effects of Trendelenburg
position and pneumoperitoneum, the intra-abdominal pressure should be kept to less than 15
cm of water and ventilation pressures to less than 30 cm of water while maintaining adequate
minute ventilation and minimising duration of surgery to decrease cerebral venous congestion
(Lam et al, 2009).

2.1.2 Local Anaesthesia

Local anaesthesia may be used for tubal sterilisation and some other minor
procedures. This may produce specific problems and complications: (Gordon, A.G. 2017)

1. Anxiety.
Anxiety may be prevented by administration of Diazepam 20 mg orally about one
hour pre-operatively.

2. Vasovagal reaction.
This may be associated with bradycardia and, in more severe cases, cardiac arrest,
convulsion and shock. The treatment should include:
 Atropine 0.5 mg given intravenously (IV)
 Oxygen given by endotracheal tube at a rate of 4-6 litres/minute
 Adrenaline 0.5-1.0 ml of 1:100,000 solution given slowly IV
 Respiratory and cardiac resuscitation.

3. Pain.
Pain may be prevented to some extent by the administration of non-steroidal anti-
inflammatory drugs such as mefanimic acid, naprosene or fentanyl. It is prudent to have an
anaesthetist available because about 2% of patients find the operation painful and
consideration must be given to completing it under general anaesthesia (Gordon, 1984).
4. Allergic reactions and anaphylaxis.
Any local anaesthetic should be given initially as a small test dose to determine if an
unsuspected hypersensitivity exists. Obviously if it does, no more medication should be
administered. If a reaction occurs it will be characterised by agitation, flushing, palpitations,
bronchospasm, pruritus and urticaria. The treatment will depend on the severity of the
reaction and may include:

 Adrenaline 0.5 mg (1:100,000 solution IVI or IMI)

 Prednisolone 25 mg IVI
 Theophylline 250 mg (10ml) given slowly IVI
 Intravenous fluids
 Oxygen

2.2 The induction of pneumoperitoneum

The creation of pneumoperitoneum can cause both immediate as well as dynamic
cardiopulmonary effects. Initial gas insufflation may result in pronounced bradyarrhythmias
and even asystole as a result of vasovagal reflex from peritoneal stretch.20,21 This needs to
be differentiated from intravascular gas insufflations, intra-abdominal blood loss from
vascular injury or anaphylactic reactions. The release of pneumoperitoneum, with or without
administration of short-acting adrenergic drugs such as atropine or adrenaline, should result
in rapid reversal of the bradycardia, and may be followed by re-insufflation at a slower rate.
Once the procedure is underway, the continuing raised intra-abdominal pressure can cause
a reduction in venous return via the inferior vena cava and a rise in systemic vascular
resistance (SVR). These changes can result in a fall in cardiac output (CO).
Pneumoperitoneum may also affect lung mechanics causing a significant reduction in
compliance and increase in airway pressures. Alterations in lung unit ventilation–perfusion
(V/Q) ratios can lead to increased mismatching and consequent effects on O2 and CO2 blood
concentrations, notably hypoxaemia and hypercarbia (Lam et al, 2009).

2.2.1 Extra-peritoneal gas insufflation

CO2 under pressure can pass through pericardial and pleural spaces through anatomic,
congenital paths or acquired diaphragmatic defects. Significant extraperitoneal gas
insufflations can lead to pneumomediastinum, pneumopericardium and pneumothorax.
Similarly, CO2 can pass retroperitoneally through vast potential spaces causing subcutaneous
emphysema (Fig. 1). Intra-operative treatment of extraperitoneal CO2 insufflation includes
the use of positive endexpiratory pressure (PEEP), increased minute ventilation to open
collapsed alveoli, increased pressure to decrease the abdominal pressure gradient (or decrease
abdominal pressure) to splint or seal the defect. Postoperatively, entrapped CO2 gas will
diffuse out using treatment with 100% oxygen and adequate ventilation in an upright sitting
position (Lam et al, 2009).

Small amounts of CO2 embolism may be inconsequential as CO2 is highly soluble in

blood. However, when large volumes of gas are lodged directly onto the pulmonary outflow
trunk, this can lead to increases in pulmonary arterial pressure (PAP), increased resistance to
right ventricular outflow and diminished pulmonary venous return. The consequent decrease
in left ventricular preload results in diminished CO, asystole and systemic cardiovascular
collapse. In addition, the alteration in the resistance of the pulmonary vessels and VQ
mismatch cause intrapulmonary right-to-left shunting and increased alveolar dead space,
leading to arterial hypoxia and hypercapnia. Studies in dogs have shown that the median
lethal dose of CO2 embolism is 25 ml kg1 , which amounts to about 1750 ml of CO2 or 375
ml of air in a 70-kg person. Diagnosis on clinical grounds can be difficult since presentations
seen with gas embolism (hypotension, hypoxia, decreased end-tidal carbon dioxide) can be
caused by other complications such as anaphylaxis, pneumothorax, coronary events and
haemorrhage.28 In any event, initial resuscitation must include communication with the
surgical team, release of pneumoperitoneum and basic lifesupport measures. In doing so,
hopefully time and additional assistance will allow for investigation of the specific cause
(Lam et al, 2009).

2.2.2 Mediastinal Emphysema

Gas may extend from a correctly induced pneumoperitoneum into the mediastinum and
create mediastinal emphysema. Extensive emphysema may cause cardiac embarrassment
which will be diagnosed by the anaesthetist. There will be loss of dullness to percussion over
the precordium. The laparoscopy must be abandoned and as much gas as possible evacuated.
The patient must be kept under close observation until the gas has been absorbed. (Gordon,
A.G. 2017)

2.2.3 Pneumothorax
Pneumothorax may result from insertion of the Veress' needle into the pleural cavity.
Whenever a high site of insertion is chosen the needle should be directed away from the
diaphragm and, as always, the standard protocol of aspiration and sounding tests employed.
(Gordon, A.G. 2017)
Pneumothorax should be suspected if there is difficulty in ventilating the patient. There
may be a contra-lateral mediastinal shift and increased tympanism over the affected area. The
procedure should be abandoned and the gas allowed to escape. The patient should be kept
under observation. Occasionally assisted ventilation and insertion of a pleural tube may be
required. (Gordon, A.G. 2017)
Although pneumothorax is a complication that is more commonly associated with upper
abdominal laparoscopy, it has been reported during gynecologic procedures. A congenital
diaphragmatic defect may allow peritoneal gas to pass into the pleural cavity. An increase in
PIP, a fall in SpO2, and decreased breath sounds on one side point to the diagnosis, which
should be confirmed by chest radiograph. The laparoscopist may be able to show abnormal
motion of one hemidiaphragm. Reduced QRS amplitude in precordial ECG leads supports the
diagnosis. Falling MAP and SpO2 suggests the presence of a tension pneumothorax that
requires immediate decompression. Inthe absence of tension, unless there is a pulmonary
cause (such as a ruptured bulla), pneumothorax resolves spontaneously after 30 to 60 minutes
in the recovery period. If the patient is stable, Joris suggests conservative intraoperative
management. Chest tube drainage should be avoided during surgery because it will make it
difficult to maintain the pneumoperitoneum. Increasing fraction of inspiratory oxygen (FiO2),
the addition of 5 cm of positive end-expiratory pressure (PEEP), and reduction of
intraabdominal pressure will maintain oxygenation and allow surgery to be completed
(Nezhat et al.,2008).
Subcutaneous CO2 emphysema may accompany pneumothorax or occur in isolation.
An abrupt and severe rise in ETCO2 is characteristic. This occurs when CO2 tracks into
tissue planes, increasing the surface area for uptake into the circulation. A higher than normal
increase in minute ventilation is required for control. ETCO2 may increase to very high
levels. Rarely, it may become necessary to discontinue surgery and release the
pneumoperitoneum until control of ETCO2 is achieved. The possibility of pneumothorax and
pneumomediastinum always should be considered when subcutaneous emphysema is present.
Subcutaneous emphysema resolves over several hours. Explanation and reassurance may be
necessary for the patient in the postoperative care unit (Nezhat et al.,2008).

