Prof. Dr.

Mohammad Abdul Quayyum MBBS, FCPS

Gynecological Endoscopic surgeon,
Professor , Parkview Medical College , sylhet
Chief Consultant, Feni Pvt. Hospital and laparoscopy institute .
Bangladesh

Born in 1959 and passed MBBS in 1983 and FCPS

( Gynae) from Bangladesh College of Physicians
and Surgeon in January 1994 .

He started his career as a Consultant (Gynae)

at Noakhali General Hospital in July 1995 .

•Appointed as Asstt. Professor at Comilla

medical college, Bangladesh in March 1999.

•Promoted as Assoc. Professor at

Faridpur medical college, Bangladesh in
Feb 2005.
Professor(Gyne).
Founder member of IMAGES .
Park veiw medical college , Bangladesh
Member of AAGL and ISGE .
Observer in the AAGL Observer ship program at Winthrop University Hospital .
St.Luke’s‐Roosevelt Hospital Center U.S.A under the supervision of Dr. Nezhat MAY-2012.
Attended and presented in more than 32 national and international laparoscopic conferences.
COMPLICATIONS OF LAPAROSCOPY

FENI PVT HOSPITAL & LAPAROSCOPY INSTITUTE

Dr. Mohammad Abdul Quayyum , FCPS
Chief Consultant (Gynae)
Gynecological Endoscopic surgeon
Feni Pvt. Hospital & Laparoscopy Institute
Park View Medical college , Sylhet ,Bangladesh .
 FENI PVT. HOSPITAL AND LAPAROSCOPIC INSTITUTE
* Hospital is equipped with the latest technology and
infrastructure, supported by an experienced team .

* Performing all minor and major gynecological laparoscopic or

minimally invasive surgeries.

* Facilities for laparoscopic workshop and training

 INTRODUCTION
1. Laparoscopic surgeries are currently being
increasingly used for wider application.

2. More surgeons are adopting this form of

management

3. New techniques are being developed .

4. Initially used as a diagnostic procedure in female infertility

and for tubal sterilization, it now allows one to perform
almost any surgery previously performed by laparotomy.

5. Entering the abdomen is the most dangerous part .

6. The complication rate can be expected to rise

 INTRODUCTION
6 It is necessary to have a
knowledge
basic of its
procedures, equipments,
limitations
and indications
complications &
7. The learning
laparoscopic curve
proceduresfor is
lengthy
8
is The risk
greatest of complications
early in the
surgeons experience.
9 The risk is higher
new instrumentation or when a
technique is utilized.
LAPAROSCOPIC COMPLICATIONS

• Most complications during laparoscopy

occur during the surgeon’s first 100
cases.
Soderstrom RM et al.
Operative Laparoscopy: The Master’s Technique.
1993
 INTRODUCTION

• What is the Incidence of Laparoscopic

Complications?

1. Minor procedures :- 1.1% to 5.2%

2. Major procedures 2.5% to

(Kane & Krejs, 1984).
6%
 INTRODUCTION
To reduce the prevalence of complications:-

1. Training programmes must include supervision at

all levels of development.

2. There must be a high degree of awareness of the

potential risks of laparoscopic surgery.
 Risk Factors for Complications

1. Prior surgeries
2. Intra-abdominal disease: (endometriosis, & PID)
3. Extensive bowel distention
4. Very large pelvic or abdominal masses
5. Extensive pelvic/abdominal adhesions
6. Cardiopulmonary disease
7. Diaphragmatic hernia
 ACCESS RELATED INJURIES

ABDOMINALACCESS INSTRUMENTS

Closed Technique
Veress Needle
Trocar Sheath

Open Technique
Hasson Cannula
 ACCESS RELATED INJURIES

Risk Factors:-
Veress Needle & Pneumoperitoneum

Undue Long Needle

Premature
Trendelnburg
Improper insertion
Distention: stomach,
colon or bladder
Adhesion
 ACCESS RELATED INJURIES

VERESS NEEDLE &PNEUMOPERITONEUM

Sharp, with a good and tested spring action.

