COMPLICATIONS OF LAPAROSCOPIC UROLOGY
ANURAG KHAITAN*, ASHOK K HEMAL**
*Pool Officer; **Professor; Department of Urology, All India Institute of Medical Sciences, New Delhi - 110 029, India.
Ignored for decades by urologists, laparoscopy has finally entered urology as a subspecialty, within a decade. The skilled laparoscopic urologist can now effectively replace many incisional procedures. It has the benefits of early postoperative recovery, less hospital stay and early recuperation besides cosmesis. After ESWL, probably the single most important development in the field of urology has been the emergence of laparoscopic urologic surgery.
Cortessi reported the first urologic use of laparoscopy in the evaluation of an adolescent with cryptorchidism in 1976. Wickham was first to perform laparoscopic ureterolithotomies in 1979. Clayman in 1991 pioneered major interventional laparoscopy in urology, when he performed the first laparoscopic nephrectomy. Since then, most of the ablative and reconstructive surgeries in urology have been accomplished with laparoscope. Retroperitoneoscopic surgery came into vogue in 1993.
Indications of laparoscopic surgeries in urology
The laparoscopic urological surgeries can be performed for ablative and reconstructive surgeries. The various indications are shown in Table 1.
Indications for laparoscopic urological surgeries
1. Adrenal Benign tumours Phaeochromocytoma Simple cyst Myelolipoma 2. Kidney Nephrectomy for non-functioning Kidneys and benign tumors Radical nephrectomy Rental cystic diseases Pyeloplasty Donor nephrectomy Nephrolysis for intractable chyluria Nephropexy for ptotic kidney 3. Ureter Ureterolithotomy Ureterolysis Correction of vesicoureteric reflux 4. Bladder Simple cystectomy Radical cystectomy Augmentation Diverticulectomy 5. Prostate Radical prostatectomy 6. Female Stress urinary incontinence urology Diagnostic Repair of vesicovaginal and vesicouterine fistula 7. Paediatric Diagnosis and orchiopexy for cryptorchidism urology Intersex Nephrectomy 8. Urinary Conduit formation diversion Ureterostomy Ureterosigmoidostomy 9. Others Lymphadenecotmy Varicocele Removal of foreign bodies
Problems and complications of laparoscopic urological surgeries
Several barriers to the urologic laparoscopic surgeries exist. The steep learning curve translates into long operative times and an unacceptably high rate of complications for experienced laparoscopic surgeons. These procedures present new potentially life threatening complications that are usually not seen with traditional open approach. It therefore is important that the benefits of laparoscopic procedures are weighed against potential complications. Awareness of these potential complications and knowledge of their management should prevent mortality and reduce morbidity, thus improving patient care and safety. The uncritical applications of laparoscopic operations due to inexperience can lead to serious complications. If the indications are carefully reviewed and individual surgeon capabilities are assessed realistically, complications can largely be avoided. The complications unique to laparoscopy include those related to creation of pneumoperitoneum, patient positioning, and surgical intervention. The incidence of anaesthesia related complications during laparoscopy are remarkably low.
In a multicentre review of 1043 cases of retroperitoneoscopic urological surgeries an overall complication rate of 4.7% was observed. The majority of these were visceral (2.5%) and vascular (2.2%). The conversion rate was 6.6% and about 40% of these conversions were emergency procedures for vascular or visceral injuries. In another large series of 2407 laparoscopic urological surgeries the complication rate was 4.4%. The reintervention rate was 0.8%.7 The majority of documented complications were vascular injuries (1.7%) and visceral injuries (1.1%) followed by complications of healing and infection (0.8%). The complication rate of the access technique was only 0.2%, whereas most complications occurred during dissection (2.9%). They further classified the procedures as easy, difficult and very difficult and they found the corresponding complications to be 1.0%, 3.9% and 9.2% respectively.
The incidence of complication varies significantly depending on the type of procedure, training and experience of the surgeons. The incidence of complications should decrease after approximately 30 to 50 procedures.[7-11] Increased experience not only decreases the incidence of complications but also changes the approach to the management of complications and reduces the incidence of conversion to laparotomy. Nevertheless, even in the initial stages of learning, the complications can be minimized by awareness of the possible complications by a systematic approach and a strict adherence to the surgical steps. It is easy to understand that complications will be more as the complexity of the procedure increases. Laparoscopic urological surgeries are among the most complex laparoscopic surgeries. Accordingly, a high rate of complications may be expected.