2.2.4 Pneumo-omentum
The omentum is penetrated by the Veress' needle in about 2 per cent of cases. The
misplacement should be recognised by the aspiration test and the position of the tip altered to
free the needle. There will also be a raised insufflation pressure which should lead the
surgeon to suspect an error in the position of the needle. The condition is usually innocuous
unless and omental blood vessel is punctured. (Gordon, A.G. 2017)

2.3 Insertion of primary and secondary trocars (entry Stage)

More than half of laparoscopic complications obviously occur during the entry stage.
As the entry is a relatively blind procedure, it also brings severe risks along. Complications
with respect to the entry technique occur in approximately 0.3-1% of the entire laparoscopic
procedures and the rate of mortality is approximately 7 in 1,00,000 (Pabuccu, E.G. 2016).

In cases with the doubt of technical difficulty, entry can be carried out on the mid-
clavicular line called Palmer’s point, approximately 3 cm inferior to the left costa; possible
several injuries may be prevented by using this localization. Palmer’s point can be used for
penetrating with Verres needle in cases with especially the presence of adhesion, previous
hernia repair, obesity, abdominal wall relaxation, the presence of a large mass and pregnancy.
Despite the measures counted, various injuries may be observed during entry. Intestinal and
retroperitoneal vascular injuries constitute the majority of complications observed during
entry. Following the entry procedure, injury regions according to the percentage of frequency
can be counted as: small intestine (25%), iliac artery (19%), colon (12%), iliac or other
retroperitoneal veins (9%), mesenteric artery (7%), aorta (6%), vena cava inferior (4%),
abdominal wall arteries (4%), bladder (3%) and liver (2%) (Pabuccu, E.G. 2016).

Several complications may also be encountered following laparoscopic penetration.

These may be as follows: vascular, gastrointestinal, urinary injuries or injuries of some
systems based on the usage of thermal energy. Vascular injuries are generally minor which
are likely to be observed during trocar insertions and are generally avoided by using the
transluminance technique. However, large vascular injuries may also be encountered during
large or lateral trocar penetrations (Pabuccu, E.G. 2016).

2.3.1 Major Vascular Injury

More than three quarters of MVI occur during insertion of the Veress needle and/or
trocars at the beginning of a laparoscopic procedure. The most frequently reported causes are
inexperience of the surgeon, insufficient acquaintance with anatomical landmarks, the
position of the patient during access to the peritoneal cavity and surgeon position in inserting
the Veress needle and/or trocars (Nezhat et a.l, 2008).

Knowledge of anatomic landmarks and relationships is very important in helping to

avoid MVI. In one study, the aortic bifurcation was found to be cephalad to the umbilicus in
more than 50% of nonobese patients. This percentage gradually decreased as the body mass
index (BMI) increased; however, the aortic bifurcation remained cephalad to the umbilicus in
less than or equal to 30% of obese patients. The same study demonstrated that the left iliac
vein always crossed the median line cephalad to the umbilicus, regardless of the patient’s
physical characteristics. Another important anatomic relationship concerns the distance
between the skin and the retroperitoneal vascular structures. In a study reporting an aortic
lesion that occurred during the incision of the skin at the umbilicus, the distance between the
umbilicus and the aorta was found to be reduced to around 2 cm. This reduction in distance
occurred after the induction of general anesthesia and the subsequentmuscular relaxation and
lateral displacement of the bowel. (Nezhat et a.l, 2008).

Treatment usually consists of conversion to open repair, but laparoscopic repair has
also been described. In either case, prompt recognition of a vascular injury is key in
performing beneficial treatment. (Nezhat et a.l, 2008).
1) Open
If blood is returned or seen at the needle/trocar insertion site or a retroperitoneal
hematoma is identified with the laparoscope, preparation for immediate
laparotomy should be made. With a retroperitoneal hematoma, it is not
uncommonto have minimal free blood in the intraperitoneal space. Initial control
should be obtained with direct pressure on the bleeding site (with hands, packs, or
vascular clamps) and then the peritoneum overlying the bleeding site should be
opened. At this point, atraumatic control of the injured vessel should be achieved,
free blood should be suctioned, and repair accomplished. The bleeding site
shouldbe fully exposed and inspected to exclude injury to the back wallof the
vessel. For extensive or complicated injuries, it may be necessary to obtain the
expertise of a vascular surgeon to assist in the repair.
2) Laparoscopic
MVI have been treated via a direct laparoscopic approach, although in many of
these cases the injury occurred under direct laparoscopic vision. This differs from
the unwitnessed, but clinically suspected, MVI sustained during access to the
peritoneal cavity; in the latter case, an open approach is recommended. Several
reports have shown that in instances where patients were not managed with
laparotomy, asignificant proportion resulted in death; the only survivor had a
small hematoma located at the aortic bifurcation that was discovered
intraoperatively.

PREVENTION
Trocar Design
In attempts to avoid MVI, new designs for trocars and new techniques for access to
the peritoneal cavity have been devised. The main improvements have been in the
development of trocars with blunt tips, trocars with protective sleeves, and optical
trocars that allow direct recognition of each layer of the abdominal wall during access
to the peritoneal cavity. However, without good technique, none of these safety
devices can eliminate the risk of an MVI. In 1996, the Food and Drug Administration
(FDA) advised manufacturers to avoid the term “safety trocar” when describing
cannulas with a blunt tip or a retractable sleeve and use the term “shielded cannula”
 because a number of MVI had occurred despite the use of these instruments. The
FDA’s advice was justified as subsequently there were several reports of MVI that
had occurred despite the introduction of these shielded cannulas. (Nezhat et a.l, 2008).

Trocar Placement
Other precautions employed by surgeons to avoid MVI include applying clamps to the
anterior abdominal wall and lifting anteriorly to increase the distance fromthe trocar
insertion site to the iliac vessels.
Another precaution is to incline the Veress needle in the sagittal plane caudally at 45
degrees with respect to the anterior abdominal wall to avoid the aortic bifurcation. In
a recent study based on computed tomography (CT) and ultrasonography, the
recommendations for the primary trocarwithout good technique, none of these safety
devices can eliminate the risk of an MVI. In 1996, the Food and Drug Administration
(FDA) advised manufacturers to avoid the term “safety trocar” when describing
cannulas with a blunt tip or a retractable sleeve and use the term “shielded cannula”
because a number of MVI had occurred despite the use of these instruments. The
FDA’s advice was justified as subsequently there were several reports of MVI that
had occurred despite the introduction of these shielded cannulas. (Nezhat et a.l, 2008).

Trocar Placement
Other precautions employed by surgeons to avoid MVI include applying clamps to the
anterior abdominal wall and lifting anteriorly to increase the distance fromthe trocar
insertion site to the iliac vessels. Another precaution is to incline the Veress needle
in the sagittal plane caudally at 45 degrees with respect to the anterior abdominal wall
to avoid the aortic bifurcation. In a recent study based on computed tomography (CT)
and ultrasonography, the recommendations for the primary trocar (Nezhat et a.l,
2008).

