INTRODUCTION

Laparoscopy was first introduced at the beginning of the 19th century. In 1901, George Kelling was the first to endoscopically examine the peritoneal cavity, and he called the procedure koelioscopie.¹ In the 1940s, French gynecologist Raoul Palmer used laparoscopy for preoperative diagnosis and tissue biopsy.² Throughout the better part of the 20th century, laparoscopy remained in the hands of gynecologists. In 1985, Dr. Erich Muhe quietly performed a rudimentary laparoscopic cholecystectomy that largely went unnoticed. It was not until Dr. Phillipe Mouret performed what is widely considered to be the first laparoscopic cholecystectomy that the surgical community heralded this procedure.³ The advent of the laparoscopic cholecystectomy opened the door for modern-day laparoscopic surgery and a revolution soon followed.

Over 750,000 laparoscopic cholecystectomies are performed each year in the United States.⁴ Whereas this operation has proved to be the “gold standard” for gallbladder disease, the complexity of operations done laparoscopically continues to be advanced. Although minimally invasive surgery offers new and often less morbid options to patients, these procedures can pose significant risks. This chapter seeks to outline the major complications in this burgeoning field.

INDICATIONS

Need to perform intra-abdominal procedure

OPERATIVE STEPS

Step 1 Induction of general anesthesia

Step 2 Access to peritoneal cavity insufflation with CO₂

ADVERSE OUTCOMES FOR ABDOMINAL ACCESS

Initial Abdominal Entry

Although laparoscopic surgery is an exciting mode of managing surgical problems because it minimizes the morbidities associated with traditional open approaches, it can be associated with a higher incidence of intra-abdominal injury.

Three basic modes of abdominal entry in laparoscopic surgery are (1) blind insertion of a primary trocar without creation of a pneumoperitoneum, (2) insertion of the Veress needle with subsequent establishment of the pneumoperitoneum, (3) Hasson technique ⁵; open cutdown and direct visualization while placing the primary trocar. All of these techniques are associated with varying degrees of complications.

Veress needle and trocar injuries account for many of the injuries seen in laparoscopic surgery. Minor complications occur during 1.58% of cases, whereas major complications—including bowel perforation, bladder injury, vascular injury, and abdominal wall hematoma—occur in 0.41% of cases (Figs. 7-1 to 7-3).⁶

Figure 7-1 Gastrointestinal injury from Veress needle.

Figure 7-2 Vascular or gastrointestinal injury from Veress needle.

Figure 7-3 Gastrointestinal injury from trocar placement.

Vascular and gastrointestinal injuries are the most troubling aspects of laparoscopic surgery. Although they occur infrequently, their occurrence can result in significant morbidity and even death. Retrospective studies suggest that major vascular and bowel injuries occur in 0.04% to 0.18% of cases. The Swiss Association for Laparoscopic and Thoracoscopic Surgery published its finding of an 0.18% incidence after a prospective study of 14,243 patients.⁷

The initial entry into the abdomen to create the pneumoperitoneum is a major cause of bowel injury during laparoscopic surgery. A review of 40 litigated laparoscopic cases that resulted in bowel injury demonstrated that many of these injuries are insidious.⁸ This delayed recognition is problematic for both the patient and the physician.

Bowel Injury

• Consequence

Trocar injuries are responsible for most of the malpractice claims associated with laparoscopic surgery.⁹ The U.S. Food and Drug Administration (FDA) through its Manufacturer and User Facility Device Experience (MAUDE) database identified 31 fatal and 1353 nonfatal injuries associated with trocar insertion from 1997 to 2002. The literature is replete with case reports detailing solid and hollow viscus organ injuries from trocars (see Fig. 7-3).

Most injuries are presumed to stem from the primary trocar placement, usually in the umbilical region. This initial placement is virtually blind, whereas the subsequent trocar insertions can be done under direct visualization.

Optical-access visual obturator trocars were supposed to provide a safer alternative for primary trocar placement. These devices are made of clear plastic and allow visualization of the separation of the abdominal wall layers as they are inserted. However, even with these instruments, there have been documented injuries.¹⁰ A study that included 1283 patients showed a 0.31% incidence rate of injury when using these devices.¹¹

The use of the Veress needle is an alternative to direct or open trocar insertion. Invented by Dr. Janos Veress in the 1930s, it was originally used to treat tuberculosis by creating a pneumothorax, which was the mainstay of treatment during this time. A dual needle consisting of a spring-loaded blunt inner core and a sharp outer sheath was created because it offered fewer risks of trauma to the lung. As the Veress needle is placed through soft tissue, the blunt inner needle is displaced and the sharp outer sheath can cut through tissue. Once the needle is inside a hollow cavity, the blunt needle springs back into position to guard the sharp outer sheath. In the 1970s, the Veress needle became popular as the field of laparoscopic surgery expanded.¹²