The complications can be divided into two groups, namely those that are common to all laparoscopic procedures and those specific to particular surgical procedures. While the scope of this chapter is limited to only those complications specific to laparoscopy it would do well to remember that laparoscopy is different from open surgery only in terms of access. This notion is also being dispelled as besides having advantages due to minimal access technique, it also provides better operative technique due to excellent visualization of anatomy and less blood loss due to good control of bleeders. Laparoscopic radical prostatectomy and robotic radical prostatectomy are perfect examples of high volume laparoscopic surgery combining ablative and reconstructive procedures. Complications inherent to a procedure performed by open surgical techniques may occur when performed by laparoscopy and these should not be lost sight of. This chapter involves description of general complications, complications related to approach, complications specific to particular procedure and methods of prevention and management of the complications.
1.Related to access
3.Carbon dioxide insufflation to create pneumoperitoneum
4.Insertion of primary port
5.Insertion of secondary port
6.Complications during dissection
7.Complications of prolonged surgery
1. Related to access
Laparoscopic urological surgeries can be performed by either transperitoneal route or retroperitoneal approach.
Advantages of retroperitoneal approach
1. Can be done in patients with multiple prior surgeries.
2. Bowel retraction is not needed.
3. Lesser risk of injury to intraperitoneal organs.
4. No risk of later development of intraperitoneal adhesions.
5. No risk of spillage of infected urine intraperitoneally.
6. Familiar anatomy to urologists.
1. Less working space.
2. Longer learning curve.
Although there are certain advantages and disadvantages of both the approaches, in a particular patient, the ideal approach should be individualized.
The creation of pneumoperitoneum is performed by an open technique or by a Veress needle. Most centres are now using the only open approach, as it is safer.
2. Complications related to balloon dissection
a.Loss of orientation due to inflation in an incorrect plane.
b. Injury to abdominal muscles due to inflation in wrong plane.
c. Rupture of peritoneum.
d. Rupture of balloon.
Rupture of balloon inflated with gas runs the risk of air embolism; so liquid medium is preferable to gas for creating retroperitoneal space as it avoids the risk of air embolism. In case of balloon rupture, a fresh balloon can be inserted and the balloon dissection can be completed before insertion of the primary port. Care must be taken to remove all fragments of latex of the balloon. Using silicone balloons, which are stronger but more expensive, can reduce the complication. Alternatively, a balloon with a double latex wall can be made so that even if one breaks the other one remains intact.
3. Complications related to carbon dioxide insufflation
Pneumoperitoneum has haemodynamic, pulmonary and endocrine consequences. The surgical complications include -
•Inadvertent extraperitoneal insufflation
The various complications are as follows -
a. Inadvertent extraperitoneal insufflation
Because the Veress needle is inserted blindly, there is potential for misplacement of needle intravascularly, or in the subcutaneous tissue, preperitoneal space, viscus, omentum, mesentery, or retroperitoneum.
b. Subcutaneous emphysema
Signs are development of crepitus over abdominal wall, excessive changes in airway pressures and increase in end-tidal CO2 concentration. CO2 absorption reaches a plateau within 10 minutes after initiation of intraperitoneal insufflation but continued to increase slowly throughout extraperitoneal CO2 insufflation.
Increased area of CO2 diffusion may lead to significant hypercapnia and respiratory acidosis. Excessive subcutaneous emphysema can extend from the abdomen to the chest wall and neck. This can further tract to the thorax and mediastinum, thereby resulting in pneumothorax or pneumomediastinum. Chest X-ray should be obtained if there is cervical emphysema. The methods to prevent are proper technique of insertion and verification of intraperitoneal location. The other methods are open technique of trocar insertion and avoidance of incision and dissection layer by layer.
c. Cardiovascular complications
There is increase in systemic vascular resistance and arterial blood pressure during laparoscopy. The cardiac output might not change significantly in healthy patients but might decrease in patients with significant cardiopulmonary disease.
Major haemodynamic complications associated with laparoscopic procedures include alterations in blood pressure (i.e. hypotension or hypertension), dysrhythmias and cardiac arrest. The intra abdominal pressure should be maintained at or below 15 mm of Hg to have minimal effect on cardiovascular function. The incidence of dysrhythmia during laparoscopy is approximately 14%. The treatment of prompt interruption of surgical stimulation, release of pneumoperitoneum and administration of an anticholinergic drugs. Methods to prevent effect of pneumoperitoneum are keeping patient in horizontal position, limiting degree of intra abdominal pressure, head up tilt and slow insufflation. Patients with severely compromised cardiopulmonary function need invasive haemodynamic monitoring.
d. Pulmonary complications
Changes in pulmonary function during laparoscopy include reduction in lung volumes, increase in peak airway pressures and decrease in pulmonary compliance secondary to increased intra abdominal pressures.