2.3.2 Nerve injury

Nerve injuries are rare in laparoscopic surgery. However, the potential risk of
neurological complications is generally related to the complexity and invasiveness of the
procedure being performed. (Lam et al., 2009).
 A study showing data collected from a gynaecological oncology fellowship
programme found the general incidence rate of nerve injury was 1.9% and was highest
(5.5%) during radical hysterectomy. (Lam et al., 2009).
Nerve injury related to laparoscopy can be due to stretching from improper patient
positioning, excessive tissue retraction, nerve compression or direct injury during dissection.
Injuries can occur in the upper and lower limbs. Brachial plexus injuries are the most
common positional nerve injury and are usually the result of positioning the patient with
outstretched arms and shoulder braces for a long duration of time.88 Ulnar and peroneal
nerve injuries are also related to positioning. (Lam et al., 2009).
Neurological damage during pelvic surgery usually involves injury to one of the
branches of the lumbosacral plexus. This includes iliohypogastric, ilioinguinal,
genitofemoral, lateral femoral cutaneous, femoral, obturator, pudendal and sciatic nerves.
Presents the mechanism of nerve injury and resulting postoperative clinical manifestation.
(Lam et al., 2009).
Since the treatment of nerve injury is quiet difficult and is associated with
unpredictable outcomes, prevention is the most crucial step in dealing with laparoscopy-
associated nerve damage. Proper positioning of the patient in the low lithotomy position
using boot stirrups is obligatory for every laparoscopic procedure.This includes mild flexion
of the hip to around 1700 in relation to the trunk and 900–1200 flexion of the knee. Abduction
of the thighs should result in no more than 90 0 between the legs, and there should be minimal
external rotation of the hips. The patient’s arms should be adjacent to the body (Lam et al.,
2009).
The commonperoneal and sciatic nerves are at risk for injury during laparoscopy in
the lithotomy position. Femoral neuropathy has also been reported. The brachial plexus may
be injured by pressure or stretching from shoulder restraints, especially in the steep head-
down position.Meticulous care is necessary when positioning the patient to minimize the risk
of injuring these vulnerable nerves. Lower limb compartment syndrome has complicated
prolonged laparoscopy performed in the lithotomy position (Nezhat et al.,2008).
 If neurological damage is suspected the patient should be examined for any kind of
sensory or motor deficit, especially those that are related to the lumbo-sacral innervation.
Early management is the key principle for success as is the case with most other types of
injuries during laparoscopy. Symptom resolution can be very slow and incomplete at times.
Success usually depends on the type of nerve, the extent of injury and the mechanism of
injury. (Lam et al., 2009).
If injury has been identified during laparoscopy, attempts should be made to repair the
injury with microsurgery, especially in cases of transection. This can be done by performing
an epineural or a fascicular repair, preferably with the aid of a neurosurgeon. Both nerve ends
must be properly aligned and repaired with a minimal amount of 8/0 to 10/0 nylon sutures
under magnification. If nerve injury has been identified after the procedure or if the
mechanism of injury was a result of crushing or extreme pressure on the nerve, a non-
invasive approach is usually required. (Lam et al., 2009).
The femoral, obturator and sciatic nerves have a motor neuron component and require
initiation of physiotherapy as soon as possible as to avoid muscle atrophy. Sensory nerve
injury is usually treated pharmacologically with oral analgesics, vitamin B supplements or
low-dose tricyclic antidepressants. The anti-epiletic medications, gabapentin and pregabalin,
can also be used in doses of 900–3600 mg day -1. For long-term relief, corticosteroids and
nerve blocks can be used. If this is not successful, surgical neurolysis, neuroma resection or
nerve resection may be required. In case of numbness without discomfort, the patient should
be reassured. Prognosis for symptom resolution is more favourable for sensory than motor
nerve injury (Lam et al., 2009).

2.3.3 Mechanical Instruments Injury

The main injuries caused by scissors or forceps are to a blood vessels. Bleeding will
be immediately obvious and should be controlled by bipolar or thermocoagulation or by
suturing. Direct inadvertent injury to other organs by mechanical instruments may result from
careless or clumsy use (Gordon, A.G. 2017)

2.3.3.1 Intestinal injury

The incidence of intestinal injuries increases from 0.06 to 0.5% for diagnostic
laparoscopy to 0.3–0.5% in operative laparoscopy. While relatively uncommon, intestinal
injuries can result in serious complications including death following laparoscopy. In a
review of 31 papers published between 1973 and 2001 examining 329,935 laparoscopic
procedures, the mortality rate from laparoscopy-induced bowel injury was as high as 3.6%,
The commonest sites of injury are small bowel (58%), colon (32%) and stomach (8%). It is
estimated that up to half of all laparoscopy-associated intestinal injuries may happen during
the entry phase of laparoscopy from the use of the Veres needle and trocar insertion. The
remainder may be due to trauma from surgery, thermal injuries from electro-surgery,
herniation through port sites or anastomotic leaks (Lam et al, 2009).
The extent of adhesiolysis performed intra-operatively has been found to be a significant
risk factor for intestinal injury. An open entry technique has not been shown to reduce the
incidence of entryrelated bowel complications but may allow immediate recognition of the
bowel injuries. Intestinal trauma may result from inappropriate use of grasping forceps,
bowel retraction, insertion and reinsertion of instruments or sharp dissection. Thermal
injuries during surgery may be caused by direct, capacitive coupling or insulation failure.
Such injury may be unrecognised or occur outside the operating field, leading to late
presentation and delayed diagnosis. Herniation through laparoscopic port sites is uncommon,
with a reported incidence of 0.06–1%. The risk is related to the size of the trocar with a 3.1%
risk associated with 12-mm trocar wounds compared to 0.2% with 10-mm trocar wounds.
Bowel herniation through 5-mm ports has also been reported. Anastomotic leakage is a rare
but serious complication. The leakage rate is related to the level of the anastomosis from the
anus.Platell et al. showed that the rate of anastomotic leakage for ultra-low anterior resection,
low anterior resection, high anterior resection and hemicolectomy were 8%, 3.2%, 2.3% and
0.4%, respectively (Lam et al, 2009).
The management of laparoscopy-associated bowel injuries depends on three main
factors:
 The timing of the diagnosis
 The patient’s clinical status
 The availability of expert assistance
It is estimated that only 30–50% of intestinal injuries are recognised during surgery. The
remainder may present any time from 1 to 30 days after surgery. The length of time from
surgery to recognition is variable depending on the site and type of bowel injury. Small bowel
injuries normally present at 4.5 days (range 2–14) while colon injuries 5.4 days (range 1–29).
Thermal injuries tend to present late. The reasons leading to delayed presentation of bowel
injuries are listed in Table 4. In general, the later the diagnosis, the higher the morbidity and
mortality associated with bowel injury (Lam et al, 2009).
 Patients with laparoscopy-associated intestinal injuries may present with subtle
symptoms such as mild abdominal distension, pain at the trocar site near the injured segment,
low-grade fever, diarrhoea with normal bowel sounds or mild hypoxia with few peritoneal
signs. Respiratory distress may be mistaken for a chest infection or pulmonary embolism.
Others may have the classical symptoms of acute abdominal pain, vomiting, tachycardia,
hypotension, abdominal rigidity and ileus. Once peritonitis becomes generalised, the patient’s
condition may deteriorate quickly with a risk of chest consolidation, sub-diaphragmatic
abscess, septicaemia and multi-organ failure (Lam et al, 2009).

