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DR UTPAL DE Department of Surgery CMCH

Access Techniques
Open, Hasson technique
• Small incision through skin and fascia and direct view of peritoneum

Closed, Veress needle technique
• Needle with safety shield placed through a small skin incision

“Optiview” Technique
• Direct visualization of abdominal wall layers with insertion

Veress Technique
Closed, Veress needle technique
• Needle with safety shield placed through a small skin incision • Insufflate abdomen with CO2 • Exchange needle for trocar

Trocars .


Orientation Positioning • Trocars. camera and surgeon Triangulation of Instruments Camera behind and in center of work Spatial Orientation • Pitch • Roll • Yaw .

Triangulation of Instruments .

Camera-Target.Monitor Axis Align Field of View and Direction of View with Target and Monitor .

“Eyes cannot see what the mind does not know” Visual cues from known anatomy Orientation changes with camera position Know where you are in the box .


1.5% to 6% in major ones (Kane & Krejs. 2.2% in minor procedures and 2. 1984).1% to 5. .INTRODUCTION  The incidence of laparoscopic complications is: 1.

. Training programmes must include supervision at all levels of development and 2.INTRODUCTION  To reduce the prevalence of complications: 1. There must be a high degree of awareness of the potential risks of laparoscopic surgery.

Thermal Instruments 5.Complications may be associated with: 1. Mechanical Instruments 6. Other associated conditions . The anesthesia 2. Insertion of primary and secondary trocars 4. The induction of pneumoperitoneum 3.

.A. ANESTHETIC complication… Local anesthesia may be used for tubal sterilization and some other minor procedures.

THE ANESTHETIC complication… May produce specific problems and complications: 1.Complications directly attributable to the general anesthesia are no different from those which may occur when any other type of surgery is performed. .A. 2.Some features of laparoscopic surgery predispose to specific anesthetic complications.

A. THE ANESTHETIC complication… The use of a steep Trendelenburg position and the distension of the abdomen may both reduce excursion of the diaphragm. Carbon dioxide (CO2) can be absorbed particularly during prolonged operations. .

A. 2. complication… . Positive pressure assisted ventilation Reduce the risk of hypercarbia to a minimum. THE ANESTHETIC Monitoring by : 1. The use of endotracheal intubation and 3. Pulse oximetry.

THE ANESTHETIC complication… If arrhythmia occurs the anesthetist will be responsible for its management and The surgeon should : 1. Evacuate the pneumoperitoneum and 3. Discontinue the surgery. .A. Return the patient to the supine position. 2.

. It may be prevented by efficient anesthesia and should only be diagnosed when other causes of shock have been excluded. THE ANESTHETIC complication… Vasovagal reflex may produce shock and collapse especially if the anesthetic is not deep enough.A.

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

. convulsion and shock. in more severe cases. Vasovagal reaction This may be associated with bradycardia and. cardiac arrest.2.

5 mg given intravenously (IV) 2.Respiratory and cardiac resuscitation.0 ml of 1:100.5-1. .Atropine 0.2. Vasovagal reaction The treatment should include: 1.Oxygen given by endotracheal tube at a rate of 4-6 litres/minute 3.Adrenaline 0.000 solution given slowly IV 4.

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. .

pruritus and urticaria. flushing. . no more medication should be administered. If it occurs it will be characterized by agitation. Allergic reactions and anaphylaxis Any local anaesthetic should be given initially as a small test dose to determine if an unsuspected hypersensitivity exists. If it does. bronchospasm.4. palpitations.

Oxygen .4.000 solution IVI or IMI) 2. 4.Adrenaline 0. Allergic reactions and anaphylaxis The treatment will depend on the severity of the reaction and may include: 1.Theophylline 250 mg (10ml) given slowly IV.Prednisolone 25 mg IVI 3.5 mg (1:100.Intravenous fluids 5.


Extra-peritoneal gas insufflation  the Veress' needle into the peritoneal cavity may produce extraperitoneal emphysema. . This occurs in about 2% of cases.1.

. If this is recognized early.. Extra-peritoneal gas insufflation The diagnosis is made by palpation of crepitus caused by bubbles of CÓ2 under the skin. the gas may be allowed to escape and the needle re-introduced through the same or another site.1.

