Laparoscopic Complications: How to Avoid Them, How to Repair Them - - PowerPoint PPT Presentation

10/17/2018 1

Laparoscopic Complications:

How to Avoid Them, How to Repair Them Alison Jacoby, MD

Director, Comprehensive Fibroid Center

No disclosures

• Review anatomy of areas prone to injury
• Tips for locating the ureters and bladder
• Learn strategies for avoiding/minimizing complications
• Make use of angled scopes, displace ureters, maintain

insufflation during morcellation

• Feel confident identifying and repairing intra-op

injuries

• Know how to repair bowel punctures, cystotomies and

minor vascular injuries

Learning Objectives

Complications happen You’re not operating enough if you haven’t had complications

10/17/2018 2 The problem is not having the injury The problem is failing to recognize and repair the injury

Laparoscopic entry

Cosmetic incisionse

Increase distance from vital structures

• Initial insufflation pressure at 20 mmHg

Safe port locations

• Left upper quadrant (Palmer’s point)
• Supra-umbilical, midline

Inspect before Trendelenberg

Laparoscopic Entry:

Port Placement

10/17/2018 3 Left Upper Quadrant Trocar Entry: Palmer’s Point

Indications:

• Prior midline incision
• Known pelvic adhesions
• Large pelvic mass
• Pregnancy
• Failed umbilical port placement

Laparoscopic entry:

Port Placement

Always have your scope higher than the fundus (with maximum cephalad displacement)

Inspect bowel before T-berg

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Visualization:

Seeing around corners

Angled scopes:

• 0°, 30° & 45°
• Invaluable for seeing over and around

large fibroids

Visualization:

Uterine manipulation

• Places tissue on

tension

• Separates ureter

and uterine artery

• Delineates vaginal

fornix

Visualization:

Identifying the Bladder

• Controlled insufflation of the bladder with CO2

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Visualization: Find the ureters

• Practice ureterolysis on your easy cases

Specimen Removal:

Options for L/S myo & LSH

• Colpotomy
• Uncontained power morcellation (with

informed consent)

• Contained power morcellation
• Contained scalpel morcellation

Specimen removal prior to November 2013

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Contained Scalpel Morcellation Specimen Bag Options

15 x 10 cm

• pening

15 mm Endocatch Bag

Alexis Contained Extraction System

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Repairing Surgical Injuries

A 34 year old woman, 8 hrs after a robot-assisted laparoscopic myomectomy, has hypotension and a significant drop in her hematocrit Concern for intra-abdominal bleeding Returned to OR for diagnostic laparoscopy Findings: Abdomen contained ~1000 cc of blood Uterine suture line was hemostatic

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Mesenteric Laceration Repair A Small or Extra Small Alexis within the bag opens the incision and creates a seal for insufflation

A 45 year old with a history of 3 C-sections presented for a total laparoscopic hysterectomy There were dense adhesions between her bladder and the anterior LUS During sharp dissection with scissors, a cystostomy was created in the dome of the bladder

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A 37 year old woman with a BMI of 40 underwent an uncomplicated ovarian cystectomy The left lateral skin and fascia were enlarged for removal of the specimen During fascial closure of the lateral port site, the Carter- Thompson device punctured the descending colon

Colon Puncture

No bowel contents were visible A colorectal surgeon in the adjoining OR was consulted A figure of eight stitch with 3-0 silk was placed through the muscularis to close the defect The pelvis was copiously irrigated No antibiotics were given And I haven’t used the Carter-Thompson device ever again!

Keys to success

• Safe laparoscopic entry: port placement
• Maximize visualization: see around corners,

locate vital structures

• Practice retroperitoneal dissections on easy cases
• Use your tools: delineate vaginal fornices,

displace ureters, insufflate during morcellation

• Check and double check: cystoscopy, final looks
• Know when to call for help

Thank you

UCSF Comprehensive Fibroid Center: 415-885-7788 Questions: alison.jacoby@ucsf.edu

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