Hypoxaemia occurs primarily because of ventilation perfusion mismatching and intrapulmonary shunting secondary to decrease in functional residual capacity. Pulmonary vasoconstriction from the direct effect of hypercapnia can be deleterious in patients with pulmonary hypertension or right ventricular ischaemia.
It is suggested that preoperative pulmonary function testing should be performed in patients with significant pulmonary dysfunction. If there is complication during surgery, there should be low threshold for conversion from a laparoscopic to open procedure.
e. Pneumothorax, pneumomediastinum and pneumopericardium
These are potentially life-threatening complications of laparoscopic surgery. Pneumothorax can occur through a tear in the visceral peritoneum, congenital defect in diaphragm, extension of subcutaneous emphysema from the cervical region into thorax and mediastinum.
Pneumothorax can be asymptomatic or can increase peak airway pressures, decrease oxygen saturation and in severe cases can lead to significant hypotension and cardiac arrest.
The suggested management of CO2 pneumothorax is to stop surgery and deflate the pneumoperitoneum, continue supportive treatment, confirm diagnosis by X-ray, treat according to the severity of cardiopulmonary compromise. If there is minimal compromise, then treatment should be conservatively with close observation. Whereas, moderate to severe pneumothorax requires placement of intercostal cannula and chest drain.
After stabilisation, conversion to open proce dure may be necessary. There also have been reports of pneumoperitoneum and pneumomediastinum during laparoscopy.[19,20] The management depends on the severity of associated cardiopulmonary dysfunction. Release of pneumoperitoneum is adequate in most of the patients.
f. Gas embolism
It is a rare but potentially lethal complication of laparoscopic surgery. It can present as profound hypotension, cyanosis and asystole.[21,22] A mill-wheel murmur can be auscultated. There is initial sudden increase in the ET CO2 concentration, which decreases later owing to cardiovascular collapse.
Air embolism episodes occur most commonly during creation of pneumothorax. It can occur through a tear in the vessel in abdominal wall or the peritoneum, inadvertent placement of the Veress needle directly into a vein or parenchymal organ. Because CO2 is soluble in blood, a large amount must enter the vessels rapidly (> 1 lit/minute) before significant CO2 embolism can occur.
Adequate monitoring and a high index of suspicion are required to prevent serious sequelae from CO2 embolism. If it is suspected, CO2 insufflation should be stopped and abdomen is deflated. Patient should be turned to left lateral decubitus with head down position to allow the gas to rise into the apex of the right ventricle and prevent entry into the pulmonary artery. Hyperventilation and administration of 100% oxygen helps in rapid CO2 elimination. Aggressive cardiopulmonary resuscitation and a central venous catheter should be placed to aspirate the gas. Other manoeuvres reported are hyperbaric oxygen and cardiopulmonary bypass.
4. Complications during insertion of primary port
The primary port when inserted by an open technique (Hasson’s) has minimal complications. However, if inserted by a close technique as described initially by McDougall there is a risk of injury to the kidney. Most centres have thus changed to the technique of open insertion of the primary port. Though, we follow closed technique described in other chapter, one has to be very careful especially during retroperitoneoscopy, as there may be injury to the kidney and possibility of peritoneal transgression, which would not allow retroperitoneal space to inflate.
5. Complications during placement of secondary port
The possible complications are :
1.Injury to peritoneum and other viscera
3.Abdominal wall haematoma
4.Tumour seeding of port site
Injury to peritoneum and other viscera
Creating an adequate space in the retroperitoneum by balloon dissection can reduce this complication. The peritoneum sac can be swept further, away from psoas fascia by the tip of the laparoscope inserted through the primary port. An adequate pressure of pneumoperitoneum can also keep the peritoneum away. All secondary ports should be inserted under vision to avoid injury to the peritoneum.
This complication has been reported following inadvertent trocar placement above the 12th rib. Though the condition resolves by intercostals drainage; it prolongs the hospital stay and may predispose to pulmonary complications. So care must be taken to insert all ports below costal margins.
Abdominal wall Haematoma
This can be avoided by keeping in mind the surface anatomy of the well-known vessels while inserting the ports. The bleeding can generally be controlled by a figure of eight stitch through the musculofascial layer at the port site at the time of closure. In case bleeding persists, the skin incision must be extended and the bleeding vessel identified and controlled under vision.
