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*Corresponding Author: Pedro Rolando López Rodríguez, First and second degree specialist in general surgery, assistant professor, assistant researcher and consulting professor.
Citation: Pedro Rolando López Rodríguez, Anthony Alvarez Morales, Yosniel Lugo Echevarría,Anaisa León Mursulí (2024), General complication of laparoscopic surgery, necesary review, Clinical Medical Reviews and Reports; 6(5): DOI: 10.31579/2690-8794/212
Copyright: © 2024, Pedro Rolando López Rodríguez. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 28 April 2024 | Accepted: 10 April 2024 | Published: 27 May 2024
Keywords: laparascopic surgery; complications; laparascopic techniques
Introduction: “Minimal Access Surgery” began in animal laboratories and was later studied in selected academic centers where it was imported to community hospitals only when its benefits and safety were established.
Objectives: To conduct a detailed review of Complications of laparoscopic surgery with emphasis on those related to entry into the abdominal cavity and bile duct surgery given their high frequency and lethality.
Subject and methods: A detailed search of literature published in Spanish and English was carried out through PubMed/MEDLINE, Cochrane's registry of systematic reviews and randomized controlled studies, using key words such as “laparoscopic entry”, “trocars injury”, “laparoscopy”. complications”, “laparoscopic injury” and “optical trocars”. Meta-analyses, randomized clinical studies, clinical guidelines, review articles and case series were mainly selected.
Conclusions: Laparoscopy is a relatively safe procedure, however, great care must be taken during access to the abdominal cavity because the majority of complications occur during entry.
“Minimal Access Surgery” began in animal laboratories and was later studied in selected academic centers where it was imported to community hospitals only when its benefits and safety were established. Low complication rates were reported by centers specialized in laparoscopic surgery, mostly academic centers. These centers were able to reduce complication rates to a minimum by developing the skills necessary for these surgeries. Unfortunately, many inexperienced surgeons developed these techniques without sufficient training and are responsible for the majority of complications obtained during laparoscopic surgery.[1]
The development of Laparoscopic Cholecystectomy (LC) was not designed to improve the safety of the procedure, but rather to reduce the discomfort associated with the surgical incision.
Doctors who have performed fewer than 100 such procedures have reported a complication rate of 14.7 per 1,000 patients. In contrast, expert surgeons reported having a complication rate of only 3.8 complications per 1000 procedures. The Southern Surgeons' Club reported that the survey or incidence of bile duct injuries was 2.2% when the surgeon had performed fewer than 13 procedures. As surgeons gained experience, the incidence of bile duct injuries eventually decreased to 0.1%[2-3].
Carry out a detailed review of the Complications of laparoscopic surgery with emphasis on those related to entry into the abdominal cavity and bile duct surgery given their high frequency and lethality.
A detailed search of literature published in Spanish and English was carried out through PubMed/MEDLINE, Cochrane's registry of systematic reviews and randomized controlled studies, using key words such as “laparoscopic entry”, “trocars injury”, “laparoscopy complications”, “ laparoscopic injury” and “optical trocars”. Meta-analyses, randomized clinical studies, clinical guidelines, review articles and case series were mainly selected.
The use of laparoscopy to perform surgical procedures is increasing as it provides greater benefits, when compared to laparotomy, in terms of faster recovery, less postoperative pain, and shorter hospital stay. However, since it is an invasive procedure, there is a risk of complications. These are divided into Intraoperative and Postoperative, but we are going to refer to Intraoperative, which in turn can be divided into 2 large groups:4
A – General Complications of Laparoscopic Procedures:
1- Related to the Introduction of Needles, Trocars and Insufflation
2- Typical of Pneumoperitoneum
3- Related to the introduction of laparoscopic surgical materials and manipulation of instruments.
B – Specific complications of each technique: (Biliary Surgery)
General Complications of Laparoscopic Procedures:
1 - Related to the Introduction of Needles, Trocars and Insufflation
It is with the introduction of the Veress needle to create the pneumoperitoneum that any laparoscopic procedure begins. The impossibility of creating this adequately makes it impossible to place trocars correctly and will cause the surgery to fail.
Veress Needle and Trocars
Despite the advantages offered by the protection system of this needle during its introduction, different injuries can occur, such as:
- Injury to the Abdominal Wall Vessels:
This complication is relatively frequent, it occurs mainly with the introduction of trocars and especially with those that have sharp edges (they have the advantage of requiring less pressure for their introduction into the abdominal cavity) than with those with a conical tip, less causing this complication. The solution to this is usually the compression of the wall, either directly with the sheath, or with the introduction of the sheath fixing sleeve that has a larger diameter and if it is not controlled, small enlargements of the wound corresponding to the point of bleeding until they are located and hemostasis is achieved.
To avoid this, it is advisable to transilluminate the wall to visualize the larger caliber vessels in order to avoid injury.