INSERTION
Insertion sites
Insertion technique
Disposable Reusable

Safety tests
 ACCESS RELATED INJURIES
What are the Entry Sites of Choice?
Usual circumstances the Veress needle is inserted:-
 In the umbilical area
 In the mid-sagittal plane
Alternative Entry: When?
Suspected or known umbilical adhesions
History or presence of umbilical hernia
After 3 failed insufflations attempts at the umbilicus
What are Alternative Entries?
Left upper quadrant (Palmer’s point) 3 cm below
the left subcostal border in the midclavicular line.
Transuterine or Trans cul-de-sac
 ACCESS RELATED INJURIES
LEFT UPPER QUADRANT (PALMER’S ENTRY)
Elevation Of The Anterior Abdominal Wall- Veress Needle Insertion

Indication :-
Suspected or known periumbilical adhesions
History or presence of umbilical hernia
After three failed insufflation attempts at the umbilicus
obese as well as the very thin patient.
Prerequisites: -
Emptying of the stomach by nasogastric suction
No previous spleen or gastric surgery
No significant hepatosplenomegaly
 ACCESS RELATED INJURIES

INSERTION TECHNIQUE

The veress needle can be inserted at right angles to the skin and should be
pushed in just sufficiently to penetrate the fascia and the peritoneum.

Two audible clicks are usually heard as these layers are penetrated.
 ACCESS RELATED INJURIES

INSERTION TECHNIQUE:-
ANGLE OF SKIN AND VERESS NEEDLE INSERTION
45° in non-obese 90° in very obese

ACCORDING TO THE BMI OF THE PATIENT FROM THE UMBILICUS IS CAUDALLY TO THE AORTIC BIFURCATION
 ACCESS RELATED INJURIES
SAFETY TESTS:-
For determining the correct intra-peritoneal placement
1) Double click sound
2) Aspiration test
3) Hanging Drop of Saline test
4) “Hiss” sound test
5) Syringe test
6) Needle Waggling test: to free any attached organ from the tip
and confirms intraperitoneal placement
What is the Most Reliable Safety Test?
The Veress intraperitoneal (VIP) Pressure Test:- ≤ 10 mm Hg is a
reliable indicator of correct intraperitoneal placement of the
Veress needle.
 ACCESS RELATED INJURIES
COMPLICATIONS OF VERESS NEEDLE & PNEUMOPERITONEUM
1- Extra-peritoneal gas insufflation ( Common).
2- Pneumo-omentum
3- Pneumothorax
4- Mediastinal emphysema
5- Gas embolism
6- Blood vessel injury
7- Injury to gastro-intestinal tract
8- Bladder injury
9- Puncture of liver or spleen
10- Complications from the distension medium
 ACCESS RELATED INJURIES

Extra-peritoneal Gas Insufflation < 2%

Recognition:-
Typical telescopic appearance
Crepitus under the skin
Management:-
Gas may be allowed to escape
Re-introduce through the same or another site.
Alternative :Open laparoscopy
 ACCESS RELATED INJURIES
(Blood Vessel Injury )
Usually occurs from laceration of the mesenteric vessels .
Small: Omental or mesenteric vessels. Major: Abdominal or pelvic large vessls
Recognition:
Blood returns up the open needle
Free blood in the peritoneal cavity or Hematoma
.
•Risk Groups: Adhesion Obese, thin or children
• Prevention
•Inserting only as much of the needle as necessary
Lifting the abdominal wall and Angling the needle towards the pelvis
Management
The needle should be left in place.
Minimal bleeding: Controlled by bipolar coagulation or a laparoscopic suture
Severe bleeding: Laparotomy and compress the aorta - ( Call vascular surgery team)
 ACCESS RELATED INJURIES
(Gastro-intestinal Tract Injury )

Predisposition:-
 Upper abdominal site of insertion
 Distension: (induction of anesthesia: Nasogastric T)
Adhesions of bowel to the abdominal

Recognition:-
 Aspiration through the needle: GIT fluid
Belching, passing of flatus or a fecal odor

Management:-
No tear:-
Broad spectrum antibiotic and observation
Tear is seen:- Surgical repair
 ACCESS RELATED INJURIES
(Urinary Badder Injury )
Usually it is simple puncture
Prevention:- Routine catheterization
Proper sitting of the needle
Recognition:- Pneumaturia
Management: - Conservative with postoperative
bladder catheter
 Complications from the Distension Medium

Co2:-
• Gas embolism
• Cardiac arrhythmia
• Chest pain

↑Intra-abdominal pressure + Anesthesia  ↓ Venous

return ↑ liability to DVT
INTRODUCTION OF TROCARS & CANNULAE

They can cause the

most serious injuries
 PRIMARY TROCAR INJURIES

Primary entry is blind

The injuries are similar to those of the Veress' needle.
The magnitude of the injury is much greater.
• Risk Factors
Inadequate pneumoperitoneum

 Periumbilical adhesions

 Poor technique

What is the Adequate Pneumoperitoneum ?

