Complications of Minimally Invasive Surgery

Vascular Injuries at Abdominal Entry

Once a vascular injury has occurred, it is important for the surgeon to quickly identify such injury and address it immediately. The presentation can be dramatic and catastrophic if unrecognized, with mortality approaching 15%. The most common sites of injury are the infrarenal aorta and right common iliac vessels. In thin patients, the aorta can be 2 cm from the umbilicus. The right common iliac traverses from its origin at the aorta to the right at the level of the umbilicus, which makes it prone to injury as well. Whereas some patients may have obvious hemoperitoneum, in others it may not be readily apparent, especially if blood dissects through the retroperitoneum. Patients who develop unexplained hypotension or tachycardia should have unrecognized vascular injury in the differential diagnosis.

Laparoscopic repair of vascular injuries is dependent on the location and severity of the injury and hemodynamic status of the patient. Any patient with a known or suspected vascular injury with signs of hemodynamic instability should undergo immediate laparotomy, with pressure applied to the injury until the patient’s condition can be stabilized, appropriate instruments obtained, and, in most cases, vascular surgery consultation requested. For injuries to vessels smaller than 1 to 2 mm, insertion of a laparoscopic sponge and application of pressure for 2 minutes may be adequate to allow clotting to occur. For intermediate injuries in which the patient remains hemodynamically stable, the most important consideration for laparoscopic repair remains close communication with anesthesia staff. If pressure can be applied to the injury with either direct compression or an atraumatic grasper, the surgical team can obtain necessary instruments, suture, and blood products to facilitate closure. Availability of a capable surgical assistant to keep the site free of blood is also essential. This may necessitate placement of additional laparoscopic port sites to allow for additional access to the surgical field. Once fully prepared, small injuries can be closed with 5-0 polydioxanone (PDS) suture, with care taken to avoid excessive traction on the defect during suturing. Larger injuries can also be repaired after distal and proximal control is obtained with laparoscopic vascular clamps, although this should generally be performed by a surgeon experienced with laparoscopic repair of vascular injuries. As with other injuries, the emphasis should be placed on safely completing the repair rather than avoiding conversion to laparotomy at all costs.

Damage to minor vessels in the abdominal wall can also occur during lateral port placement. Although generally less severe than injury to retroperitoneal vessels, injury to the inferior epigastric vessels can lead to morbidity due to reoperation, blood transfusion, and conversion to laparotomy. The inferior epigastric arteries lie at the lateral border of the rectus abdominis muscles in the lower abdominal quadrants and are usually injured during lateral port placement. Direct visualization of lateral port placement with transillumination of the abdominal wall before placement can prevent many of these injuries. Bleeding from the inferior epigastric vessels can be treated with direct suture ligation, full-thickness abdominal wall mattress sutures, or tamponade with a temporary Foley balloon.

Bowel Injuries at Abdominal Entry

As reviewed elsewhere in the chapter, the main risk of bowel injury results from delayed recognition and subsequent peritonitis and sepsis. The bowel and omentum underlying all trocar sites should be examined immediately on entry into the peritoneum. Repeat examination of the entry site should be performed after a second port is inserted to help identify any loops of bowel that are adherent near the original entry site that may have inadvertently been injured. If a “through-and-through” bowel injury is encountered during trocar placement, the injured bowel should be left attached to the trocar until additional ports have been placed to facilitate repair. This is a critical point: Once the bowel has been removed from the trocar, the injury often decreases in size and can be more difficult to identify. Insufflation tubing should be connected to an alternate port before removal to prevent dissection of the bowel wall while the trocar is being withdrawn.

Prevention of vascular and gastrointestinal injuries is of utmost importance. Decompression of the stomach and bladder before the procedure is started will help keep the operating field clear. When possible, prior incisions should be avoided because abdominal entry points are often a site of adhesion formation. This is particularly true if mesh was used during the closure of the previous incisions. If extensive abdominopelvic adhesions are anticipated, the surgeon may elect to use a left upper quadrant approach through the Palmer point, where adhesions tend to be less common.

Mechanism of Thermal Injuries

To an even greater extent than during open procedures, the use of electrosurgery is vital to the success of most minimally invasive procedures. The often subtle and delayed impact of electrosurgical injuries during laparoscopy makes recognition more difficult. In fact, the full extent of damage may not be apparent until several days after the operation. Thermal injury is associated with a progressive zone of tissue destruction that extends beyond the area, if any, identified at the time of the procedure. This leads to subsequent tissue necrosis and possible viscus perforation 72 to 96 hours after the initial injury. This is of utmost importance for the bowel, because delayed recognition and/or development of bowel perforation is a major source of morbidity and mortality in laparoscopic surgery. If abdominal pain continues to worsen after the operation, especially if accompanied by tachycardia and fever, a bowel injury should be suspected. Because of these potentially life-threatening complications, surgeons must have a thorough understanding of the lateral thermal spread that any device they are using will cause. Some examples of commonly used devices are listed in Table 27.1 .