Avoiding complications in endoscopic surgery

We all want to perform surgery and have no complications. But if you operate and for long enough, you will have complications. Recognizing that unfortunate truth mandates preparation for injury prevention.

Why do complications occur? 

Poor knowledge of anatomy, distractions, being above one’s limits of expertise, inadequate preparation for a case, overconfidence, being in the learning curve of new technology or surgical technique, not knowing how to properly use an instrument, being in a rush, inadequate or inappropriate tissue dissection, and inability to recognize different tissues or structures are all familiar causes that may lead to visceral injuries. If you want to avoid injuries, avoid what is listed above. 

At the end of every operation, check for injuries to the bladder, ureters, rectum, sigmoid, and small bowel. Dictate the findings in the operative report. Intraoperative recognition of an intestinal injury is a blessing compared to a late diagnosis with full blown peritonitis. There are no excuses for preventable complications. An additional few minutes spent dissecting and clearly identifying the bladder, rectum, or ureters is more rewarding and much shorter than 10 to 45 minutes necessary to repair any of these structures. The time is extended even further if another surgeon is requested.

Laparoscopic mortality and its major causes: Entry injuries

Laparoscopic mortality is directly related to the type of injury. Major vascular injuries and unrecognized intestinal injuries are associated with the highest mortality: 9% to 17% for vascular¹ and 3.2% for unrecognized intestinal injuries.² The riskiest time for vascular and intestinal injuries is at closed entry: 83% of major vascular injuries¹ and 55% of intestinal injuries occur at closed entry.² For this reason, closed entry with the Veress needle and initial trocar insertion must be performed by expert surgeons or trainees under their direct supervision. 

Once an entry major vascular injury is under control, remember to perform a thorough inspection of the entire gastrointestinal tract, since 50% of such injuries are associated with intestinal injuries. It is a simple fact: the bowel is in between the abdominal wall and the retroperitoneal vessels. 

Avoidance of mortality at entry

The open technique of creating a transumbilical 1-cm incision and using a blunt trocar is not associated with entry deaths.¹ Proper technique mandates elevating the umbilicus when making the skin and fascial incision, since aortic injuries, not lethal, have been described when this was not done.

Intestinal injuries are not reduced with the open technique, but they are promptly recognized. Remember that intestinal adhesions are present in 27% of patients with a previous laparoscopy and 80% are at the umbilicus.²

If you use the Veress needle and closed trocar insertion, you need to increase the distance from the entry point to the aorta, which is 0.4, 2.4, and 2.9 cm in normal, overweight, and obese patients, respectively.³ Elevate the umbilicus, insert the Veress needle at 45 to 90 degrees according to normal to obese body mass index, and ensure that the pressure is < 10 mmHg. Inflate the abdomen to 25 mmHg, place traction on the umbilicus and insert the optical trocar at 45 degrees towards the pelvis with the patient in supine position. Immediately check for any injury below the umbilicus. Once all trocars are in place, reduce the intra abdominal pressure to your working level, and introduce the endoscope through another trocar site and inspect the umbilical area for unrecognized intestinal injury. 

If you like the Palmer point entry site, the patient must be in supine position and a nasogastric tube must have decompressed the stomach to prevent gastric injury. The distance to the aorta is 10 cm³ but the stomach and spleen are at risk.

There should never be an intestinal or major vessel injury with insertion of secondary trocars as they must always be inserted under direct visualization.

Prevention of bladder injury

A vaginal probe or a manipulator with a vaginal ring is necessary for safer bladder dissection and identification of the cervicovaginal junction. A distended bladder is useful if the margins are unclear. We use a 3-way Foley catheter in all patients to distend the bladder with water whenever necessary during the operation or to check its integrity at the end. 

Bladder dissection is always performed in the midline of the vesicovaginal space in the absence of adhesions, and for at least 1 cm past the cervicovaginal junction or the planned colpotomy site, and then developed laterally.

In the presence of adhesions, typically from a cesarean scar, bladder dissection is started lateral, right or left of the scar where there are no adhesions, and with a distended bladder (Figure 1). 

Prevention of ureteral injury

There is no other proven method for avoidance of ureteral injury than ureter identification during surgery. If the ureters are not identified, there is a high risk (88%-97%)⁴ of unrecognized injury. Remember that ureteral jets at cystoscopy are present with ureteral thermal injuries, and lack of ureteral jets is only indicative of ureteral entrapment or transection, and uncommonly of renal agenesis, atrophy, or insufficiency. 

Ureteral stents are not needed in the presence of normal anatomy. In scarred retroperitoneum, they are useful to recognize ureter transection, but not to identify them. However, given a tubular structure difficult to recognize, instrument palpation of a ureteral stent will prevent its transection. 

With normal pelvic anatomy, can all ureteral injuries at endoscopic hysterectomy be prevented?

The answer is yes. 

At the level of the ovarian vessels, creating a peritoneal window between the vessels superiorly and the ureter inferiorly will guarantee ureter safety when sealing the ovarian vessels. At the cardinal ligaments, 1 out of 8 patients are at ureter injury risk because the ureters are < 5 mm from the lateral cervical wall.⁵ Because laparoscopic and robotic instruments are 5 and 8 mm in diameter, respectively, their use may result in some type of ureteral injury in such patients (Figure 2). 

The uterine artery is the reason for approaching the ureter to the lateral cervical wall. Cephalad displacement of the uterus with a uterine manipulator in such a situation does not increase the distance of the ureters to the cervix (Figures 3 A and B). Division of the uterine artery at its intersection with the ureter liberates the ureter from the arterial embrace and allows its lateral displacement, preventing injury when securing the uterine vessels or dividing the cardinal ligaments (Figure 4). 