Early recognition and appropriate intervention is the key to minimising morbidity and
mortality associated with laparoscopy-associated intestinal injuries. Faecal contamination at
the tip of the Veres needle or trocar, or subtle signs such as bowel-wall haematoma should
raise suspicion and require careful inspection of the bowel surface for possible injury. If in
doubt, submerging bowel loops under irrigation fluid may reveal air bubbles or bowel content
spillage from the bowel defect. The injured bowel should be repaired immediately. This can
be done laparoscopically or by exteriorising the injured loop through a mini-laparotomy.
Gastric, small-bowel and colonic injuries can be repaired with one or two-layered closure
using 4/0 Vicryl or PDS sutures. All non-viable tissue should be excised. The management of
all bowel injuries should also include a thorough peritoneal lavage and antibiotic coverage.
Early consultation and involvement of the colorectal team are paramount if the gynaecologist
does not have the experience or technical ability to deal with bowel complications (Lam et al,
2009).
Patients with suspected intestinal injuries in the postoperative period should be
promptly admitted for assessment, intravenous rehydration, parenteral antibiotics and
insertion of a nasogastric tube. Abdominal radiographs, ultrasound examination, computed
tomography (CT) with contrast of the abdomen and pelvis may reveal air under the
diaphragm, distended bowel loops with multiple fluid levels or localised fluid/air collections
due to abscesses. However, imaging studies and blood tests should not be used solely to
guide clinical decision making as they are not always conclusive. If in doubt, early
involvement of other specialists, such as a colorectal surgeon, intensive care specialist,
anaesthetist, microbiologist and chest physician, is advised. So is a low threshold for an
exploratory laparoscopy or laparotomy if the patient’s condition is unclear (Lam et al, 2009).
Detection and management of bowel injury
According to a review by van der Voort et al., 61.6% (154/250) of bowel injuries
were recognized intraoperatively; 5.2% (13/250) and 10.4% (26/250) were recognized during
early (within the next 48 hours) and late (at least on the 3rd postoperative day or later)
postoperative phases, respectively. Laparotomy was the most frequently performed procedure
to manage laparoscopyinduced bowel injury (78.6%). Conservative and laparoscopic
treatment were used considerably less often (7.0% and 7.5%, respectively). (Huang et al,
2014).
The sigmoid colon is especially vulnerable because of its close proximity to the uterus
and ovaries. A generous segmental excision (up to 5 cm on each side of the margin of the
injury site) is required to prevent subsequent reperforation caused by coagulation necrosis.
Currently, the best way to treat bowel injury during laparoscopic surgery is by traditional
laparotomy. However, as laparoscopic surgeons become more experienced in these
techniques, laparoscopic suture repair will become another choice in the management of
selected cases. A full-thickness penetration of the rectum can occur during excision of rectal
endometriosis. After excision of the nodule of the rectosigmoid colon, a single- or double-
layer repair can be performed by laparoscopic-assisted transvaginal approach or total
laparoscopic intracorporeal technique. Laparotomy followed by repair and colostomy should
be considered for the unprepared bowel with a large amount of fecal contamination. (Huang
et al, 2014).

2.3.3.2 Urinary tract injury

The incidence of urinary tract injury ranges from 0.05% to 8.3% of all laparoscopies.
Trauma to the bladder occurs more frequently (0.02–8.3%) than to the ureter (0.5–3%).
While injuries to the bladder are easily recognised, injuries to the ureters are frequently
missed during surgery. Delayed diagnosis of urinary tract injury is associated with serious
morbidity such as fistula formation, peritonitis, loss of renal function and is a frequent cause
of medicolegal litigation. Mechanism of injuries Bladder injury during laparoscopic surgery
may occur due to insertion of a suprapubic trocar into a full bladder, bladder dissection
during laparoscopic hysterectomy, excision of endometriosis, or removal of pelvic masses
such as uterine myoma or ovarian tumours. Conditions which cause distortion of normal
pelvic anatomy, such as adhesions from previous caesarean section or radiation, increase the
injury risk. The bladder dome is the most common injury site, followed by the posterior
bladder base. The mechanisms of bladder injury during laparoscopic surgery include
electrocautery, blunt dissection, or trauma from laser, scissors and from trocars. The common
sites of ureteric injury are next to the infundibulopelvic ligament where the ureters cross the
pelvic brim, the ovarian fossa, lateral to the cervix where the ureter passes under the uterine
arteries, the uterosacral ligament and the anterior vaginal fornix. The mechanisms of injury
include transection, ligation or necrosis from energy damage or ischaemia (Lam et al, 2009).

Factor that distort pelvic anatomy may incrase the risk of bladder damage (Minas et
al.,2014).

Although not evidence-based, bladder catheterisation prior to peritoneal insufflation

and insertion of trocars is recommended to avoid injury to a bladder distended by urine.
Kyung et al. also advise insertion of an indwelling catheter in long procedures. Keeping the
bladder empty during surgery will protect it not only because its decreased size will keep it
out of the surgeon’s operating field, but also because an empty bladder cannot be penetrated
as easily as a distended one. Specific attention is drawn to the risk associated with LAVH,
and particularly to those cases where the bladder is dissected laparoscopically and the cuff is
then closed vaginally (Minas et al.,2014).
Finally, it is important to be aware of and adhere to the rules of safe electrosurgery.
There are four causes of inadvertent laparoscopic electrosurgical injuries, namely inadvertent
tissue contact, insulation failure, direct coupling and capacitive coupling. The above apply to
all visceral injuries that may occur during laparoscopic surgery. Such injuries may be difficult
to identify, as they can occur at a site distant to the surgeon’s view, and/or present as delayed
tissue breakdown several days following the primary insult. Safety measures to prevent such
complications are listed in Box 2 (Minas et al.,2014).

Prevention of urinary tract injuries requires a detailed knowledge of pelvic anatomy,

meticulous dissection skills, use of the avascular surgical spaces and good haemostatic
principles. Bladder injury risk is reduced by routine bladder drainage during surgery,
insertion of suprapubic trocars above the bladder dome, sharp rather than blunt dissection of
the bladder from the cervix during hysterectomy and an awareness of congenital
abnormalities. The avoidance of ureteric injury requires the ability to identify its course from
the pelvic brim to the bladder, the dissection skills to separate the ureter away from the
infundibulo-pelvic ligament (before ligation of this pedicle) or during excision of
endometriotic implants on the lateral pelvic sidewall and before ligation of uterine vessels
during laparoscopic hysterectomy (Lam et al, 2009).

Early recognition and repair of the bladder defect are important to prevent the
development of fistulas. Ostrzenski et al., in a review of 1372 articles on laparoscopic surgery
published between 1970 and 1996, reported that an intra-operative diagnosis of bladder injury
was made in 53.24% of all bladder injury cases.70 Gilmour found that 97% of
postoperatively recognised bladder injuries presented as vesico-vaginal fistulas.79 Partial
trauma to the bladder can present as a mucosal bulge through the muscularis layer. A
complete injury will result in the loss of urine through a hole in the bladder wall. If in doubt,
instillation of methylene blue dye into the bladder via an indwelling urinary catheter will
confirm whether dye leaks through the defect into the abdominal cavity. Cystoscopy should
help evaluate the extent of bladder trauma in relation to the ureteric orifices. Bladder injuries
can be repaired laparoscopically or through a mini-laparotomy with fine, absorbable
polydiaxanone or vicryl sutures in one or two layers, with interrupted or continuous closure
as long as a watertight repair is achieved. Non-absorbable sutures should not be used as this
can result in formation of calculus, granulomas and fistulas. An indwelling urinary catheter
should be placed for 7–10 days to promote tissue healing (Lam et al, 2009).