- Large Vessel Injury:
This is usually due to injuries to the abdominal aortic bifurcation or the inferior vena cava, producing a large retroperitoneal hematoma that requires urgent laparotomy. The incidence of this complication is fortunately low, amounting to 0.05% in large multicenter series, but frequently fatal, which is why the introduction of the needle and the first trocar must be done with great care and with gentle maneuvers. If an injury occurred, depending on its magnitude, a laparotomy must be performed, checking for the existence of a vascular wound on the posterior face of the vessel at the level of the previous wound, and suturing it if necessary [5-6].
- Hollow Viscera Injury:
This can be in: Stomach, Small Intestine or Colon. It can occur more frequently when there is a previous abdominal surgery, which implies the possible existence of adhesions of the digestive tract to the anterior wall, which recommends puncture with the Veress needle away from the laparotomy scar, in an upper quadrant, normally the left another method of avoiding this is by placing a Hasson trocar under direct vision (open Pneumoperitoneum). This injury can go unnoticed, which increases its severity as it is diagnosed late.
- Solid Viscera Injury:
It is infrequent, it is discovered once the optic is inserted and it is not usually serious; it is usually superficial punctures of the liver, which spontaneously stop bleeding.
- Hernias in the trocar orifices:
Infrequent complication in holes of 5 and 10 mm in a lateral situation, but very common in holes > 10 mm, especially in the midline and in the region of the lower abdomen, although it can appear in the upper abdomen if the incision for extraction is extended. of the surgical specimen, so suturing the aponeurosis of the midline trocars is always recommended. It is also important to take into account when removing the 10 mm trocar, especially the one in the umbilical region, since it cannot be removed suddenly because the CO2 must first be emptied from the cavity otherwise evisceration occurs due to the pressure. positive intra-abdominal that forces the greater omentum, small intestine, out of the abdominal cavity and may go unnoticed at the end of the surgery [7-9].
An example of all of the above is that, in 2001, Bhoyrul and collaborators analyzed 629 injuries caused by trocars, reported to the Food and Drug Administration (FDA) between 1993 and 1996. 32 deaths were reported, of which 26 resulted from injury. vascular and 6 intestinal injuries, disposable trocars were used in 28 deaths, 3 by optical vision and 1 by reusable trocars, 408 injuries were vascular injuries and 182 were visceral injuries, 30 wall hematomas occurred and the other patients were not analyzed. These authors conclude that disposable trocars and direct entry do not reduce visceral complications, and an unrecognized intestinal injury can be fatal [10-12]
Insufflation
- Gas insufflation into the abdominal wall, mesentery, omentum or retroperitoneum:
Insufflation of CO2 into the omentum, mesentery or retroperitoneum produces emphysema that does not have great repercussions and disappears quickly, but the possibility of a vascular or visceral injury below this must be ruled out. These emphysemas often make the operating field difficult since they reduce the visual field and modify anatomical structures.[13]
If this insufflation occurs in the abdominal wall, it causes subcutaneous emphysema, which, although it has no clinical significance, can make it difficult to achieve pneumoperitoneum. It is evidenced by an asymmetrical abdominal distention of the abdominal wall, the presence of subcutaneous emphysema due to crepitus in the abdomen and high pressures marked by the insufflator and which warn us of incorrect placement of the needle.[14-15] In obese patients Gas insufflation may occur in the preperitoneal space that simulates a pneumoperitoneum since it can hold 3 to 4 liters in the preperitoneal space that occurs even with symmetrical abdominal distention, but it is quickly recognized by high pressures maintained in the laparoinsufflator, as well as the absence of negative pressure. Therefore, it is important to always perform negative pressure tests of the abdominal cavity, injection of air or liquid into the abdominal cavity with subsequent aspiration, and laparoinsufflator values below 8 mmHg. This is often detected when introducing the optic and observing that it is not in the abdominal cavity, making it necessary to communicate this space with the intra-abdominal space. [16-18]
2 - Typical of Pneumoperitoneum:
- Gas Embolism:
Produced by the sustained insufflation of CO2 pressures directly into a large-caliber venous vessel, it is a serious complication that requires rapid decompression of the abdominal cavity followed by cardiorespiratory recovery maneuvers, which is why it is recommended not to use flows at the establishment of pneumoperitoneum greater than 1 or 1.5 liters per minute. [19-20]
It is recognized by the appearance of profuse sweating, sustained arterial hypotension, jugular engorgement, tachycardia, cardiac arrhythmias and distal cyanosis, as well as the recording of arterial O2 desaturation and hypercapnia raise the suspicion of this complication.
- Pain in the shoulders:
It seems to be related to the irritation of the diaphragms by CO2 and the rupture of its myofibrils. So an inflation pressure of 1 – 1.5 liters/min. prevents sudden distension of the diaphragm. This pain is easily combatable with analgesics and disappears in the first 48 hours after surgery.