Intestinal injury

Most injuries occur at entry, whether at laparoscopy (55%)² or during robotics (67%) ⁶. There are no deaths if such injuries are recognized, but the rate of mortality is notable at 1 in 31 (3.2%) for unrecognized bowel injuries, which occur in 13% of patients.⁶

Simple rules for prevention of intestinal injuries

At entry, when a patient has a history of adhesions or previous laparoscopy, use the open technique and elongate the transumbilical incision if necessary for adhesiolysis. A preoperative abdominal wall ultrasound may identify areas of “fixed” bowel and “clear” areas for entry. A closed or open entry at Palmer point is another consideration with the measures outlined above. 

During surgery

Displace the entire small bowel and as much of the sigmoid as possible in the abdominal cavity with adequate Trendelenburg. A redundant sigmoid can be mobilized out of the pelvis with a suture encompassing its mesentery and the peritoneum lateral to the psoas muscle. 

Most intestinal injuries during surgery are a result of enterolysis.⁶ Safe enterolysis requires at least 3 instruments: one for traction, another for counter traction, and a third one for the division or removal of the adhesions. Use sharp dissection and avoid the “pulling” technique. The use of cold scissors and acceptance of manageable bleeding is preferable to thermal injury. Minimize the use of short pulses of monopolar coagulation when performing enterolysis. 

Bowel preparation is not helpful for avoiding injuries. It should be  abandoned except in rare situations.

Steam generated by a standard bipolar instrument, noticed as blanching of the tissue, may cause a thermal injury up to 1 to 2 cm away from the application site if the instrument is applied long enough. Use short applications to allow cooling of the tissues. Vessel sealers are preferable due to their increased safety profile as compared to bipolar instruments. 

Rectal injury

A rectal probe and a vaginal probe or vaginal ring of your preference will transform a difficult rectovaginal dissection into a safer and easier one. A rectal probe improves identification of the outer limits of the rectal and sigmoidal walls by palpation and by visualizing its movement within their lumen.

Obliteration of the cul-de-sac due to fixation of the rectosigmoid to the posterior cervical wall is common with cul-de-sac endometriosis. Some simple rules apply in that situation.

• The same rules for cesarean scar apply here. Start the dissection lateral, right or left, to the fixed rectosigmoid, and dissect the free rectovaginal space, and then proceed to safely dissect the rectosigmoid from its attachments to uterus or cervix. 

• If the above approach is impossible, proceed with dissection into the uterine or cervical wall instead of the rectosigmoid, leaving a shaving of the cervix attached to the rectosigmoid, which can be safely removed later. 

• If a hysterectomy is planned, another alternative is to perform a colpotomy starting at the anterior vagina and dividing the posterior vaginal wall intravaginally under direct visual control. Then dissect the rectovaginal space distal to the colpotomy and once the uterus is separated from the vagina proceed to safely dissect the attached rectosigmoid from the cervix in an antegrade or retrograde fashion.

A rectum filled with air and submerged in a pelvis filled with water will identify full thickness rectal wall defects. A methylene blue enema will identify a blue rectal mucosa in an almost full-thickness type of injury. In any case, you must clamp the sigmoid upstream with an atraumatic forceps before testing for leaks. 

Major vascular injury prevention

Prevention of injury of large vessels must be the most important goal of all endoscopic surgeons because such injuries are associated with major blood loss, high mortality, and permanent sequelae. In our institution, a blood loss of 165 mL/minute or higher dictates the start of massive blood transfusion protocol. Acute blood loss of that magnitude, if long enough, is usually associated with disseminated intravascular coagulation (DIC), further compounding the problem. For prevention of entry injury, see above. 

Prevention during surgery

About 20% of major vessel injuries occur during surgery, especially lymphadenectomies, and they are associated with a high mortality of 12.5%.¹

Awareness of the location of major vessels must be a constant thought. Any dissection must be kept away from the large vessels, placing the organ in the center of the pelvis, away from the lateral pelvic walls. 

When the dissection is near major vessels, the dissecting instrument must be directed opposite to the vessels in case of loss of control of the instrument. 

Anterior abdominal wall nerve and vascular injury prevention

Placement of the lower quadrant trocars superior to the anterior-superior iliac spine will avoid nerve injury, since the ilioinguinal and iliohypogastric nerves emerge inferior to that anatomical site. Insertion of the lower quadrant trocars lateral to the rectus muscles will avoid injury to the inferior epigastric vessels, since they curve below the muscle and up to 6 cm from the midline.⁷

Other situations in which to avoid injury

Insulation failures

Insulation failures are more common with robotic instruments.⁸ They are responsible for vessel injury and unrecognized bowel injury. Routine testing for insulation failures should be mandatory at all facilities using electrosurgical instruments. 

Removal and insertion of instruments 

Removal and insertion of instruments should always be performed under direct visual control, more so in robotics since the trocars are cephalad or lateral to the umbilical camera. The same rules apply when removing or inserting sutures with needles. 

Loss of the visual of a robotic instrument may result in injury from undue movements while attempting to bring it to the field due to the lack of tactile feedback. The da Vinci Xi system provides yellow chevron lines which provide an approximate location of the instrument. With other da Vinci systems, removal of the instrument, if not holding tissue, and safe visual reinsertion is an effective solution. 

Disclosures:

The authors report no potential conflicts of interest with regard to this article.

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