Current evidence from the literature indicates that over 70% of ureteric injuries
present postoperatively.71,75,80 Several measures may facilitate an intra-operative diagnosis
and decrease the delay in recognition of ureteric injuries. Cystoscopy after giving intravenous
indigo carmine dye may raise suspicion of ureteric damage if the ureteric jet is significantly
slower or dye-stained urine cannot be visualised from the orifice of the affected ureter.
Failure to freely pass a ureteric stent should also raise suspicion of ureteric obstructive injury.
Laparoscopy may demonstrate dye leakage through a defect of the ureteric wall. Finally,
blanching of a segment of the ureter should alert the surgeon to the possibility of diathermy
injury which, if not recognised, may result in necrosis, urinary leakage and urinary
peritonitis. Intra-operative diagnosis of ureteric injuries should allow immediate repair with
the help of a urologist. Traditionally, these injuries are managed via laparotomy. However,
successful laparoscopic ureteric injury repairs have been reported in the literature where the
outcome was similar for both laparoscopy (91.3%) and laparotomy (90.4%) (Lam et al,
2009).
Cystoscopic visualisation of ureteric jets into the bladder can be falsely re-assuring in
case of incomplete or delayed ureteric injuries. Retrograde ureterogram involving injection of
contrast up into the ureters via a cystoscope can be used to diagnose more subtle ureteric
injuries not evident on IVP or CT studies. In cases of suspected fistula formation, methylene
blue can be instilled into the bladder. Vesicovaginal fistula may be diagnosed on the basis of
finding blue dye staining of a tampon placed in the vagina. A ureterovaginal fistula may be
confirmed when seeing intravenous pyridium producing an orange stain on a tampon in the
vagina.84 Once ureteric injury is recognised, corrective surgery should be performed
immediately (Table 5). If surgery is contraindicated due to severe infection or tissue necrosis,
a percutaneous nephrostomy or retrograde stent placement should be performed to maintain
urinary drainage and promote spontaneous healing (Lam et al, 2009).
Ureteric Injury
Just like the bladder, the ureter’s proximity to the female genital tract puts it at risk of
injury during pelvic surgery. Most published studies quote a range of ureteric injury rates at
laparoscopic gynaecological surgery from <1% to 2%. Rates as low as 0.06% (large series of
laparoscopic subtotal hysterectomies), and as high as 21% (deep infiltrating endometriosis
associated with hydronephrosis) have been reported. A Cochrane review reported a higher
incidence of ureteric injuries associated with laparoscopic hysterectomies compared to
abdominal and possibly vaginal hysterectomies (Minas et al.,2014).
These observations were largely based on the eVALuate study which involved two
parallel randomised trials comparing laparoscopic with abdominal and laparoscopic with
vaginal hysterectomies. The study found a 9.8–11.1% incidence of major complications in
the laparoscopic hysterectomy groups. However these conclusions have been criticisedby
other authors on the grounds of bias. Donnez et al. suggested that the unusually high
complication rates reported by the eVALuate study were probably due to the relative
inexperience of the surgeons in laparoscopic hysterectomy than to the technique itself. In the
absence of further well-designed sufficiently-powered trials this debate remains unresolved to
date (Minas et al.,2014).
The most common sites of ureteric injury in laparoscopic surgery are at the pelvic
brim (where the ureter comes into close proximity with the infundibulo-pelvic ligament
which contains the ovarian vessels) and lateral to the cervix (during division or coagulation of
the uterine artery or the uterosacral and cardinal uterine ligaments). Less often, injuries may
occur at the ovarian fossa, for example during resection of endometriosis or ovarian
remnants. Risk factors due to distorted anatomy are essentially the sameas those described
above for bladder injuries (Box 1). Electrocautery may be involved in up to one quarter of
ureteric injuries. Interestingly, video analysis of laparoscopic procedures where a ureteric
injury occurred in a patient with severe endometriosis concluded that unconscious
acceleration of surgery, possibly caused by fatigue, contributed to a judgement error that led
to the injury (Hurd et al.) showed that the ureter passes lateral to the cervix with an average
distance of 2.3±0.8 cm (Minas et al.,2014).
Analysis of CT images of 52 women with apparently normal pelvic anatomy, showed
that in 12% of the patients the distance was less than 0.5 cm. In addition, the higher the body
mass index the closer the ureter was found to be to the cervix. Prevention The principles of
bladder injury prevention (knowledge of the anatomy, safe electrosurgery and meticulous
technique) apply here as well. Instruments such as virtual reality models of pelvic anatomy
are now at the disposal of modern surgeons and complement traditional textbooks and
learning anatomy ‘on the job’. Preoperatively, an MRI with or without an intravenous
urogram (IVU) may help the surgeon plan a complex procedure, for example, in cases of
endometriosis with suspected ureteric involvement; however, this investigation offers no
benefit in routine cases. Intraoperatively, the detailed vision offered by the magnified
laparoscopic view should be used to identify ureteric peristalsis and thus localise and follow
the course of the ureter. Patience is needed to keep the laparoscope still until peristalsis is
seen. This process may be repeated as many times as necessary during the course of a
complex procedure. On occasion it may be easier to identify the ureter if one starts looking
for it at the pelvic brim where it crosses the bifurcation of the common iliacs (Minas et
al.,2014).
In complex cases which carry increased risk of ureteric injury (for example extensive
pelvic endometriosis, large ovarian cysts, pelvic adhesions, cervical fibroids) it is usefuland
often mandatory to dissect and expose the ureter (ureterolysis) (Video S1). Mobilisation of
the ureter should be performed through a peritoneal incision using a medial to lateral blunt
sweeping technique. The ureter is an organ that carries its own blood supply system within a
layer of adventitia that surrounds it. Provided that this vascular plexus is preserved, the ureter
can be mobilised over a length of 15 cm (approximately half its total length) without
compromising viability. It follows that electrosurgery should be used with caution and, if
possible, avoided in close proximity to the ureter. Ureterolysis performed through dense
surrounding pathology, such as severe endometriosis, is an advanced laparoscopic skill and
should normally only be performed in centres with the appropriate expertise (Minas et
al.,2014).
Ureteric stenting (including lighted stents) is useful only invery select cases, where
the pelvic anatomy is severely distorted and/or usual methods of ureter identification have
failed. (De Cicco et al.) suggest that in cases of severe endometriosis associated with ureteric
obstruction and hydronephrosis, preoperative stenting is mandatory (Minas et al.,2014).
Finally, adequate reflection of the bladder off the uterus and the cervix during total
laparoscopic hysterectomy will move not only the bladder, but also the ureters away from the
uterine vessels and the cervix, thus reducing the risk of injury (Minas et al.,2014).

There are seven types of ureteric injury (Box 3), withtransection the most commonly
reported at laparoscopy. Only a third of such injuries are recognised intraoperatively,
therefore any uncertainty about the integrity of the ureter should prompt intraoperative
investigation and involvement of a urologist. Cystoscopy allows visualisation of the ureteric
orifices and urine jets which rules out obstruction, but does not exclude other types of
injuries. Presence of blood or air suggests injury. Intravenous administration of indigo
carmine colours the urine blue within 5 to 10 minutes and will assist a cystoscopic
assessment as well as potentially allow the surgeon to identify a urine leak laparoscopically.
Stents inserted without resistance, under direct laparoscopic visualisation to ensure they do
not exit through a possible injury, can also rule out obstruction. Occasionally, insertion of a
stent alone can be therapeutic if the problem was angulation (kinking) of the ureter.
Ureteroscopy may locate the approximate height and extent of injury. Retrograde, antegrade
and/or intravenous uretero-pyelography can confirm or refute the diagnosis and determine the
location of an injury (Minas et al.,2014).
The consequences of an unrecognised injury can vary from spontaneous healing to
fistula and/or stricture formation with associated deterioration of the function of the affected
kidney. This may occasionally require nephrectomy. Up to 25% of unrecognised ureteral
injuries result in eventual loss of the ipsilateral kidney (Minas et al.,2014).
However, the recommended amount of time for which the ureter should be stented in
such cases, varies in the literature between 2 to 6 weeks. Similarly, limited areas of thermal
injury may require stenting to prevent stenosis and urine leakage during healing.20 Caution is
required when more extensive deep thermal injury has occurred, in which case, excision of
the affected part and ureteral re-anastomosis or re-implantation might be needed. Ureteric
lacerations appear to heal better when managed with suturing and stent rather than stent alone
(Minas et al.,2014).
In cases of major ureteric injuries (transection, resection)the suggested techniques are
site-specific. At the upper third of the ureter an end-to-end re-anastomosis of the ureter
(uretero-ureterostomy) should be performed. At the middle third either a uretero-
ureterostomy or atrans-uretero-ureterostomy (end-to-side anastomosis of the injured ureter
with the contra-lateral healthy ureter) can be performed. It follows that trans-uretero-
ureterostomy involves intentional injury and therefore risk to the contra-lateral healthy ureter
and should not be used as a first-line option. At the lower third uretero-neocystostomy (re-
implantation of the ureter into the bladder) should be preferred. If a tension-free anastomosis
cannot be achieved by simple re-implantation (due to a shortened ureter, for example), then a
psoas hitch or a Boari flap can be performed. In these two techniques the bladder is mobilised
and used to bridge the gap. A psoas hitch involves fixing the bladder to the iliopsoas muscle
tendon. To create a Boari, an oblique flap from the dome of the bladder is cut and the
cystotomy is closed vertically extending the flap to the ureter. The Boari flap technique can
provide up to 12–15 cm of additional length (Minas et al.,2014).
Urinomas can often be managed by involving a specialist radiologist. A combination of
percutaneous drainage of the urinoma, percutaneous nephrostomy, ureteral stents and bladder
drainage may help avoid re-operation. When late presentation is associated with a septic
unstable patient and/or abscess formation, conservative initial management similar to that
described for urinomas plus aggressive antibiotic treatment is required. The patient should
ideally be stabilised before considering a laparoscopic or open approach. At the end of the
healing period, an intravenous or retrograde urogram must be performed to confirm ureteral
patency and integrity (Minas et al.,2014).