The Veress needle can be used as a substitute for other methods of establishing a pneumoperitoneum. However, many studies have shown that its use may yield higher complication rates. Published studies demonstrate that the Veress needle is more likely to cause minor complications such as subcutaneous emphysema and extraperitoneal insufflation.^13,¹⁴ These studies are in line with older studies that concluded that Veress needle use results in a significantly higher incidence of minor complications.^15,¹⁶ However, a great deal of debate exists in the literature with many reviews concluding that the Veress needle is a safe alternative to the other entry techniques. A retrospective review of 2126 laparoscopic operations, in which the Veress needle was exclusively used, yielded no complications.¹⁷

Grade 2/3/4 complication

• Repair

A study that analyzed laparoscopic injuries that were reported to the FDA and Physician Insurers Association of America (PIAA) found that the organ most commonly injured is the small bowel. The study also showed that small and large bowel injuries were the most likely to go unrecognized in a 24-hour period. Because delay in recognition can lead to significant morbidity, the surgeon’s suspicions should be heightened if the clinical course deviates from the norm. Moreover, this delay in treatment has been shown to cause a 26% rate of mortality.¹⁸

Although vascular injuries occur with less frequency than bowel injuries, the odds of mortality are very high. The aorta, inferior vena cava, portal vein, and iliac vessels are all prone to injury from initial trocar placement. In some thin individuals, the aorta can lie within 5 cm of the anterior abdominal wall. This underscores a critical element of laparoscopic surgery in that every attempt should be made against pushing trocars all the way into the abdomen. Trocars that are fully advanced to the external cannula are prone to diving into the retroperitoneum, causing significant vascular injury.¹⁹

As common sense dictates, recognized injury repair should be completed during the original operation. Laparoscopic repair should be attempted unless delay, as with hemorrhage, may adversely affect the patient’s outcome.

• Prevention

Although there is no true consensus on the safest technique for initial abdominal entry, many believe that open laparoscopic access, as described by Hasson, is the safest. A retrospective analysis of 5284 patients who underwent open laparoscopy discovered that only 1 patient suffered a bowel injury.²⁰

In patients with presumed umbilical adhesive disease from prior abdominal surgery, alternative techniques for abdominal insufflation and entry have been described. Insufflating with a Veress needle placed in the left ninth intercostal space and primary trocar placement in the left upper quadrant has been used with low injury rates.²¹ Placing the initial trocar in this region, specifically in the left midclavicular line 3 cm below the costal margin, has been advocated by many surgeons as a safe alternative when umbilical adhesions are suspected.²²

Veress needle insufflation should be guided by initial intra-abominal pressure. In a study of 259 women, initial pressures lower than 8 mm Hg at 1 L/min flow of CO₂ demonstrated correct position; pressures greater than 8 mm Hg correlated with interstitial placement.²³

Abdominal wall lifting has been advocated when placing a Veress needle to avoid potential complications. In theory, this technique allows for lifting the abdominal wall away from bowel and vasculature. However, this method is associated with an increased number of insertion attempts, which may increase the likelihood of organ perforation.

The most consistent means of prevention of trocar placement injuries requires macrobracing (Figs. 7-4 and 7-5). As the trocar is placed in the abdominal wall, the tip will separate the layers of the abdominal wall. Eventually, the tip will penetrate the peritoneal cavity, with the resultant loss of resistance on the trocar. Without bracing by the nondominant hand, the trocar can damage nearby structures such as the intestines or retroperitoneal tissues. By bracing with the nondominant hand, the loss of resistance does not result in distribution of force to unwanted structures.

Figure 7-4 Inadequate macrobracing.

Figure 7-5 Correct macrobracing.

Retroperitoneal Hematoma

The literature offers sparse details on the prevalence of retroperitoneal hematomas caused during abdominal laparoscopic procedures. However, one can extrapolate from the penetrating trauma guidelines to help foster decision making because inadvertent trocar insertion can mimic stab wounds (Figs. 7-6 and 7-7).

Figure 7-6 Retroperitoneal vascular injury from Veress needle.

Figure 7-7 Abdominal wall hematoma from trocar placement (arrow).

• Consequence

The mortality associated with retroperitoneal hematomas deserves notice. The trauma literature reports a mortality of 13%.²⁴ Superior mesenteric artery (SMA) injuries are particularly dangerous to the patient, with mortality rates approaching 54%.²⁵

Grade 2/3/4 complication

• Repair

The abdomen is divided into three zones with respect to retroperitoneal hematomas. Zone I is the centromedial aspect of the retroperitoneum, lying between the kidneys and extending from the diaphragmatic hiatus to the inferior vena cava (IVC) bifurcation. Zone II extends laterally from the kidneys to the paracolic gutters, and zone III comprises the pelvic region.

Penetrating trauma to zone I should always be explored because injury in this area can involve major vessels.²⁶ These guidelines should be followed during laparoscopic surgery. The most likely scenario involves a trocar injury to the major vessels that course in zone I. If an injury to a major vessel is found, the surgeon must decide whether to proceed with ligation, primary repair, or interposition graft placement.

Penetrating trauma to zones II and III can be managed without exploration if the patient is stable. A computed tomography (CT) scan should be obtained to identify the site of injury. An angiogram may be used to further characterize the hematoma and for therapeutic embolization.