.1. the typical appearance of extra-peritoneal gas may be recognized when an attempt is made to introduce the telescope. Extra-peritoneal gas insufflation If the complication is not recognized during the introduction of gas. It is always essential to view through the telescope during its insertion through its cannula.

.1. Extra-peritoneal gas insufflation The typical spider-web appearance caused by preperitoneal insufflation will be seen when the telescope reaches the end of the cannula and further stripping of the peritoneum by the tip of the telescope avoided.

.1. Extra-peritoneal gas insufflation The laparoscope should be withdrawn and attempts made to express the gas. Alternatively the trocar and cannula may be introduced by 'open laparoscopy'. The needle may then be re-introduced through the same or another site.

1. . Extra-peritoneal gas insufflation 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.

.Complications from the distension medium Carbon dioxide (CO2) is the distension medium most commonly used for operative laparoscopy.

even if there has been a moderate embolus. Up to 400ml of gas may be intravasated without producing changes in the ECG.Carbon dioxide (CO2) Gas embolism is possible but uncommon because the gas is highly soluble and is reabsorbed so quickly that. the circulatory changes return to normal within a few minutes and the patient recovers. .

This will cut out if the intra-abdominal pressure rises. . Monitor the intra-abdominal pressure throughout the operation and use an automatic pneumoflator for all but the simplest forms of surgery.Carbon dioxide (CO2) Cardiac arrythmia may be due to excessive absorption of CO2. Endotracheal intubation and positive pressure respiration will help to prevent complications from CO2 insufflation.

Carbon dioxide (CO2) 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. .

Anesthetists can dispense with intubation and allow the patient to breath through a laryngeal mask. .Complications from the medium distension Nitrous oxide (N2O) has become popular with some laparoscopists because there are less side effects than with CO2.

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. a diagnostic laparoscopy may develop into a complicated operative procedure. .Complications from the medium distension However.

rings. or bipolar coagulation. This is applicable to tubal sterilization with clips.Complications from the medium distension The main place for N2O is when laparoscopy is being performed under local anesthesia in which case the pain factor becomes important. but not to more advanced laparoscopic procedures. .

Extensive emphysema may cause cardiac embarrassment which will be diagnosed by the anaesthetist. Mediastinal emphysema Gas may extend from a correctly induced pneumoperitoneum into the mediastinum and create mediastinal emphysema. .2.

Mediastinal emphysema There will be loss of dullness to percussion over the precordium. The patient must be kept under close observation until the gas has been absorbed. The laparoscopy must be abandoned and as much gas as possible evacuated. .2.

Whenever a high site of insertion is chosen the needle should be directed away from the diaphragm and. the standard protocol of aspiration and sounding tests employed. . Pneumothorax May result from insertion of the Veress' needle into the pleural cavity. as always.3.

The patient should be kept under observation. There may be a contra-lateral mediastinal shift and increased tympanism over the affected area. Pneumothorax Should be suspected if there is difficulty in ventilating the patient. . Occasionally assisted ventilation and insertion of a pleural tube may be required.3. The procedure should be abandoned and the gas allowed to escape.

The misplacement should be recognized by the aspiration test and the position of the tip altered to free the needle. The condition is usually innocuous unless omental blood vessel is punctured. . Pneumo-omentum The omentum is penetrated by the Veress' needle in about 2 % of cases. There will also be a raised insufflation pressure which should lead the surgeon to suspect an error in the position of the needle.4.

.5. Adhesions of bowel to the abdominal wall.  These include : 1. Injury to gastro-intestinal tract  Certain conditions may predispose to injury by the Veress' needle. Distension of the gastro-intestinal tract or 2.

. Injury to gastro-intestinal tract Penetration of the stomach may occur when an upper abdominal site of insertion is chosen or the stomach is distended during induction of anesthesia.5.

5. . Injury to gastro-intestinal tract Gastric distension may also occur if anesthesia is maintained with a mask and should be suspected if there is upper abdominal distension or increased tympanism. In this case the stomach should be aspirated with a naso -gastric tube.