2.3.3.3 Blood Vessel injury

Vascular injury Incidence Vascular injuries are undoubtedly the most alarming and
serious laparoscopic complications with a 9–17% mortality rate. The reported incidence
varies from 0.04% to 0.5% of all laparoscopies. A recent study by the Swiss Association of
Laparoscopic and Thoracoscopic Surgery examining 43,028 laparoscopic procedures
reported a 1.7% intra-operative and a 1.5% postoperative incidence of internal bleeding or
haematoma of the abdominal wall, and a 0.09% incidence of major vascular injuries. This
suggested that the actual incidence of vascular injuries in laparoscopy may be under reported
(Lam et al, 2009).
Most vascular injuries occur during insertion of the Veres needle or the trocar. The
proximity of the distal aorta and the right common iliac vessels to the umbilicus put them at
higher risk of injury than the inferior vena cava, the left common, the internal and external
iliac vessels. Vascular injuries have also been reported with the Hasson open entry, direct
entry and insertion of secondary trocars (Lam et al, 2009).
Bleeding on aspiration of the Veres needle or through the trocar, frank or concealed
bleeding within the pelvis or abdomen and unexplained hypotension should warrant
exploration and identification of the bleeding vesselimmediately. Due to delayed recognition,
vascularinjury during the entry phaseis associated with greater morbidity and mortality than
injury during the surgical phase of a laparoscopic procedure (Lam et al, 2009).
Significant bleeding can also arise from injury to the superficial epigastric, superficial
circumflex, inferior epigastric or deep circumflex vessels from insertion of secondary trocars.
The bleeding may present as a diffuse haematoma within the abdominal wall or profuse
haemorrhage into the peritoneal cavity. At times, port-site bleeding may be tamponaded by
the trocar and seems minimal during surgery but may present during the postoperative phase
(Lam et al, 2009).
Risk factors contributing to major vascular injury include the surgeon’s skill,
instrument sharpness, angle of insertion, patient position, degree of abdominal wall elevation
and volume of pneumoperitoneum. To eliminate these risk factors and to avoid entry-related
vascular injury, the authors use a standardised entry technique that involves:

 Abdominal wall elevation while making a 1-cm vertical incision through the skin,
the rectus sheath and the peritoneum at the umbilicus
 Abdominal wall elevation while inserting a blunt or dilating tip trocar through the
abdominal wall incision
 Insufflation only after confirmation of correct placement of the laparoscope (Lam
et al, 2009)
The insertion of the secondary trocars is always under direct vision to avoid injuring
the vessels in the abdominal wall and the pelvic sidewall. The superficial epigastric and the
superficial circumflex iliac vessels can be identified by transillumination while the inferior
epigastric vessels can be traced by direct visualisation of the anterior abdomen (Lam et al,
2009).
 Vascular injury requires prompt, directed and coordinated response. The authors use
the acronym SAAS for dealing with vascular injury:
 Stop the arterial bleeder immediately by occluding the vessel with atraumatic
grasping forceps, or tamponading diffuse venous bleeding with a 2-inch vaginal
pack inserted through a 10–12-mm port or through a laparotomy incision. Do not
inadvertently extend the tear or blindly coagulate with bipolar diathermy forceps.
 Alert the team so that resuscitation measures (intravenous (IV) access, blood cross-
matching, volume replacement and blood transfusion) can be commenced while a
laparotomy tray and, if required, help from a vascular surgeon can be obtained.
 Access the bleeding site by the quickest and safest route. This usually means
conversion to laparotomy. The laparoscopic approach may be considered if the
patient is haemodynamically stable, the injured vessel is clearly located, the
bleeding temporarily controlled and the surgeon is experienced in handling such
injury.
 Secure the vascular injury by using an appropriate haemostatic method according
to the nature of the injury (Lam et al, 2009).

2.3.3.4 Gas Embolism

CO2 embolism is a rare but potentially fatal event. It occurs most commonly during
initial insufflation of gas as a result of inadvertent insertion of the trocar or Veress needle into
a vessel or abdominal organ. The severity of the response depends on the volume of gas
entering the circulation and the speed of entrainment. Small CO2 emboli appear to follow a
more benign and transient course than do air emboli because of the high solubility of CO2 in
blood and tissues and the large buffering capacity of blood, which leads to rapid elimination.
The lethal dose of CO2 is about five times that of air (25 mL/kg for CO2 and 5 mL/kg for air)
in dogs. The expansion of an air embolus caused by diffusion of nitrous oxide into the bubble
of air does not occur with CO2 emboli because CO2 has a solubility similar to that of N2O.
Unlike air embolus, CO2 embolus does not cause bronchospasm. Large volumes of gas
injected under pressure, however, can cause an “air lock” in the vena cava or right atrium,
causing sudden cardiovascular collapse (Nezhat et al.,2008).
Intravascular insufflation of gas may lead to gas embolism or even death. This can only
happen if the penetration by the Veress' needle goes unrecognised and insufflation
commences. It should be prevented by routine use of the aspiration test. The patient should be
turned on to the left lateral position and, if immediate recovery does not take place, cardiac
puncture performed to release the gas (Gordon, A.G. 2017).

2.3.3.5 Puncture of liver or spleen

The liver or spleen may be punctured by the Veress' needle when a high insertion site is
chosen. It may also occur in the presence of hepatomegaly or splenomegaly. The aspiration
test and the high insufflation pressure will make it obvious that the needle is sited incorrectly
in which case it should be withdrawn and re-sited (Gordon, A.G. 2017).

2.3.3.6 Complications from distension medium

Carbon dioxide (CO2) is the distension medium most commonly used for operative
laparoscopy. Gas embolism is possible but uncommon because the gas is highly soluble and
is reabsorbed so quickly that, even if there has been a moderate embolus, the circulatory
changes return to normal within a few minutes and the patient recovers. Up to 400ml of gas
may be intravasated without producing changes in the ECG (Gordon, A.G. 2017).
Cardiac arrythmia may be due to excessive absorption of CO2. It is important to
monitor the intra-abdominal pressure throughout the operation and to use an automatic
pneumoflator for all but the simplest forms of surgery. This will cut out if the intra-abdominal
pressure rises. Endotracheal intubation and positive pressure respiration will also help to
prevent complications from CO2 insufflation (Gordon, A.G. 2017).
Post-operative pain is common with CO2 insufflation due to peritoneal irritation
which is a result of conversion of CO2 to carbonic acid. The chest pain may be confused with
coronary heart disease and be treated inappropriately with anti-coagulants. This may produce
a wound haematoma or intraperitoneal bleeding (Gordon, A.G. 2017).
 Nitrous oxide (N2O) has become popular with some laparoscopists because there are
less side effects than with CO2. Anaesthetists can dispense with intubation and allow the
patient to breath through a laryngeal mask. However, in modern laparoscopic practice, a
diagnostic laparoscopy may develop into a complicated operative procedure. N2O supports
combustion. Methane gas may be released into the peritoneal cavity following bowel injury.
A high frequency monopolar current used during laparoscopic surgery may cause an
explosion (Gordon, A.G. 2017).
The main place for N2O is when laparoscopy is being performed under local
anaesthesia in which case the pain factor becomes important. This is applicable to tubal
sterilisation with clips, rings, or bipolar coagulation, but not to more advanced laparoscopic
procedures (Gordon, A.G. 2017)

2.4 Electrothermal Injury

The rate of electrosurgical complications during delivery of energy to the surgical site
is estimated to be 25.6% (70/273) and is the second most common laparoscopic complication
after a misplacement of trocar or Veress needle, which is 41.8% (114/273). Surgical
techniques are more difficult if the surgeon's spatial orientation and hand-eye coordination
are not well established. Injuries during laparoscopic electrosurgical procedures are similar to
those during laparotomy and can be attributed to misidentification of anatomic structures,
mechanical trauma, or electrothermal injuries. The possible mechanisms are listed in the next
paragraphs (Huang et al, 2014).