Tumour seeding of port site
Seeding along the tracks of an instrument leading to recurrence of malignancy at the trocar insertion site has been reported.[24-26] Further study is required in this regard before firm conclusion can be drawn.
6. Complications related to dissection
These are :
- Injury to blood vessels.
- Injury to peritoneum and viscera like bowel.
- Injury to other retroperitoneal structures like kidney, ureter and urinary bladder.
- Injury to retroperitoneal nerves.
Bleeding can occur from renal vessels, aberrant renal, gonadal vessels, lumbar vessels, aorta and inferior vena cava during retroperitoneoscopic procedures. Retroperitoneoscopy is contraindicated in patients with portal hypertension as clonic vessels form portocaval anastomosis with lumbar veins in the retroperitoneum. This can be a source of uncontrollable bleeding during retroperitoneal dissection. Injuries to bowel, spleen and pancreas have been reported.[7,27,28] Injury can also occur to kidney or ureter. Injuries to femoral nerve, obturator nerve, ileo-hypogastric nerve and lumbar sympathetic chain have also been reported.[7,29] These injuries may be avoided by performing dissection under vision.
7. Complications of prolonged surgery
- Deep vein thrombosis
- Nerve palsy
- Paralytic ileus
Pneumonitis can be prevented by chest physiotherapy and deep breathing exercises.
Elastic stocking, intermittent calf compression, subcutaneous injection of heparin before and after surgery and early ambulation can prevent deep vein thrombosis. Paying attention to proper positioning of patient and padding the points of compression well can prevent nerve palsy. Paralytic ileus may be due to extensive retroperitoneal dissection, retroperitoneal haematoma, intra-abdominal sepsis and bowel injury. Provided serious complications are ruled out, the condition can be managed conservatively until it resolves spontaneously.
In patients undergoing gastrointestinal and urologic laparoscopic procedures, the incidence of major vascular injuries is approximately 0.03 to 0.06%.30 Postoperative haemorrhage requiring transfusions or reexploration is reported to occur at a rate of approximately 0.5%. The insertion of Veress needle or trocar into major vessels such as the aorta, common iliac vessels or IVC has been reported, therefore extreme caution is required.
These types of complications can be avoided by identification of patients at risk and by strict adherence to basic principles of insertion of the Veress needle and trocar. Open placement of trocar can avoid these injuries. Secondary trocars should be placed under direct vision.
Injury to major vessel can be easily diagnosed by the return of blood from the Veress needle to the trocar, however in some cases the bleeding is concealed and it may present as unexplained hypotension, fall in haematocrit, haematoma formation or excessive postoperative pain.
Most of abdominal wall bleeding resolves with out intervention, but if it persists, haemostasis can be achieved with sutures, ligation, or tamponade with a Foley’s catheter balloon. If the Veress needle or trocar is inadvertently inserted into a major vessel, they should be left in situ and immediate laparotomy should be performed to repair the injury.
These frequently involve the small intestines, colon, duodenum and stomach. The incidence of bowel injuries has been reported to range from 0.06% to 0.4%, with a relatively high mortality rate of 5%.30 The risk factors for bowel injuries are previous abdominal surgery, metastatic disease and gastric distension during anaesthesia. These injuries often are detected later, when the patient presents with peritonitis, sepsis or intraabdominal abscesses. Bowel injury by Veress needle can be managed conservatively. However, bowel injury by the trocar must be repaired either laparoscopically or through a laparotomy.
Urinary tract injuries
The reported incidence is two per 10,000 cases.
Injury to bladder can occur during placement of the Veress needle or the trocar. The risk factors are previous abdominal surgery and the congenital anomaly of the lower urinary tract.
The signs to recognize bladder injuries include the following -
1.Sudden deflation of the abdomen.
2.Carbon dioxide in the urine catheter bag during insufflation.
3.Blood in the urine
4.Postoperatively the amount of urine obtained during catheterisation is less than anticipated.
5.Postoperative presentation may be with peritonitis, azotaemia, ascites and hyponatraemia.
For prevention of bladder injury during laparoscopic surgery the following steps are essential -
1.The bladder should be emptied prior to surgery.
2.Insert all ports under direct vision.
3.Make sure the bladder is not inside the jaws of the laparoscopic stapling device before firing it.
4.Avoid excessive electrocautery around the bladder.
The particular approach to repair bladder injuries is dependent upon whether the injury is thermal or mechanical, whether the injury is at base or dome of the bladder and the proximity of the injury to the trigone and ureteral openings.
