{"paper_id":"ee340266-f552-403b-a5e0-ed1e6f41611e","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nAs the number of endoscopic procedures has increased \ntremendously over the years, several different complications may \narise affecting different systems. More than approximately half of \nthese complications occur during entry; while the rest occurs during \nor after the operation. The majority of studies related to this subject \nrevealed that the rate of complications decrease by increasing surgical \nexperience.1,2 Complications are generally classified as; entry stage, \nintra‒operative or post‒operative complications.\nComplications during the entry stage\nMore than half of laparoscopic complications obviously occur \nduring the entry stage. As the entry is a relatively blind procedure, it \nalso brings severe risks along. Complications with respect to the entry \ntechnique occur in approximately 0.3‒1% of the entire laparoscopic \nprocedures and the rate of mortality is approximately 7 in 1,00,000.3,4 \nAt this stage, especially vascular, urinary and intestinal‒gastric \ninjuries can be observed. Primarily, 3 entry techniques are used for \ndiagnostic or operative laparoscopic procedures; entry following CO2 \ninsufflation with Verres needle (closed), direct trocar entry and open \nHasson’s technique. All techniques have their own advantages and also \nseveral different risks for each of these entries are obviously available. \nAt this stage, proper elevation of the abdominal wall is of importance \nto preclude complications. In order to elevate the abdominal wall, \nmanual elevation (Figure 1A), elevation from umbilical edges with \nclamps (Figure 1B) and elevation from 2 cm lateral to the umbilicus \nwith clamps (Figure 1C) are frequently used. It was reported that the \nmethod clearing the distance between the abdominal wall and viscera \namong these 3 methods is the method of elevation from umbilical \nedges with clamps.5\nWhen this method is used, the distance between the needle and \nviscera is approximately 6.8cm and the force applied while inserting \ntrocar does not change this distance. However, the distance becomes \nless by manual elevation or laterally 2 cm elevation with clamps.6\nThere are several methods available to predict whether the Verres \nneedle is properly inserted into the abdominal cavity or not (Figure \n2A & 2B):\nPrevious studies reported that the abdomen was penetrated by a \nsuccess of 85% on the first trial of Verres needle insertion and 2 or \nmore trials are needed for approximately 8% of the cases. 7 The rate \nof complication was 0.8% on the first trial; this rate was determined \nas 44% on the third trial and as 84.6% on more trials. If the abdomen \nis unable to be successfully penetrated on 3 trials by Verres needle, \nalternative entries must be considered because of the prediction that a \nprominent increase will be among complication risks.\nIn cases with the doubt of technical difficulty, entry can be carried \nout on the mid‒clavicular line called Palmer’s point, approximately \n3cm inferior to the left costa; possible several injuries may be \nprevented by using this localization. Palmer’s point can be used for \npenetrating with Verres needle in cases with especially the presence of \nadhesion, previous hernia repair, obesity, abdominal wall relaxation, \nthe presence of a large mass and pregnancy. Despite the measures \ncounted, various injuries may be observed during entry. Intestinal \nand retroperitoneal vascular injuries constitute the majority of \ncomplications observed during entry. Following the entry procedure, \ninjury regions according to the percentage of frequency can be \ncounted as: small intestine (25%), iliac artery (19%), colon (12%), \niliac or other retroperitoneal veins (9%), mesenteric artery (7%), aorta \n(6%), vena cava inferior (4%), abdominal wall arteries (4%), bladder \n(3%) and liver (2%).8\nFigure 1A Manual elevation of abdominal wall.\nObstet Gynecol Int J. 2016;4(1):7‒10. 7\n©2016 Pabuccu. This is an open access article distributed under the terms of the Creative Commons Attribution License , which \npermits unrestrited use, distribution, and build upon your work non-commercially.