2.4.1 Direct application

Injury by direct application of the electrosurgical probe can arise either from mistaken
targeting or unintended activation. The speed of the procedure will result in either less or
more coagulation and thermal spread. Proximity between the electrode and the tissue can
determine contact (desiccation) or noncontact tissue effect (fulguration). The dwell time
determines the amount of tissue effect. Prolonged activation will produce wider and deeper
tissue damage more than the anticipated desired tissue effect (Huang et al, 2014).

2.4.2 Stray current

A stray current arising from defective insulation can injure the bowel or blood vessels.
A careful preoperative inspection of equipment and after use is the best means of identifying
defective insulation. The two major causes of insulation failure include the use of high
voltage currents and the frequent resterilization of instruments, which can weaken and break
the insulation. The risk of an insulation break increases when using a 5-mm insulated
instrument through a 10-mm sleeve, or by repeated use of disposable equipment (Huang et al,
2014).

2.4.3 Direct coupling

Direct coupling occurs when the active electrode is accidentally activated or is in
close proximity to another metal instrument within the pelvic cavity, e.g., laparoscope or,
metal grasper forceps. Direct coupling can be prevented with visualization of the electrode
and avoiding contact with any other conductive instruments prior to activating the electrode
(Huang et al, 2014).

2.4.4 Capacitive coupling

Capacitive coupling occurs when the electric current is transferred from one
conductor (the active electrode), through intact insulation, into adjacent conductive materials
(e.g., bowel) without direct contact. Longer length of instruments, thinner insulation, higher
voltages, and narrow trocars increase the risk of this type ofinjury. Capacitor coupling can be
minimized by activating the active electrode only when it is in contact with target tissues and
limiting the time length of high-voltage peaks (Huang et al, 2014).

2.4.5 Return electrode or alternative site burns

The grounding (dispersive) pad offers the path of least resistance from the patient
back to the generator and ensures an area of low current density. If the return electrode is not
completely in contact with the patient's skin, or is not able to disperse the current safely, then
the exiting current can have a high enough density to produce an unintended burn. It is
important to have good contact between the patient and a dispersive pad. A burn at an
alternative site can occur if the dispersive (ground) pad is not well attached to the patient's
skin. When the dispersive pad is compromised in the quantity or quality of the pad or patient
interface, the electrical circuit can be completed by some small grounded contact points such
as electrocardiogram leads, towel clip, intravenous stand, etc., and produce high current
densities, causing a burn (Huang et al, 2014).
The management of electrosurgical injury
Bipolar electrosurgical injury, compared with monopolar injury, can be readily
identified by viewing the area of blanch on the surface of the colon. The spread of
electrothermal injuries is greater than the initial area of blanching, creating a large area of
necrosis. Thus, the depth of injury is difficult to assess even if it is noticed intraoperatively.
Thermal injury of the bowel necessitates segmental resection with a wide margin around the
site of injury because thermal damage may extend several centimeters away from the site of
thermal contact (Huang et al, 2014).
When bladder injury is recognized intraoperatively, it can berepaired vaginally,
laparoscopically, or by laparotomy. Early recognition with immediate salvage procedure,
along with extended use of an indwelling catheter, may help overcome further sequelae.
Intraoperative bladder injury can be detected by direct visualization of the bladder mucosa or
Foley balloon or through the instillation of diluted dye via the Foley catheter. A urine bag
inflated with gas during the operation is suggestive of an injury. Intraoperative ureteral
injuries in gynecologic laparoscopy are usually not recognized during the procedure. Patients
with persistent abdominal and/or flank pain, abdominal distention, and fever may raise
concern during the postoperative phase. Ureteral injuries recognized intraoperatively can be
treated by direct laparoscopic end-to-end reanastomosis, or double-J ureteral stent with or
without the assistance of ureteroscopy. If the initial salvage procedure fails, percutaneous
nephrostomy and antegrade ureteral double-J stent is performed as a backup procedure to
avoid the subsequent development of a ureteral fistula (Huang et al, 2014).

Detection and management of late complications

Delayed manifestation of bladder injury may result in vesicovaginal fistula, which
requires repetitive repair if the first salvage procedure fails. An intravenous pyelogram is
helpful if a ureteric injury is suspected but not confirmed at the time of the initial surgery. A
urology consultation is recommended to manage these complications. If ureteral injury is
detected in the late postoperative period after the formation of ureteral fistula, ascites with
urine content (urinoma) may complicate the situation. Laparotomy for end-to-end
anastomosis is usually necessary in cases with complete transection, ligation, or
electrothermal injury-induced ischemic necrosis. Delayed manifestation of bowel injury may
cause high morbidity and mortality. van der Voort et al. reported an overall mortality rate of
3.6% (16/450) associated with complication of a bowel injury. However, the clinical picture
may be varied. The early manifestation may be nonspecific, e.g., vomiting, abdominal pain,
distension, and malaise, and later followed by additional features such as a localized
peritoneal abscess or generalized peritonitis. In this stage, fever, leukocytosis, and even septic
shock can occur. Bowel injury caused by direct trauma or electrothermal injury may have a
variable clinical course and histopathologic findings. Symptoms of bowel perforation after
electrical injury usually appear later (4-10 days) than those of a traumatic perforation (usually
within 12-36 hours. Most electrothermal injuries, commonly of the large bowel, are
unrecognized intraoperatively and lead to long-term sequelae. As for the timing of detection,
van der Voort et al. reported that more than 10% of injuries were unrecognized until the 3rd
postoperative day or later. Some identifiable risk factors associated with bowel injuries were
emergent nonscheduled surgeries, tubo-ovarian abscess, or uncertain preoperative diagnosis.
Multiple initial injuries had grave outcomes, were associated with prolonged hospitalizations,
and demanded multiple salvage procedures (Huang et al, 2014).

2.5 Other Associated Conditions

A number of other complications may result from laparoscopy (Gordon, A.G. 2017).
2.5.1 Cervical Laceration
It is common for the cervical tenaculum to cause a laceration of the anterior lip of
cervix. The cervix should always be inspected at the end of the procedure. The bleeding may
usually be controlled by pressure from sponge forceps but occasionally requires suturing.

2.5.2 Uterine Perforation

Uterine perforation may be caused by the manipulating cannula or during dilatation
and curettage. The perforation should always be inspected with the laparoscope during and at
the end of the procedure. Bleeding is usually slight and the complication does not usually
require treatment.

2.5.3 Shoulder Pain

Carbon dioxide is converted to carbonic acid when it is in solution with body fluids.
This is irritant to the peritoneum. Diaphragmatic peritoneal irritation produces pain which is
referred to the shoulder by the phrenic nerve. This pain may be confused with cardiac pain by
the unwary physician and treated inappropriately.
2.5.4 Pelvic Inflammatory Disease
There is a small risk of producing or exacerbating a pelvic infection by uterine
cannulation and chromopertubation. Post-operative pelvic infection is probably less common
after laparoscopic surgery than after laparotomy.

2.5.5 Omental and Richter's Herniation

If the primary cannula is withdrawn with its valve closed, it is possible to draw a
piece of omentum into the umbilical wound by the negative pressure so produced. This is
usually recognised immediately and the omentum is easily replaced. Herniation may occur
some hours after the operation. It is usually easy to replace it under local anaesthesia and
resuture the wound. Herniation does not occur commonly with 5mm skin incisions. Incisions
greater than 7mm should be sutured in layers to prevent formation of a Richter's hernia.