Laparoscopic dissection or tissue retraction in the retroperitoneum may result in ureteral injury. When difficult ureteral or retroperitoneal dissection is anticipated, a preplaced ureteral catheter or superstiff guide wire facilitate identification and dissection of the ureter by movement in the retroperitoneum, when the catheter is manipulated at urethral meatus. In addition, indigo carmine solution may be injected retrograde through the catheter to evaluate the integrity of the ureter or upper collecting system. Routine confirmation of the integrity of the lower urinary tract system prior to the conclusion of a very difficult pelvic surgery is crucial in recognizing ureteral injury. Ureteric injury can be repaired laparoscopically and indwelling stent is inserted for [4-6] weeks to assess ureteral healing. If ureteral injury is not recognised intraoperatively, it may present in postoperative period as flank pain, unexplained fever or persistent discharge or leakage from port site. It should be evaluated with intravenous urography or com puted tomography. Retrograde pyelography provides the best details of pelvicalyceal system. It can be managed with double J stenting. However, the presence of urinoma or significant upper tract obstruction may necessitate placement of percutaneous drain or nephrostomy tube. Complete transection or occlusion of ureter may require open surgery.
Closure related complications
Before terminating the laparoscopic procedure, haemostasis must be confirmed at low intra-abdominal CO2 pressure (< 5 mm of Hg) to unmask venous bleeders. All ports must be removed under laparoscopic monitoring. In addition fascial closure of all 10 mm or larger ports mut be performed under direct laparoscopic visualization.
Persistent inordinate abdominal pain is ominous and merits close attention. Computed tomography is useful for evaluating intestinal integrity. The patients with signs of acute peritoneal irritation may warrant laparotomy. Haemorrhage, bowel or ureteral injuries and pancreatitis must be adequately evaluated with appropriate laboratory studies in addition to radiographic imaging.
The postoperative complications are pain, nausea and vomiting, pulmonary impairment, wound infection, peritonitis, delayed haemorrhage, incisional hernia, metastasis at trocar insertion site.
The pulmonary impairment in postoperative period is most likely due to diaphragmatic dysfunction and inadequate pain relief.[34,35] CO2 concentration in the blood returns to the preinsufflation values, after 45 minutes of deflation of the abdomen. Patients with impaired ventilation after anaesthesia or those with significant cardiopulmonary disease therefore can be adversely affected by hypercapnia in the immediate postoperative period.
The lithotomy and the Trendelenburg positions impede blood flow in the lower extremities and result in venous stasis. High intraabdominal pressures (> 20 mm of Hg) can cause compression of the femoral veins and reduce the femoral vein flow velocity, which can increase the potential for deep vein thrombosis and pulmonary embolism.
Wound and peritoneal infections although rare and usually minor, can occur in elderly, obese, diabetic, or immunocompromised patients.
Delayed bleeding from the surgical site can present as prolonged or redeveloping abdominal pain, abdominal distension, falling haematocrit, haemodynamic instability or oliguria. The incisional hernia at trocar insertion site can develop in approximately 0.1% of patients because of inadequate reapproximation of the wound, premature suture disruption or infection. This can be prevented by closure of any access port that is 5 mm or greater in diameter.
COMPLICATIONS RELATED TO SURGICAL APPROACH
Hemal et al in a report of 316 patients reported that minor and major complications occurred in 15.8% and 3.5% of patients respectively. The conversion to open surgery was required in 11.7% of cases.40 The minor complications were peritoneal rent, emphysema, kidney puncture, pleural effusion, retroperitoneal collection, persistent drainage, ileus, port site infection, fever, etc. the major complications were vascular, visceral, collection and hernia in 2.2%, 0.3%, 0.6% and 0.3%, respectively.
Multiple factorial analysis revealed that the extraperitoneal, as compared to the transperitoneal approach, coupled with the presence of subcutaneous emphysema was strongly and independently associated with greater increase in blood CO2 levels. Pneumothorax or pneumomediastinum were significantly more common during extraperitoneal (37%) than transperitoneal (3%) laparoscopy.
Peritoneal tear may occur during insertion of ports or during dissection. Placing the ports under vision and keeping patient in full lateral position to allow peritoneum and bowel to displace from the site of the primary port can avoid it. If a tear does occur, the problem can be managed using a variety of techniques. An intravenous cannula can be inserted into the peritoneum to vent CO2. This helps to increase the retroperitoneal space by reducing intra-peritoneal pressure. The patient is tilted 15° towards the contralateral side and fan retractor is used to retract the peritoneum medially and cover the tear. Another option is to widen the tear to equalize the pressure on the two sides. The other option is to convert to a transperitoneal laparoscopic procedure.