Injury to gastro-intestinal tract The diagnosis of gastric perforation by the Veress' needle may be made when the patient belches gas.5. . The laparoscope should be introduced and the stomach inspected carefully.

. If the stomach has been torn. no surgical treatment is necessary but a broad spectrum antibiotic should be given. Injury to gastro-intestinal tract Provided the stomach wall has not been torn.5. surgical repair either by laparotomy or laparoscopy is mandatory.

5. Injury to gastro-intestinal tract Aspiration following initial insertion of the needle should permit early recognition of perforation of the bowel but it is not fool-proof. .

Injury to gastro-intestinal tract Bowel penetration should be suspected if there is 1. .5.Asymmetric abdominal distension.Passing of flatus or a fecal odour. 2.Belching. 3.

5. The gastro-intestinal tract should be examined carefully for perforation. Injury to gastro-intestinal tract The induction of pneumoperitoneum should be stopped and the needle re-sited to introduce the pneumoperitoneum correctly. .

5. . Injury to gastro-intestinal tract It is important that both sides of the bowel be examined as the exit wound may be larger than the entry wound. Fecal soiling demands immediate laparotomy and repair of the bowel.

.5. Injury to gastro-intestinal tract It is important to ensure that there has not been a through-and-through injury of a loop of bowel which is adherent to the peritoneum at the site of insertion.

. Injury to gastro-intestinal tract A simple needle penetration requires no treatment but the patient should be kept under observation and given broad spectrum antibiotics.5.

Bladder injury Routine catheterization of the bladder and proper sitting of the needle should prevent bladder penetration. .6.

Bladder injury If pneumaturia is noted the needle should be partially withdrawn and the creation of pneumoperitoneum continued. .6.

. Bladder injury The bladder peritoneum should be carefully inspected to ensure that no significant injury has been caused.6. The treatment of a simple puncture is conservative with postoperative bladder drainage.

. Blood vessel injury The Veress' needle may penetrate: 1. omental or 2. any of the major abdominal or pelvic arteries or veins. mesenteric vessels or 3.7.

7. Blood vessel injury Minor vascular injuries involving the omental or mesenteric vessels are difficult to prevent as it is impossible to ensure that the omentum is not close to the abdominal wall during blind insertion of the insufflating needle. .

blood returns up the open needle or if : 2. Blood vessel injury  Injury may be suspected if: 1. . free blood is seen in the peritoneal cavity after insertion of the laparoscope.7.

7. Blood vessel injury If blood returns up the needle and the patient's condition is stable, the site of injury may be investigated laparoscopically. The needle should be left in place and a 5 mm laparoscope introduced through a suprapubic cannula.

7. Blood vessel injury
Minimal bleeding may usually be controlled by bipolar coagulation or a laparoscopic suture. Laparotomy is not usually necessary except in the case of injury to the superior mesenteric artery. Such injury requires repair by a vascular surgeon
(Bassil et al, 1993)

7. Blood vessel injury

Injury to the major vessels may be prevented by: 1. Lifting the abdominal wall, 2. Angling the needle towards the pelvis once the initial thrust through the fascia has been made and by 3. Inserting only as much of the needle as necessary.

.7. Withdrawal of blood on aspiration following insertion of the needle should allow early detection of blood vessel injury. Blood vessel injury Thin patients and children are at particular risk of this injury.

. inferior vena cava or common iliac vessel is suspected.7. Blood vessel injury If injury to a vessel such as the aorta. the needle should be left place to mark the site of the injury and laparotomy performed through a mid-line incision.

The aorta should be compressed with a clamp or hand until a vascular surgeon arrives to perform definitive surgery. . Blood vessel injury There is usually a large haematoma which obscures the site of the injury.7.

Blood vessel injury Dramatic collapse may result from penetration of a major vessel but the bleeding may not be immediately evident if it is retro-peritoneal. The loose areolar tissue anterior to the aorta can allow accumulation of a considerable amount of blood before frank intra-abdominal bleeding is seen.7. .

This includes retraction of bowel to expose the aorta above the pelvic brim which is the most common site of perforation.7. . Blood vessel injury A thorough search must be made to determine the extent of vessel damage.