\nLaparoscopic complications of gynecologic \nprocedures\nVolume 4 Issue 1 - 2016\nEmre Goksan Pabuccu\nDepartment of Obstetrics and Gynecology, Ufuk University \nSchool of Medicine, T urkey\nCorrespondence: Emre Goksan Pabuccu, Department of \nObstetrics and Gynecology, Ufuk University School of Medicine, \nMevlana Bulvar No 86, Ankara, T urkey, T el 90-312-204-4000, \n+90-532-414-7844, Email \nReceived: August 19, 2015 | Published: January 09, 2016\nAbstract\nComplications of gynecologic laparoscopic procedures are relatively uncommon but may \nbe devastating. These complications occur approximately in 5 per 1000 procedures and \nmajority of them are encountered during the entry stage of the surgery. Vascular structures, \ngastro‒intestinal organs and urinary tract are the most common affected sites. There are \nseveral patients and surgeon related factors that might influence complications, however in \nthe presence of adequate expertise, most of these complications can be avoided. Not only \nprevention, but also early detection is of importance during laparoscopic procedures.\nKeywords: laparoscopy, gynecology, complication\nObstetrics & Gynecology International Journal\nMini Review\n Open Access\n\n\nLaparoscopic complications of gynecologic procedures\n8\nCopyright:\n©2016 Pabuccu\nCitation: Pabuccu EG. Laparoscopic complications of gynecologic procedures. Obstet Gynecol Int J. 2016;4(1):7‒10. DOI: 10.15406/ogij.2016.04.00092\nFigure 1B Elevation from umbilical edges with clamps.\nFigure 1C Elevation from 2cm lateral to the umbilicus with clamps.\ni. Double ‘click’ sound while penetrating.\nii. Aspiration test with injector after penetrating with Verres needle.\niii. Negative pressure test applied by 1 drop of isotonic into the posterior \nlumen of the Verres needle after entry (Figure 2A).\niv. Insufflation pressure <8 mmHg and easy gas flow.\nv. Following gas flow, receiving tympanic sound by infra-hepatic percussion \n(Figure 2B).\nFigure 2A Negative pressure test applied by 1 drop of isotonic into the \nposterior lumen of the Verres needle after entry.\nFigure 2B Gas flow, receiving tympanic sound by infra-hepatic percussion.\nFigure 3 The most appropriate region in many cases is 1.25cm superior or \ninferior to the imaginary line from the iliac eminentia.\nAs well as being the rarest, major vascular complications occurring \nafter closed or direct trocar entry are observed in approximately \n0.04‒0.1% of laparoscopic procedures. 9,10 Despite low prevalance, \nthe rate of mortality is 9‒17% in the presence of major vascular \ncomplications.3 These injuries, which can generally occur during the \nentry by Verres needle or large trocar are observed in the 2nd or 3rd \ntrial following unsuccessful intervention.8 Abundant bleeding behind \nthe needle after Verres needle entry is probably due to major vascular \ntrauma. In this case, performing emergency laparotomy without \ndislocating the needle, efficient buffering and requesting immediate \ncardiovascular surgery consultation is crucial.\nDuring laparoscopic entry, gastrointestinal system injuries may \nalso be observed (0.06%).11. The risk increases even more, especially \nwith a peritonitis history or the presence of an adhesion. Cruise of \nfilling pressure above 8‒10 mmHg, asymmetric distention of the \nperitoneal cavity, observing gastric or intestinal content from Verres \nlumen are likely associated with intestinal injury. Small Verres injuries \nmay sometimes be managed by follow‒up only; however, if the lesion \nis large or occurs following direct trocar entry, a surgical method may \nbe required. Large gastrointestinal injuries may result in diffuse intra‒\nabdominal infection and sepsis, as delayed diagnosis contributes \nto morbidity and mortality prominently. Half of the entry‒related \nintestinal injuries show signs at least after 24 hours. 