Adequate pneumoperitoneum should be determined by a

 pressure of 20 to 30 mm Hg .
IS THIS HIGH PRESSURE ENTRY SAFE?

Shift from 15 to 20 mm Hg  ↓ pulmonary compliance

by 20%

Transient high-pressure 20- 25 mm Hg causes minor

hemodynamic alterations of no clinical significance
 THE HIGH INTRAPERITONEAL
LAPAROSCOPIC ENTRY

The abdominal pressure may be increased

immediately prior to insertion of the first trocar
with the patient flat.

The transient high intraperitoneal laparoscopic

entry technique does not adversely affect
cardiopulmonary function in healthy women.
ADEQUATE PNEUMOPERITONEUM PRESSURE
The distension pressure should be reduced to 12–15
mmHg once the insertion of the trocars is complete.
This gives adequate distension for operative
laparoscopy and allows the anesthetist to ventilate
the patient safely and effectively.
Once the laparoscope has been introduced through
the primary cannula.
It should be rotated through 360 degrees to check
visually for any adherent bowel and for any
evidence of hemorrhage, damage or
retroperitoneal hematoma
HOW SHOULD THE PRIMARY TROCAR
BE INSERTED ?

Bowel may be adherent under the umbilicus

Primary trocar site should be visualized from a

secondary 5 mm port
 RISK FACTORS IN SUSPECTED
PERIUMBILICAL ADHESIONS
A 5m Entry
Palmer site- Advocated for previous laparotomy .

Minilaparoscopy
Open laparoscopy (Hasson)
Optical trocar (Visual Entry Systems)
 OPEN LAPAROSCOPIC ENTRY
(Hasson Technique71)

A skin small incision at the umbilicus then the fascia,

then entering the peritoneal cavity under direct Vision.
The cannula is inserted with obturator with sutures on
either side of the cannula.
The laparoscope is then introduced and insufflation is
commenced.
At the end of the procedure the fascial defect and the
skin are closed.
 RISK FACTORS 
(Poor Techniques)
Use of long trocar

Premature Trendelnburg

Uncontrolled sudden entry

Excessive force:  Small umbilical incision

 Scar tissue
 Dull trocar
Improper Angle of Entry
PREMATURE TRENDELNBURG

Premature Trendelnburg
High liability to vascular injuries
WHERE SHOULD THE PRIMARY TROCAR
BE INSERTED?
The primary trocar should be inserted in a controlled
manner at 90 degrees to the skin, through the
incision at the thinnest part of the abdominal wall,
in the base of the umbilicus.
Insertion should be stopped immediately the trocar
is inside the abdominal cavity.
HOW SHOULD THE PRIMARY TROCAR
BE INSERTED?

One useful technique is to gently twist the trocar while

exerting firm downward pressure.
Excessive pressure to overcome skin or fascial resistance can
lead to uncontrolled trocar entry, increasing the risk of injury
to bowel or other abdominal or retroperitoneal structures.
Management of Primary Trocar Injuries
 PRIMARY TROCAR INJURIES

•Trocar is left in place

•Laparoscopic management

•Immediate laparotomy if indicated

Secondary Ports
 HOW SHOULD SECONDARY PORTS BE
INSERTED?
Secondary ports must be inserted under direct vision
perpendicular to the skin, with maintaining the
pneumoperitoneum at 20 mmHg

During insertion of secondary ports, the inferior

epigastric vessels should be visualized laparoscopically to
ensure the entry point is away from the vessels.