Subcutaneous emphysema can be prevented by avoiding creation of any plane between the skin, subcutaneous tissue and muscle layers, making only a small incision in the thoracolumbar fascia and placing silk sutures through all layers of the abdominal wall to fix the port cannula. The German urological association reported their experience of 482 laparoscopic nephrectomies (344 transperitoneal and 138 retroperitoneal), wherein intraoperative and post-operative complications occurred in 29 (6%) patients, while the conversion rate to open surgery was 10.3% excessive bleeding was the commonest complication (4%), while bowel injury occurred in 3 cases.
Currently available 2 mm instruments and scopes lack the versatality and durability of their conventional laparoscopic counterparts. The instruments are less sturdy and have suboptimal grasping power. The instruments get bent. The image resolution and clarity provided by the needloscope are inferior to that of 5 mm laparoscopes. At present its use is limited to specific surgeries.
COMMENTS ON COMPLICATIONS RELATED TO VARIOUS SURGERIES
Renal laparoscopic surgeries
Laparoscopic deroofing/excision of renal cysts can be accomplished via transperitoneal or retroperitoneal route. The relatively small working space in the retroperitoneoscopic approach may cause difficulty in mobilizing a large kidney for complete deroofing of cyst, especially in adult polycystic kidney disease. The complications are rare. There may be retroperitoneal haematoma, bleeding recurrence of cyst, small bowel obstruction or prolonged ileus. It is easy to handle the posteriorly located peripelvic cyst, but sometimes, multiple cysts present anteromedial near the vessels and may not allow complete decortication of cysts.
The safety and efficacy of donor nephrectomy for the donor and recipient are of utmost concern. The conversion rate reported is 6-13%. The most important reason for conversion is excessive bleeding. The reoperation rate is 1-5% for haemorrhage, small bowel obstruction, internal hernia, splenic injury, retrieval of foreign body and wound neuroma. No significant differences were observed in recipient or allograft survival, rejection episodes or in long term creatinine level when compared with open donor nephrectomy.
In the review of literature, Janetschek et al, has reported that the morbidity of laparoscopic pyeloplasty is low and the results match those of open surgery. The intra-operative complications reported were 3.8 to 15%. The success rate ranged from 80-100%. Authors have done 12 cases and noted one complication in the form of conversion due to technical reasons.
Laparoscopic radical nephrectomy is a rapidly emerging technique for the treatment of renal cell carcinoma and can be performed with acceptable morbidity and mortality. The results of few of the series are shown in Table 2.[47-52] In a multi-institu tional study of 185 patients undergoing transperitoneal laparoscopic nephrectomies 30 (16%) patients had 34 complications. The complication rate following laparoscopic nephrectomy for benign disease and malignancy was 12% and 34% respectively. The incidence of complications decreased with experience, 71% occurred during initial 20 cases at each institution. The complications were access related (2.2%), intraoperative (2.7%), and post-operative (13.5%). The most common access related complication was trocar site hernia formation (2 patients). Intra-operatively vascular injury occurred in 3 cases (1.6%), two of these required emergent conversion to open surgery. Post-operative complications involved gastrointestinal tract (32%), cardiovascular system (3.2%), genitourinary system (2.2%), musculoskeltal system (1.1%) and miscellaneous (1.6%).
Results of radical nephrectomy in the literature
Author Year Total Patients Operative Time
Complications (%) Open Conversation (%) Minor Mejor Transperitoneal Barrett et al 47 1998 72 2.9 - 3 8 8 Ono et al 48 1999 60 5.2 255 5 8 3 Dunn et al49 1999 61 5.5 172 48 5 - Janetschek 50 2000 73 2.4 170 8 4 4 Retroperitoneal Abbou 51 1997 13 2.2 80 8 0 0 Ono 48 1999 14 4.9 285 7 7 0 Gill 32 1999 47 2.9 128 16 5 5
Rassweiller et al53 have reviewed the  patients of laparoscopic partial nephrectomy and reported the mean operating time was 191 minutes and the blood loss ranged from 20 to 1500 ml. Complications occurred in 20% of patients. Bleeding and urinoma occurred in 10% each. Conversion was required in 8% of patient due to bleeding or technical problems in 4% each. Reintervention was reported in 12% of the patients in form of percutaneous drainage, indwelling stent, open vision and nephrectomy.
Shalhav et al reported their results of laparoscopic radical nephroureterectomy in 25 cases. The mean operating time was 7.7 hours, the average blood loss was 199 ml, minor and major complications occurred in 40% and 8% respectively. Three patients had local recurrences.