7. Blood vessel injury Failure to do search may result in continued bleeding and formation of a large haematoma leading to a second episode of shock some hours later .

Gas embolism Intravascular insufflation of gas may lead to gas embolism or even death.8. . This can only happen if the penetration by the Veress' needle goes unrecognized and insufflation commences.

Gas embolism It should be prevented by routine use of the aspiration test. If immediate recovery does not take place. cardiac puncture performed to release the gas.8. The patient should be turned on to the left lateral position and. .

Puncture of liver or spleen The liver or spleen may be punctured by the Veress .9.

. blind. of necessity. Insertion of the primary trocar and cannula is.C. INTRODUCTION OF TROCARS AND CANNULAE Some of the most serious injuries that occur during laparoscopy are caused by the insertion of the trocars and cannulae.

.INTRODUCTION OF TROCARS AND CANNULAE The causation of injuries by the primary trocar are similar to those caused by the Veress' needle but the magnitude of the injury is greater.

.INTRODUCTION OF TROCARS AND CANNULAE The sites of the secondary portals of entry must be selected carefully and the insertion must always be made under visual control.

Bleeding from puncture of the deep inferior epigastric artery is more serious. .1. Injury to vessels in the abdominal wall Superficial bleeding from the incision rarely gives rise to concern and always stops with application of pressure.

Inferior epigastric artery The artery is at risk during the insertion of secondary trocars and cannulae. .

Inferior epigastric artery Injury may be prevented by transilluminating the abdominal wall before insertion in a thin patient or by visualizing the artery laparoscopically as it runs lateral to the obliterated umbilical artery. .

. The diagnosis may be made by the sight of blood dripping into the pelvis from the trocar wound.Inferior epigastric artery The site of insertion can then be chosen by depressing the wall skin with the handle of the scalpel and noting its relationship to the vessels.

. Alternatively the immediate or delayed appearance of a large abdominal wall haematoma indicates injury to the deep inferior epigastric artery.Inferior epigastric artery Occasionally blood may actually be seen spurting across the abdominal cavity.

.Inferior epigastric artery The treatment is usually simple. The trocar and cannula should be left in situ to act as a marker and also prevent the artery slipping away. A Foley catheter passed down the cannula and inflated may act as a compress and control the bleeding.

Inferior epigastric artery Alternatively the incision should be enlarged to about 2 cm in length to expose the anterior rectus sheath. . A round bodied needle should be inserted through the full thickness of the abdominal wall from the sheath to the peritoneum under laparoscopic control.

This is preferable to tying the knot on the skin which is painful and leaves an unsightly scar although it is acceptable to tie the knot over a gauze swab to prevent skin injury.Inferior epigastric artery The needle point should be brought out again to the surface of the rectus sheath and a knot tied firmly on the sheath. .

Inferior epigastric artery
It may be necessary to insert two sutures, one above and one below the site of bleeding.

Inferior epigastric artery
Occasionally it may be necessary to open the wound wider to locate the bleeding artery. This should be reserved for those cases where there is profuse bleeding or primary laparoscopic suturing is

2. Injury to an abdominal vessel


Injury to minor blood vessels is usually self-limiting or can be controlled by bipolar electro-coagulation. Damage to major vessels is more serious than with a Verres' needle because of the size of the trocar tip and may result in profuse bleeding.

4. Bowel resection and anastomosis with the assistance of the appropriate surgical colleague. . Laparotomy. 2. Injury to an intra-abdominal vessel  Injury to omental vessels may compromise the vitality of a segment of bowel. 3. Vascular repair or ligation and.2. where necessary.  Treatment of these injuries is by: 1. Resuscitation.

However. as soon as the intra-abdominal and venous pressures return to normal. Injury to an intra-abdominal vessel A small leak from the a major vein may not be immediately apparent. The intra-abdominal pressure of the pneumoperitoneum and the decreased venous pressure induced by the Trendelenburg position may temporarily control it. the bleeding may recommence and produce a retro-peritoneal haematoma and shock. .2.

2. This applies particularly to the treatment of endometriosis at this site. at the completion of any laparoscopic procedure. but especially those involving the pelvic side wall. . to inspect the course of the major vessels and look for a haematoma. Injury to an intra-abdominal vessel It is essential therefore.