Any secondary punctures should be made medial or

lateral to the lateral edge of the rectus muscle
 SUPERFICIAL EPIGASTRIC ARTERY INJURY

It arises from the femoral artery and

runs medially over the rectus muscle.
Prevention: Identified By
transillumination of the abdominal wall

S.Circumflex Iliac
Injury: subcutaneous haematoma
Management:
S Epigastric A
suture around the 5mm cannula
 INFERIOR EPIGASTRIC ARTERY INJURY

The inferior epigastric artery can

be identified at the junction of
the round ligament and the
umbilical ligament (obliterated
umbilical artery) at the inguinal
canal.
 INFERIOR
EPIGASTRIC
ARTERY INJURY

Injury:
Retroperitoneal haematoma
Management:
‑ Suture around 5mm cannula or coagulation
‑ Foleys catheter technique.
- Open surgery
INFERIOR EPIGASTRIC ARTERY INJURY

Bipolar Coagulation.

Foleys catheter technique.

HOW SHOULD SECONDARY PORTS
BE INSERTED?

Once the tip of the trocar has pierced the

peritoneum it should be angled towards
the anterior pelvis under careful visual
control until the sharp tip has been
removed.
RCOG Guideline No. 49 May 2008
SECONDARY PORTS REMOVAL

Secondary ports must be

removed under direct vision to ensure

that any hemorrhage can be observed

and treated, if present.

REMOVAL OF THE PRIMARY TROCAR

Primary port must be removed under direct vision to

ensure that bowel is not intraped
 SMALL INTESTINE INJURY

Recognition
Early:
Observation of lacerated area
Observation of the intestinal contents
Introduction of laparoscopy inside the intestinal
lumen
Late:
• 3rd, 4th post operative day fever, vomiting, distension
 LARGE INTESTINE INJURIES
Most common site is transverse colon
Diagnosis: -
• Direct observation
• Delayed: abdominal pain, distension,
fever, passage of fecal material from
abdominal wound
Treatment:-
• Exploration and repair, or colostomy
 5. Omental and Richter's herniation

• May occur in 10 mm incisions and if 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 recognized immediately and the omentum is easily replaced.

Herniation may occur some hours after the operation.

• It is usually easy to replace it under local anesthesia and resuture the wound.

• Herniation does not occur commonly with 5 mm skin incisions.

• Incisions greater than 7 mm should be sutured in layers to prevent formation

of a Richter's hernia.
 Omental and Richter's herniation

• Herniation may occur some hours after the

operation.
• It is usually easy to replace it under local
anesthesia and resuture the wound.
• Herniation does not occur commonly with 5
mm skin incisions.
• Incisions greater than 7 mm should be
sutured in layers to prevent formation of a
Richter's hernia.
POSITION RELATED INJURIES

NERVE ENTRAPMENT/TRACTION

Brachial plexus
Ulnar nerve
Femoral nerve
Common peroneal nerve
 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.
 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.
• It is important that the patient touches
no metallic parts of the table if electric
energy is being used.
 OTHERS COMPLICATIONS
 Wound hematoma:-
Delayed bleeding from trocar sites with significant
drops in Hb and large ecchymoses conservative
 Port site metastasis:-
If a patient with malignancy is explored after
laparoscopy, excision of port sites is a
consideration if feasible.
 Shoulder pain:-
Due to irritation of the diaphragm - positive pressure
pulmonary inflation 5 times, with port valves open
at Trendelenburg position OR intraperitoneal
irrigation with 50 ml of 0.5% percent lidocaine
REMOTE COMPLICATIONS
 Ureteric stenosis: Hysterectomy with
electro-surgery. Endometriosic ablations
 Hernia: > 10mm central port or >5m lateral
port (suturing the opening layers)
 Ovarian atrophy: Over drilling
 Adhesions: Improper use of the principle of
microsurgical technique
 Rupture uterine scar: Myomectomy
 LAPAROSCOPIC SKILLS

It requires 5 to 7 years to gain

adequate laparoscopic skills by
doing several procedures each
week, with gradually increasing
levels of complexity.  
 PATIENT SELECTION
Select appropriate patients for laparoscopy.

Cases that may pose greater risks than usual for laparoscopy

= Weight > 100 kg

= Previous bowel obstruction or peritonitis.