The major and minor complication rates were 21% and 5% respectively for retroperitoneoscopic nephrectomy for benign disease. In a review of 185 cases of retroperitoneoscopic nephrectomy and nephroureterectomy for benign diseases, authors have reported conversion to open surgery in 18 cases. A total of 37 complications (16.2% were minor and 3.8% were major) occurred. Reintervention was needed in only one patient. There was no mortality. Apart from one incisional hernia, no long-term complication occurred.
Laparoscopic surgeries in renal tuberculosis is challenging due to sever inflammation and fibrosis. The author has modified the technique and places the balloon outside the Gerota’s fascia. This area has few adhesions and vessels are controlled during initial period of dissection. With this technique only 2 minor complications of renal puncture and leakage of caseous material were reported out of 9 cases.
Hemal et al have reported injury to external iliac artery in one patient during retroperitoneoscopic ureterolithotomy. The reasons were dense adhesions and inflammation secondary to previous treatment with shockwave lithotripsy and endoscopic procedure in a patient of horseshoe kidney. scopic ureterolithotomy. The reasons were dense adhesions and inflammation secondary to previous treatment with shockwave lithotripsy and endoscopic procedure in a patient of horseshoe kidney.
Finding the left adrenal gland is difficult, particularly in men, in whom there is more perinephric fat. Starting at left renal vein is good strategy but requires careful dissection near the relatively large renal vein. Intra-operative ultrasound can be helpful for locating the adrenal. A potential pitfall on the right side is finding the adrenal vein. In this case, the surgeon must first establish the location of the right renal vein. It may be necessary to mobilize and lift the liver. Suzuki et al reported 24 (32%) complications in 75 patients of laparoscopic adrenalectomy. Seventy one per cent of complications occurred in the first 25 patients.
The most serious intraoperative complication of retroperitoneoscopic adrenalectomy is vascular damage. There is also risk of damage to organs such as adrenal gland, kidney, liver and pancreas. Dissection should be carried out using clear landmarks, such as Gerota’s fascia, the transverses abdominis muscle, psoas muscle, diaphragm, and renal surface, to avoid major complications. Pneumothorax can be avoided by avoiding direct contact between electrocautery probe or harmonic scalpel and diaphragm. The other complications reported were shoulder pain, paralytic ileus, angina, lung atelectasis, subcutaneous emphysema and retroperitoneal haematoma.
Several factors render surgery for phaeochromocytoma a risky procedure. There may be release of catecholamines and severe hypertensive crisis due to direct manipulation of adrenal gland or direct mechanical pressure of the pneumoperitoneum on the tumour. Appropriate management by an experienced anaesthesiologist is of great importance. In a series of 24 patients of phaeochromocytoma the various complications reported were bleeding from the vena cava in 2 cases, hypertension in 6 cases, pneumonia and chylous ascites in one case.
LAPAROSCOPIC RADICAL PROSTATECTOMY (LRP)
Although a steep learning curve exists for LRP, with experience operative time can be reduced to between 3 and 5 hours. Major intra-operative concerns during LRP are the potential for rectal injury and large blood loss.[64-66] Rectal injury occurs when Denonviller’s fascia is not incised at bladder base but farther on the posterior side and during dissection of the lateral margins of prostate at the apex, where Denonviller’s fascia is near the rectum and the dissection space becomes narrow. The use of intrarectal bougie, manipulated as required by the nurse, may facilitate dissection by better detection of limits of rectal wall. The other injuries are bladder injury at the approach of Retzius space and ureteral injury when it is mistaken for vas deferens. The best way to avoid this complication is to follow vas until the ampulla and seminal vesicles are identified. Obturator nerve injury can occur during lymphadenectomy. The antithrombotic prophylaxis is recommended to prevent post-operative thromboembolic risk.
The surgical margins were positive in 23% of patients. Cadeddu in a review reported that with experienced surgeons, incontinence rates for open radical prostatectomy are better than early results of LRP, but the return of continence is early in the later group. The manoeuvres of preserving the external striated sphincter, its innervation, and fascial attachments are critical for preserving continence. This may be facilitated during LRP by the operative magnifications provided by the endoscope. LRP could provide an advantage in nerve preservation due to better vision and this improves functional results in terms of potency.
Laparoscopic Retroperitoneal lymph node dissection (LRLND)
The long and steep learning curve remains the biggest obstacle in LRLND. In a review of world literature of 154 cases the conversion rate was 5.2%, minor and major complication rate was 7.8% and 0.7% respectively. Antegrade ejaculation was preserved in 98% of patients. The most common complications were injury to vena cava, renal vein and lumbar vein. Other complications were lymphocoeles and chylous ascites.