2. Occasionally there may be a defect in the overlying peritoneum which indicates the site of entry of the trocar. Injury to an intra-abdominal vessel A small haematoma may be the only evidence of injury to a vein at the pelvic brim. .

Injury to an intra-abdominal vessel It is essential to proceed to laparotomy to repair the vessel. A vascular surgeon should be consulted and the vessel compressed until the arrival of specialized assistance. .2.

. The trocar may pass right through the a loop of bowel which becomes impaled upon it. If penetration has occurred: 1. rarely: 3. The trocar may remain within the lumen or. 2. Injury to a hollow viscus Injury to a hollow viscus may vary from superficial damage of the serosa to complete penetration into the lumen. The viscus may slip off the trocar.3.

Injury to a hollow viscus It is always important to inspect the bowel at the axis of insertion of the primary trocar and cannula to ensure that it has not been damaged.3. .

.3. A through and through injury may be missed and only become apparent by the sight of faecal soiling. a faecal smell when the pneumoperitoneum is released or the subsequent development of peritonitis. Injury to a hollow viscus If the cannula remains within the bowel the injury will be obvious by the recognition of mucosal folds.

3. A skilled surgeon may perform the repair by laparoscopic suturing. . The management depends on the skill of the surgeon. Injury to a hollow viscus Injury to the stomach or bowel are always serious. The classical treatment is to perform laparotomy and suture the bowel in two layers.

there should be copious peritoneal irrigation and a drain should be inserted into the abdomen. . Injury to a hollow viscus The defect should be closed in two layers in such a way as to avoid stricture formation.3. Appropriate antibiotic therapy should be instituted.

In this case it is essential to perform laparotomy to find and treat the bowel injury. Injury to a hollow viscus It may not be possible to identify the site of bowel injury by laparoscopy.3. Failure to do this will result in the patient developing faecal peritonitis .

Injury to a hollow viscus Bladder laceration may occur during mobilization of the bladder in advanced pelvic surgery. It should be sutured in two layers using laparoscopic suturing technique and a Foley catheter inserted into the bladder.3. .

They should be inspected at the completion of the procedure. Peritoneal lavage must be carried out to remove blood and clot and ensure that the bleeding has stopped. .4. Damage to other organs Minor injuries to other organs are usually self-limiting.

4. Damage to other organs

A small puncture on the surface of the uterus may be treated with bipolar electro-coagulation if bleeding does not stop spontaneously.

4. Damage to other organs
Injuries to the liver and spleen are rare unless the organ is pathologically enlarged. Such injuries are more likely to occur in operations performed by general surgeons. Minor bleeding will stop spontaneously. Major haemorrhage requires immediate laparotomy.

Burns from electric current were one of the major causes of complications when monopolar tubal coagulation was the principle method of female sterilization. The incidence of burns was dramatically reduced by the introduction of bipolar and thermal coagulation and mechanical devices to occlude the tubes.

.THERMAL DAMAGE Monopolar electric current passes into the patient's body from the electrode which may be forceps or a needle. The current passes into the patient's tissues at the point of contact and then must return to the generator via the return plate. This is usually placed on the patient's leg.

. in turn depends on the area and duration of application.THERMAL DAMAGE The effect of the electric current will depend its power and the power density which.

The current passes from that small area along the path of least resistance towards the return plate.THERMAL DAMAGE To obtain maximum tissue effect the area of application at the target organ is small. . In gynecological surgery this pathway is usually over the surface of loops of bowel.

The power density at that point . However on its return pathway the current may pass over a small area of contact between two organs.THERMAL DAMAGE The area of the return plate is large so the power density at its site of application to the skin is low.

.THERMAL DAMAGE In this way a burn may occur outside the surgeon's visual field. Normally this does not happen and the current passes harmlessly to the dispersive plate.

Insufficient or faulty insulation or from 2.  This may result from : 1.THERMAL DAMAGE  Thermal injury to organs such as bowel may also result from leakage of current from the shaft of the instrument. . Capacitative coupling in which there is a build up of current in the shaft of the instrument because the normal escape route has been shut off.

the power density may be high and thermal injury will result. If the contact point between instrument and bowel is small. . If a plastic cannula has been used this route is closed and the current may escape to bowel.THERMAL DAMAGE Current normally escapes from the metal cannula through the patient's anterior abdominal wall to the return plate.