2.5.6 Injuries from The Operating Table

Care must always be taken in positioning the patient on the operating table. Injury can
be caused to the nerves of the leg and to the hip and sacro-iliac joints. Compression of the leg
veins may predispose to venous thrombosis. The brachial plexus may be injured if the arm is
abducted. The hands may be caught in moving parts of the table. It is important that the
patient touches no metallic parts of the table if electric energy is being used.

2.5.7 Foreign Bodies

Occassionally tubal clips or rings or parts of instruments such as saphire laser tips
may be inadvertently dropped and lost in the peritoneal cavity. They should be removed if
they are easily found but there have been no reports of long term complications from such
foreign bodies.
 CHAPTER III
THE POSTOPERATIVE COMPLICATIONS

Laparoscopic surgery is a very common and widely established technique. Benefits

include decreased postoperative pain, improved patient satisfaction (including cosmetic
results), reduced hospital stays and fewer postoperative complications compared with open
techniques. The range of surgical techniques is increasing in complexity and about the kind
of patients undergoing these procedures (pluripathological patients, associating co-
morbidity). Number of emergency operations performed laparoscopically has been increased
as well (Belena & Nunez, 2014).
Complications of laparoscopic surgery are mainly divided into three groups:
complications derived from pneumoperitoneum, complications caused by the operative
procedure and postoperative complications. In case of complications derived from the
surgical technique, we can include: hemorrhage, vascular injury, retroperitoneal hematoma.
Postoperative complications include: intestinal perforation, retroperitoneal hematoma, and
postoperative air embolism (Belena & Nunez, 2014).

3.1 Intestinal Perforation

This is the second most common cause of mortality of laparoscopic surgery. Its
incidence varies between 0.1% and 0.3% of cases. Approximately one third of these injuries
occur during the access into the abdomen, but it may also occurs during removal of
instrumental, dissection of structures or electrocautery burns. One of the problems related to
this complication is intraoperative difficulty to diagnose it. Most of lesions (70%) are
diagnosed in the postoperative period and may have already evolved into a severe peritonitis.
Depending on the time of occurrence can be classified as: Early: occur in the first 48 hours
after surgery (Belena & Nunez, 2014).
Delayed: appear 48 hours after the intervention. Produced in many cases by a
secondary local inflammatory mechanism after laparoscopic technique. Perforations are also
classified according to the location of the lesion in the gastrointestinal tract or laparoscopic
instrument type used. The presence of adhesions or history of previous laparotomies increase
risk for perforation. With respect to location, the small bowel injuries are the most common
(58%). In laparoscopic cholecystectomy, duodenal injury is the most common lesion. Next in
frequency are colon lesions (32%) and finally gastric are rare and account for only 7% of
cases. Regarding the material used at the beginning of the intervention, Veress needle and
blind trocars puncture used at the beginning of the procedure are those that most frequently
cause intestinal perforations (Belena & Nunez, 2014).

3.2 Retroperitoneal Hematoma

Injury of a large retroperitoneal vessel is a serious complication in laparoscopic
approach. Its incidence is around 0.1%. Up to 75 % of cases, usually occurs after insertion of
the Veress needle or trocar (Belena & Nunez, 2014).
Early diagnosis of vascular injury is essential, considering that delay is an important
factor to increase postoperative morbidity and mortality. However, it is often a delay in
diagnosis because the retroperitoneal bleeding vascular lesion is not visible in the field. It is
produced is a bulge of retroperitoneum, elevating intestine and producing that
pneumoperitoneum is insufficient despite being correct (Belena & Nunez, 2014).
In immediate postoperative period patient show tendency to hypotension and severe
anemia. Clinical and analytical alterations should make us think about the diagnosis. If
retroperitoneal hematoma diagnosed intraoperatively, in most cases needs conversion to
laparotomy. In case of postoperative diagnosis, patients require urgent surgical reintervention
(Belena & Nunez, 2014).

3.3 Hernia Formation in Trocar Region

When compared to laparatomic surgery, one of the most significant advantages of
laparoscopy is to enable decrease in postoperative hernia formation. The incidence is between
0.06 and 1% and this rate is approximately 10-100 times lower when compared with
laparotomy [14]. This complication is due to improper and inadequate closure of trocar
penetration sites and is somehow preventable. Hernia formation generally occurs in trocar
inlets that are larger than 5 cm, however they may also be observed in small trocar sites.
Small intestine, rarely colon and omentum are found as content in hernias that are observed in
extraumbilical regions where a large trocar is used. Especially in undetected hernias, the risk
for intestinal incarceration may be as high as 20% [20]. In order to avoid hernia formation,
using 10 mm trocar instead of 12mm, preferring those with blunt-conic tip instead of sharp
tip, repairing fascias, removing small trocars in guidance of a camera, and closing the valve
mechanism while removing are recommended. Hernia repairs are generally performed
laparotomically; however, laparoscopy may also be used (Pabuccu, E.G. 2016).

3.4 Postoperative Air Embolism

Gas Embolism (GE) is a rare complication (15 interventions/100,000/year) but with a
high mortality (70- 90%). It is produced by the passage of CO2 to the venous systemand then
through the right ventricle to the pulmonary circulation (Belena & Nunez, 2014).
The gas can also pass to arterial blood circulation in any organ causing ischemia.
There are two conditions that are required in order to produce GE: the first one is a direct
communicationbetween the gas source and the vascular system, the second one is a favorable
pressure gradient of gas inlet to circulation. These conditions occur during laparoscopic
surgery at different times of the procedure. Considering the time of onset of symptoms the
GE is classified as early (initial), during the procedure and after deflating. The first two are
intraoperative complications and were treated in another part of the chapter. GE after
deflation is less frequent and difficult to explain. Experimental studies suggest that CO2
could be “trapped” in the splanchnic vessels in a high concentration, favored by the gradient
of CO2 during the procedure. When abruptly release the neumoperitoneum, CO2 may form
small bubbles in the circulation in a similar manner to what occurs with the nitrogen in the
sudden decompression of divers. In this case the symptoms may appear in the immediate
postoperative period or deferred in general in relation to active and passive mobilization of
the patient. Clinical is related to the amount of gas that enters the circulation and with the
organ affected by the ischemia. Most GE are subclinical. However, if it is clinical, differential
diagnosis with symptomatic pulmonary thromboembolism, ACVA or myocardial infarction is
difficult. Crepitus in the neck vessels is uncommonbut diagnostic (Belena & Nunez, 2014).
Diagnosis is usually suspected in patients with acute onset of clinical support in times
of risk procedure. Hemodynamic and respiratory monitoring usually helps us for diagnosis.
Control of expiratory pCO2 (ETCO2) by capnography is useful since the passage of CO2 into
the bloodstream, producing an initial increase in pCO2 followed by a sharp drop from
pulmonary embolism. It is followed by hypoxia and fall in O2 saturation with hypotension
sharp decrease in cardiac output. The absorption of CO2 produced mixed, respiratory and
metabolic acidosis. Other diagnostic procedures such as echocardiography, CT scan or
pulmonary arteriogram is made on the basis of clinical status (Belena & Nunez, 2014).
 Most effective treatment is prevention: careful puncture gas, repeated aspiration,
initial injection of gas at low flow and work with the least intra-abdominal pressure. Use of
other less soluble gases like Argon also increases the risk of GE. After initial treatment
begins, supportive measures with vasopressors and mechanical ventilation with high oxygen
concentration are necessary. In patients with a large gas bubble obstructing the right
ventricular outflow, Trendelenburg position and left lateral position can reposition the air at
the tip of the right ventricle allowing the pulmonary circulation (Durant maneuver). Gas
extraction is also recommended by a central venous catheter in the event that the patient
already had channeled. The channeling of central venous access for resuscitation is often
difficult. Closed cardiac massage is an option and that chest compression could break a big
bubble in other small to pass the pulmonary circulation. Hyperbaric oxygen urgent therapy is
usually inaccessible in most hospitals, but is the only one that has shown a reduction in
mortality (Belena & Nunez, 2014).