10/17/2018 Laparoscopic Complications: How to Avoid Them, How to Repair Them No disclosures Alison Jacoby, MD Director, Comprehensive Fibroid Center Learning Objectives • Review anatomy of areas prone to injury Complications happen • Tips for locating the ureters and bladder • Learn strategies for avoiding/minimizing complications • Make use of angled scopes, displace ureters, maintain You’re not operating enough if you insufflation during morcellation haven’t had complications • Feel confident identifying and repairing intra-op injuries • Know how to repair bowel punctures, cystotomies and minor vascular injuries 1
10/17/2018 Laparoscopic entry Cosmetic incisions e Increase distance from vital structures The problem is not having the injury • Initial insufflation pressure at 20 mmHg Safe port locations The problem is failing to recognize and • Left upper quadrant (Palmer’s point) repair the injury • Supra-umbilical, midline Inspect before Trendelenberg Laparoscopic Entry: Port Placement 2
10/17/2018 Laparoscopic entry: Left Upper Quadrant Trocar Entry: Port Placement Palmer’s Point Indications: • Prior midline incision • Known pelvic adhesions • Large pelvic mass • Pregnancy • Failed umbilical port placement Always have your scope higher than the fundus (with maximum cephalad displacement) Inspect bowel before T-berg 3
10/17/2018 Visualization: Visualization: Uterine manipulation Seeing around corners Angled scopes: • 0°, 30° & 45° • Places tissue on • Invaluable for seeing over and around tension large fibroids • Separates ureter and uterine artery • Delineates vaginal fornix Visualization: Identifying the Bladder • Controlled insufflation of the bladder with CO2 4
10/17/2018 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 5
10/17/2018 Specimen Bag Options Contained Scalpel Morcellation 15 mm Endocatch Bag 15 x 10 cm opening Alexis Contained Extraction System 6
10/17/2018 A 34 year old woman, 8 hrs after a robot-assisted Repairing Surgical Injuries 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 7
10/17/2018 Mesenteric Laceration A Small or Extra Small Alexis within the Repair 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 8
10/17/2018 Colon Puncture No bowel contents were visible A 37 year old woman with a BMI of 40 underwent an uncomplicated ovarian cystectomy A colorectal surgeon in the adjoining OR was consulted The left lateral skin and fascia were enlarged for removal of A figure of eight stitch with 3-0 silk was placed through the the specimen muscularis to close the defect During fascial closure of the lateral port site, the Carter- The pelvis was copiously irrigated Thompson device punctured the descending colon 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 Thank you • Check and double check: cystoscopy, final looks • Know when to call for help UCSF Comprehensive Fibroid Center: 415-885-7788 Questions: alison.jacoby@ucsf.edu 9
10/17/2018 10
Recommend
More recommend