If the current passes via an ECG electrode instead of to the return plate.THERMAL DAMAGE Occasionally the monitoring system may not be properly earthed. . the patient may suffer a skin burn because the ECG electrode is small and so the power density is high at this site.

if not properly insulated. . may produce a skin burn at the portal of entry or the surgeon may suffer a burn on the hands or face.THERMAL DAMAGE Alternatively. the current may pass along one of the ancillary instruments which.

It is important to ensure that no other organ is in contact with or near an organ to which electricity is being applied.THERMAL DAMAGE There is a danger of lateral heat spread with monopolar or bipolar current. .

THERMAL DAMAGE Lateral spread may also be minimized by keeping the forceps blades close together. Build-up of thermal energy may be prevented by intermittent application of energy which. in effect. produces a pulsed current .

The injury may range from minor blanching of the serosa to frank perforation. Perforation requires laparotomy. excision of the surrounding devitalized bowel and repair of the defect. .THERMAL DAMAGE The bowel is the most commonly injured organ.

Failure to do so may result in delayed ischemic necrosis at the site of the burn. . laparotomy excision of the damaged tissue and surgical repair should be performed immediately.THERMAL DAMAGE If blanching is significant.

THERMAL DAMAGE Initially there may be few symptoms but commonly the patient will complain of feeling unwell and this feeling may not improve as quickly as usual. .

. may have an unsuspected injury to the bowel. The unwary physician may allow the patient to return home.THERMAL DAMAGE It should be realized that any patient who feels unwell on the day after surgery and whose condition does not improve over the next few hours.

THERMAL DAMAGE The insidious development of vague abdominal symptoms. A faecal fistula may not form for 48-72 hours. . anorexia and possibly pyrexia may not be recognized by her medical attendants. discomfort.

Radiology followed by laparotomy reveals the desperate situation. .THERMAL DAMAGE Fecal peritonitis slowly develops and the patient may become seriously ill over a period of days before re-admission is requested.

. colostomy and drainage of the peritoneum.THERMAL DAMAGE Laparotomy is followed by repair of the bowel or. more often. A prolonged period of serious illness may follow.

.THERMAL DAMAGE It must always be remembered that electric current is potentially dangerous and all the safety rules for its use must be strictly obeyed.

. 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.INJURY FROM MECHANICAL INSTRUMENTS The main injuries caused by scissors or forceps are to a blood vessels.

.OTHER COMPLICATIONS A number of other complications may result from laparoscopy.

This pain may be confused with cardiac pain by the unwary physician and treated inappropriately. Diaphragmatic peritoneal irritation produces pain which is referred to the shoulder by the phrenic nerve. .3. This is irritant to the peritoneum. Shoulder pain Carbon dioxide is converted to carbonic acid when it is in solution with body fluids.

5. it is possible to draw a piece of omentum into the umbilical wound by the negative pressure so produced. This is usually recognized immediately and the omentum is easily replaced. Omental and Richter's herniation If the primary cannula is withdrawn with its valve closed. .

It is usually easy to replace it under local anesthesia and resuture the wound. Omental and Richter's herniation Herniation may occur some hours after the operation. Incisions greater than 7 mm should be sutured in layers to prevent formation of a Richter's hernia. Herniation does not occur commonly with 5 mm skin incisions. .5.

.6. Injury can be caused to the nerves of the leg and to the hip and sacro-iliac joints. Injuries from the operating table Care must always be taken in positioning the patient on the operating table. Compression of the leg veins may predispose to venous thrombosis.

It is important that the patient touches no metallic parts of the table if electric energy is being used. .6. Injuries from the operating table The brachial plexus may be injured if the arm is abducted. The hands may be caught in moving parts of the table.

They should be removed if they are easily found but there have been no reports of long term complications from such foreign bodies .7. Foreign bodies Occasionally tubal clips or rings or parts of instruments such as saphire laser tips may be inadvertently dropped and lost in the peritoneal cavity.


Questions .