Complications of Laparoscopy in Connection with Entry Techniques

Abstract

The anatomy of the human being has not changed. However, technical developments in operating materials and methods call for improvements in surgical procedures as well as the management of complications. A fundamental distinction between any operating method and laparoscopy is that, in the latter, the initial entry is usually performed in blind fashion. Blind entry may result in vessel or organ damage, especially in patients who have undergone previous surgery. One of the difficulties associated with the entry is that the damage may not be identified immediately and then necessitate major abdominal repair. Furthermore, the improvement of surgical instruments and techniques enables the surgeon to perform even major operations by the laparoscopic approach. This is associated with renewed learning curves and a high rate of complications due to vascular, bowel, uterine, or bladder damage. The improvement of surgical techniques must be accompanied by advancements in the management of complications. The aim of this review is to address the risks of laparoscopy as well as their correct and professional management. (J GYNECOL SURG 33:81).

Keywords: bladder injury; bowel injury; complication; entry technique; laparoscopy; management.

FIG. 1.

(A) Entering the primary trocar site with a 5-mm optical trocar; stool is visible in the distant parts of the trocar. (B) The injury is clearly seen after inserting an ancillary trocar in the lower abdomen. It is important to leave the primary trocar in its respective location. (C) After mobilizing the adhesions that fixed the bowel to the abdominal wall, (D) the defect can be demarcated and sutured.

FIG. 2.

Secondary trocar placement, left lower abdominal entry. (A) The three plicae are visualized. (B) The palpating finger is showing the area lateral to the lateral umbilical fold. (C) Entry of the sharp ancillary trocar lateral to the lateral umbilical fold. (D) Once the peritoneum has been penetrated, the trocar heads toward the fundus of the uterus and thus avoids injury to the major vessels and the bowel.

FIG. 3.

(A) Acute bleeding from the inferior epigastric artery. (B and C) The surgeon's view is obliterated within seconds. Blood flows at the site; the situation is obviously precarious. (B–D) The artery is closed by the inside-out suturing technique and the suture is fixed to the abdomen.

FIG. 4.

(A) The Lee-Huang point can be palpated directly beneath the xiphoid. (B–D) Alternative entry site showing Palmer's point. It is situated in the midclavicular line, about 3 cm below the costal margin, and is used in patients with known or anticipated umbilical adhesions.

FIG. 5.

(A) Monopolar drilling of the ovary just before ending the operation. (B) The final view reveals a massive retroperitoneal hematoma increasing in size. (C) Detailed inspection of the retroperitoneum shows a laceration just above the vena cava.

FIG. 6.

(A) Morcellation of a medium-sized uterus. (B) The morcellator has been inserted into the midline; this ensures the best overview and the greatest distance to the organs. (C and D) Grasping the remaining uterus. (E) The tenaculum has grasped a small intestinal sling but, as the area of interest is not in the middle of the picture and the camera is too far away, the problem is not identified. (F) The surgical team identifies the bowel injury only after morcellation of the intestine.

FIG. 7.

A 32-year-old patient with continuous vaginal bleeding, para 1, with suspected placental remnants 5 weeks after delivery. (A and B) The soft anterior wall of the enlarged uterus was perforated during curettage for removal of placental remnants. The extent of perforation was identified during the simultaneous laparoscopy. Active bleeding, hematoma, and free fluid (rinsing fluid used for hysteroscopy). (C and D) The hole can be closed with a thick monofilament suture and intracorporeal knotting.

FIG. 8.

The same patient as in Figure 7. (A) Attempt to perform curettage under laparoscopic vision reveals a second perforation at the cervico-corporal transition. Only the peritoneum of the bladder has remained intact. (B) Immediate subperitoneal bleeding. (C) An early attempt to manage the area of perforation by performing a hysteroscopy leads to a large edema in the subperitoneal space. (D) The peritoneum needs to be opened. After complete exposure of the anterior uterine wall down to the vagina, the sole hysteroscope is inserted without dilution medium, the perforation is demarcated and treated under laparoscopic vision. The left forceps is used to pull the distal part of the perforated tissue onto the distal part of the hysteroscope. The distal portion of the uterine corpus can now be examined.

FIG. 9.

The same patient as in Figures 7 and 8. (A) After complete exposure of the anterior uterine wall, only the vesicovaginal ligament is preserved. (B) A probe is inserted into the cervix and (C) directed into the uterine cavity under laparoscopic guidance. The defect is bridged by the probe and closed easily by making intracorporeal full-thickness sutures to the wall. (D) Hysteroscopic view of placental remnants, which may then be removed in a stepwise manner. After closure of the defect there is no further leakage and the dilution medium permits intrauterine vision.

FIG. 10.

A 35-year-old patient, para I, after cesarean section in a developing country (A), with a suspected defect of the cesarean scar. Hysteroscopy shows the margin of the intact wall; the defect seems to be covered by peritoneum alone. (B) The laparoscopic view shows a strong adhesive cord of the anterior uterine wall to the anterior abdominal wall. After opening the left (C) and the right (D) anterior leaf of the broad ligament, the bladder can be kept at a distance and the uterine defect demarcated.

FIG. 11.

Same patient as in Figure 10. (A) After complete adhesiolysis the bladder is moved away from the uterus and the deep defect demarcated. (B) A simultaneous hysteroscopy confirms that the defect covers the entire wall. (C) The thin cover of the defect is seen after the introduction of fluid through the hysteroscope. Additionally, the defect is demarcated by the illumination fixed to the hysteroscope. (D) Once the intra-abdominal illumination has been dimmed, the hysteroscopic illumination becomes very clear.

FIG. 12.

Same patient as in Figures 10 and 11. (A) Planned perforation with the hysteroscope allows (B) specific resection of the respective area. (C) The defect is demarcated and bridged with the hysteroscope (D), thus permitting end-to-end coverage.

FIG. 13.

Same patient as in Figures 10–12. (A) Final view of the covered defect of the anterior uterine wall. (B) As the patient still wishes to have children, an antiadhesion barrier gel is applied (Hyalobarrier, Nordic Pharma, Germany).

FIG. 14.

Laparoscopic supracervical hysterectomy (LSH): Final view after the LSH procedure. The peritoneum closes the cervical canal and drainage is possible from both sides. Both sacrouterine ligaments are under slight tension and thus achieve suspension of the cervix. The preserved integrity of the ureter is confirmed by observing peristalsis (A–C). Coagulation of the right trocar entry point after removal (D).

FIG. 15.

Opening the bladder usually requires the simultaneous insertion of a ureteral stent. This is achieved via cystoscopy (A and B). When the trigone of the bladder and the intramural pathway of the ureter are distant to the laceration, the latter can be closed securely by laparoscopy (C and D). The hole is closed by making an interior suture line with Vicryl 3.0, using a continuous suture, and an interrupted suture line above with Vicryl 2.0 including the muscle and the peritoneum.

FIG. 16.

(A) Second-look laparoscopy 3 days after nonproblematic myoma enucleation of the uterine back wall. The patient experienced bouts of high temperature and had increasing inflammation parameters. No drain was inserted. The overview shows normal pelvic anatomy and no sign of peritonitis or organ damage. (B) Atypical adhesions in the right lower abdomen (cecal region). (C) The endoscope clearly demarcates the bowel damage and signs of local peritonitis. The bowel injury probably occurred when the bowel was moved out of the operating field. (D) The upper right quadrant is also free of any signs of peritonitis.