= > 2 previous subumbilical vertical incisions

 Patient Counseling

Discuss with all patients, in simple

language and with documents, the risks
benefits and alternatives to laparoscopy.
 Operative Difficulties
• Consider conversion to laparotomy if difficulties are
encountered, or abandon the procedure if no harm
has been done and surgery is elective.
• Report technical difficulty in the operative record and
discuss complications postoperatively with the
patient.
 Complications
Consult an appropriate colleague if a
complication occurs. This could be another
gynecologist,
general surgeon,
vascular surgeon
Or urologist.
 CONCLUSIONS
There is fair (Class B) evidence to
support the recommendations that
appropriate patient selection, early
recognition of complications, and full
disclosure to patients minimize the
physical, emotional, and economic
consequences of laparoscopic
complications.
Preoperative Assessment
Operation Room team
Co-morbidities
(OR-team participate directly Vital Role)

Patient anatomy
Panniculus
Hernias
Scars
Central obesity
Short neck
Preparing the Operative Suite
Patient and surgeon positioning
Location of monitors and foot pedals
Strategic organization of cables
“Stocking” appropriate instruments
 Operation Room team

Trocar Placement
Size of incision respective to each trocar
Controlled insertion
Optimal positioning
Maximal access ,Ergometrics & Visualization

Intraoperative Role of the Assistant

Should be familiar with different techniques of achieving Pneumoperitoneum
Monitoring and understand flow rate and intraabdominal pressure during insufflation
Recognize pitfalls and react quickly
Incomplete abdominal wall penetration
Adhesions
Visceral injury
Ergonomics &Its Importance In Laparoscopic Surgery

Ideal angles!

1. Manipulatation angle :- 60 degree

2. Azimuth angle :- Equal/30 degree each
3. Elevation angle :- 60 degree
 Ergonomics &Its Importance In Laparoscopic Surgery
Ideal Relaxed Position

-straight head, in the axis of the trunk,

without rotation or extension of the
cervical spine;
- Shoulders in a relaxed and neutral
position;
- Arms alongside the body
- Elbows bent to 70 to 90 degrees
- Forearms in an horizontal or slightly
descending axis-
-Hands pronated (physiological resting
•Waist line table
•Gaze down view of monitor
position);
•Straight line principle - Hands and fingers lightly grip the
•Triangulation handles/hand piece
 Veres needle
Spring needle mechanism(protects viscera)

to create pneumoperitoneum(20-22mm)Pressure .
Connector to insufflation tubing
Sharp outer cannula

Inlet for gas

Spring-loaded inner stylet
with a blunt tip Proper handling position
1. Check Verses needle for proper plunger/spring action and assure easy
flushing .

2. If Veress needle tip not in free peritoneal cavity - Reinsert needle

3. Verses needle is inside peritoneal cavity but gas is not flowing –

omentum is stuck /not patent - flush it with saline
 Trocar- cannula

* Size – 3 mm , 5 mm 7 mm 10 mm & 12 mm
* Trocar with flap valve is better than trumpet valve
* Pyramidal tip is better than conical tip
* Introduction of primary trocar after
Pneumoperitoneum (20-22mm) Pressure is better .
*Introduction of Secondary trocar always under vision.
 Trocar Insertion

The first trocar is inserted blindly,

usage of safety trocars is mandatory!
 Access technique and Port Placement

Contraindications Of Umbilical Entry

Previous midline incision .
Portal hypertension with recanalised umbilical artery
Umbilical abnormalities viz. Urachal cyst, sinus, hernia
 Access technique and Port Placement

1 All port are at and below umbilicus

2 Position depen upon pathology,H/o of surgeries,nature of operation
Suturing techniques, hight of surgeon and surgeon comportness.
3 Umbilicus port (primary) 10 or 5 mm - for telescope
4 Lateral Port (secondary) 5 or 3mm - for working instruments
-Bet. two instruments tips make 60 degree
5 Difficult or extraperitoneal pneumoperitoneum-then through
Palmar’spoint
wrong port position cause of stressful surgery
Access technique and Port Placement
Pneumoperitoneum In Special Conditions

Obese Patients- Transumbilical perpendicular

to abdominal wall . Assistant’s hand in obese patients
can help in introduction
Patient With Prior Abdominal Procedure
Choose site distant to abdominal scar
Thank U For A Patience Hearing