- Iatrogenic Pneumothorax:
Its mechanism of appearance is not clear but barotrauma is invoked due to the sudden insufflation of the pneumoperitoneum, as well as possible congenital diaphragmatic defects that establish a pleuropulmonary communication that makes its establishment possible by increasing intra-abdominal gas pressures. Generally this is resolved in the same surgical procedure, being very complicated if a hypertensive pneumothorax occurs where there is an increase in intrapulmonary pressures and O2 desaturation that is resolved with a Pleurostomy.
- Pneumomediastinum:
This generally occurs in esophageal hiatus surgeries when the abdominal cavity comes into contact with the lower mediastinum, so it is recommended to work with pressures < 12>
-Respiratory problems:
The hypercapnia that occurs during laparoscopic surgery is due to the sum of two factors: the increase in dead space (well-ventilated but poorly perfused alveoli) and the absorption of CO2 by pneumoperitoneum. The measurement of expired CO2 (ETCO2) will be a good non-invasive control method; on the other hand, O2 saturation does not seem to be altered by pneumoperitoneum, but peak pressure (maximum pressure produced in the airway at each time) is elevated. ventilatory cycle, also producing a discrete metabolic acidosis, which becomes more evident the greater the hemodynamic impact. [21-23]
- Hemodynamic Repercussions:
At the beginning of insufflation, there is an increase in Central Venous Pressure (CVP), mean arterial pressure and cardiac output, but once the mean working pressure (12-14 mmHg) is established, it is higher than that of the vena cava, which decreases CVP as well as cardiac output. Hypoxia, hypercapnia and decreased cardiac output may be the most important factors in the development of cardiac rhythm disorders.
3- Related to the introduction of laparoscopic surgical materials and manipulation of instruments:
The use of instruments inside the abdominal cavity must always be carried out under optical vision, to avoid injuries to the different abdominal organs, so we will follow their entire journey from their entry into the cavity. The design of this type of instruments such as scissors, aspiration cannulas and forceps are long, so perforation can occur at any level if these instruments are not entered under endoscopic vision. Injuries caused by incorrect use or uncontrolled mobilization of surgical instruments can go unnoticed, increasing their severity. [24-26]
Electrocoagulation deserves a separate comment, which is used with the dissector, scissors or hemostasis forceps. Its improper use can cause thermal injuries in unwanted places (diaphragm, digestive tract, bile duct, etc. [26]
The high intensity of the light produced by the xenon source is capable of providing burns if the contact between the tip of the endoscope and the tissue or organ is prolonged. Inadvertent burns at the gastrointestinal level can cause perforation peritonitis, which generally appears on the 4th day. postoperative period, which is why the laparoscope must always be removed inside the trocar in the event of loss of pneumoperitoneum. [27]
Specific complications of each technique: (Biliary Surgery)
The risk of bile duct injury during laparoscopic cholecystectomy has increased due to the position and exposure of the anatomical structures of the extrahepatic bile ducts.
"Post-surgical or Iatrogenic Bile Duct Injury" is defined as any change secondary to surgery that causes bile leak from the biliary tree before the duodenal papilla, difficulty or impossibility of the passage of bile to the duodenum, or combinations of these. Vascular lesions of the biliary tree are also included, and can be of the hepatic, common, right or left arteries, as well as the portal vein.[28]
The annual incidence of bile duct injuries increased from about 0.2% in the open cholecystectomy era to approximately 0.5
Laparoscopy is a relatively safe procedure, however, great care must be taken during access to the abdominal cavity because most complications occur during entry.
Cholangiography continues to be, above cholangioresonance, the ideal imaging method to visualize and stage bile duct lesions since it allows percutaneous derivation to control, leak or obstruction of the biliary tree [5].
Biliary Tract Injuries have increased considerably in the last two decades, due to the predominance of laparoscopic cholecystectomy over open surgery, which has been correlated with an increase in the incidence of bile duct injuries. Overall, the frequency of bile duct injuries ranges from 0.1 to 0.6%. These injuries are three to four times more frequent during laparoscopic cholecystectomy (0.3-0.6%) than open cholecystectomy (0.1-0.3%). Strasberg's review is very significant, since in 124,433 patients studied in 22 case series, a percentage of 0.52 is reported with a range of 0 - 2.35% [7].
Bile duct injuries produced during cholecystectomy can be avoided, almost without exception, if several aspects are taken into account, although it seems that the surgeon's good judgment, experience and expertise usually have the greatest weight.
The main Iatrogenic Biliary Tract Injury (LIVB) is undoubtedly the most disastrous accident that a patient could suffer during a laparoscopic cholecystectomy. This is an operation from which “everyone comes out well” and yet Suddenly the panorama has changed radically, the “easy” surgery has become a nightmare. By injuring a patient's bile duct we will have completely changed his life and his future, since the serious consequences of this fact can range from prolonged open surgery with the permanent possibility of repeated cholangitis, restenosis and therefore reoperations to cirrhosis. gallbladder and death.
Conflicts of Interest: The authors declare that they have no conflicts of interest.
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