Female urinary incontinence
Laparoscopic bladder neck suspension is a technically challenging operation with a steep learning curve. These increased demands on the surgeon’s skill and time are not rewarded by an acceptable surgical outcome. The long-term results of the procedure are poor with recurrence of stress urinary incontinence.
Laparoscopic Vesicovaginal fistula repair
There may be loss of pneumoperitoneum from vaginal opening during laparoscopic dissection and requires conversion to open surgery.
Laparoscopic bowel surgeries
Laparoscopic bladder augmentation is a long and challenging operation. The complications reported are bleeding or urine leak.
Fingenshau et al a series of 134 paediatric patients, who underwent laparoscopic nephrectomy and nephroureterectomy reported complication rate of 5%. Only 2 cases were converted to open nephrectomy, one for vena cava injury and another for camera failure. Minor intra-operative complications reported at the rate of 4% and included splenic laceration and trocar injury to dilated renal pelvis.
PREVENTION OF COMPLICATIONS
Thorough preoperative evaluation of cardiopulmonary status is essential. Impaired cardiopulmonary function predispose to fluid overload and CO2 retention. Patient positioning is of critical importance to prevent postoperative neurological sequelae. All body prominences should be adequately padded. The open (Hasson) approach is preferable in patients with a history of multiple prior surgeries. All secondary trocars should be placed under laparoscopic visualization.
The insensible fluid losses and 3rd spacing are minimal during laparoscopic as compared to open surgery. Furthermore, prolonged, massive increase of intra-abdominal pressure during pneumoperitoneum causes oligoanuria. Accordingly, fluid requirements during prolonged laparoscopic procedures are minimal. Failure to limit intra-operative fluid administration may result in post-operative congestive heart failure.
Intraoperative dissection injuries occur due to mechanical or thermal trauma. Renal hilar dissection must be meticulous. The renal artery and vein should be mobilized separately and a 360° window created around these blood vessels before applying clips or staples. While in experienced hands, a bleeding vessel may be controlled laparoscopically; prompt conversion to open surgery should be done by those less experienced. Occasionally thermal injury may occur to the intestines or the ureters. Avoid indiscriminate electrocautery in the vicinity of these structures. Typically an unrecognised thermal injury to the ureter or bowel presents in a delayed fashion with urinary or faecal leakage.
GENERAL PRINCIPLES OF SAFE LAPAROSCOPY
Besides the various specific measures suggested above for prevention of complications at each step of laparoscopy, certain general principles should be followed for safe surgery. There are 5 areas that deserve attention.
1. Patient selection and preparation
Absolute contraindications for laparoscopy are
- Uncorrected coagulopathy
- Active retroperitoneal infection
- Abdominal aortic aneurysm
- Abdominal wall infection
Relative contraindications are
- Severe pulmonary or cardiovascular disease
- Portal hypertension
- Morbid obesity
- Massive ascites
- Extensive previous surgeries
- Severe inflammatory diseases of the kidney like xanthogranulomatous pyelonephritis
- Severe traumatic injuries of kidney and ureter
Adequate blood should be arranged and operation theatre should be suitable for open surgery in case conversion is required. Surgeon should be comfortable with open procedure in such an eventuality.
All procedures must be done under intubated anaesthesia. Stomach must be decompressed by nasogastric tube to reduce intra-abdominal pressure and also to reduce risk of gastric injury. End tidal carbon dioxide should be monitored in all cases to detect any instance of hypercapnia or air embolism. Attention should be given to fluid balance during the procedure.
3. Patient positioning
Attention should be given to patient positioning as many of these procedures extend over long duration. Bony points must be well padded. Compression must be avoided on the legs and calf to prevent deep vein thrombosis.
4. Surgical technique
Safe surgical technique requires the following :
To avoid electrocautery injury following guidelines should be followed -
1.Inspect the insulation for the defect
2.Use the lowest power setting that achieves the desired results
3.Use brief activation versus prolonged activation
4.Avoid metal to metal sparking
5. The entire non-insulated portion of the instrument should be under vision when electrocautery is activated.
6.Do not activate the electrode until it is touching or is in close proximity to the target tissue.
7.Use bipolar electrocautery when appropriate.
5. Proper training of the surgical team
Laparoscopy is teamwork. Assistant has a very important role to play and he is the active member of the operating team. He has to anticipate the surgeon’s movement and direct the laparoscope accordingly. Thus not only the surgeon but the assistant should be adequately trained.
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