11 Generally, \nlaparotomic approach is adopted in the management of these cases \n(63%); mortality may occur in approximately 5% despite efficient \n\n\nLaparoscopic complications of gynecologic procedures\n9\nCopyright:\n©2016 Pabuccu\nCitation: Pabuccu EG. Laparoscopic complications of gynecologic procedures. Obstet Gynecol Int J. 2016;4(1):7‒10. DOI: 10.15406/ogij.2016.04.00092\nfollow‒up and therapy.3,4 According to the degree of injury, primary \nrepair, segmental resection‒anastomosis or colostomy procedures \nmay be required.\nT able 1 Comparison of benefits\n Sensitivity \n%\nSpecificity \n%\nPositive \npredictive \nvalue %\nnegative \npredictive \nvalue %\nDouble Click \nT est 39 69 19 86\nAspiration T est 0 98 0 83\nDrop T est 16 89 22 85\nIntraabdominal \nPressure <10 \nmmHg\n79 63 32 93\nComplications during operation\nSeveral complications may also be encountered following \nlaparoscopic penetration. These may be as follows: vascular, \ngastrointestinal, urinary injuries or injuries of some systems based \non the usage of thermal energy. Vascular injuries are generally minor \nwhich are likely to be observed during trocar insertions and are \ngenerally avoided by using the transluminance technique. However, \nlarge vascular injuries may also be encountered during large or lateral \ntrocar penetrations.\nMajor Vascular Injuries: Despite low prevalence (0.04‒0.5%), \napproximately 20% of the cases may result in mortality. 12 The \nmost common injury sites during an operation are aorta, vena cava \nand iliac arteries. There are several risk factors contributing to the \ncomplications. In the report of Baggish et al. 13 majority of the cases \n(71%) where major vascular complications were encountered was \noverweight or obese patients. 13 Furthermore, inadequate surgical \nexperience and inappropriate patient positioning may also contribute \nto increased complication rates. It is crucial to determine the site of \nthe aortic bifurcation conjecturally before starting the procedure. \nThis region may not always be palpated or detected according to \nthe umbilicus. The most appropriate region in many cases is 1.25cm \nsuperior or inferior to the imaginary line from the iliac eminentia \n(Figure 3).\nMajor Intra‒operative vascular injuries are frequently observed in \nmore complicated procedures and in cases with adhesion formation. \nSuch procedures as lymph node and retroperitoneum dissections or \nsacral colpo‒pexia procedure are relatively risky due to anatomic \nlocalizations. Sudden and major bleeding following penetration \nwith Verres needle/trocar or intra‒abdominal growing hematoma \nespecially in the retroperitoneal region following thermal energy \nusage is most likely to be due to a major injury. According to the \ninjury site and dimension, laparoscopic repair may be preferred \nmostly depending on surgical experience. If there is a suspicion of \ninjury during penetration, reaching the injury site through midline \nlaparotomy and planning repair without removing trocar is a more \nappropriate approach; because it will be more difficult to reach the \nrepair area by abundant bleeding when trocar is removed (Table 1).\nIntestinal injuries:  The incidence of intestinal injuries is \napproximately 0.5% and near one half of these complications occur \nintra‒operatively.14 Small intestine and colon (recto‒sigmoid) are \nthe most frequent regions of injury mostly due to inappropriate use \nof the thermal energy. Because the injuries during the operation are \ngenerally not recognized, a delay in diagnoses generally contributes \nto peritonitis, severe intra‒abdominal infections and sepsis. Typically, \nthe most frequent reason of laparoscopy‒related mortalities is \naccepted as intestinal injuries due to delayed diagnosis. 15,16 The most \npredictive factors in these complications are: technical difficulty of the \nsurgical procedure, condition of the case and surgeon’s experience. In \nthe review of Brosens & Gordon.17 it was reported that the reliability \nof surgeon increases where complications decrease as a consequence \nof performing 100 laparoscopic procedures yearly.17\nAspiration of the intestinal content from Verres needle, smelling \nfaecaloid from trocar areas or notable faecaloid coming from trocar \nis apparent signs of an injury. Intra‒abdominal pressure during \npenetration to be between 8 and 10 mmHg may also be an indirect \nindicator. If rectosigmoid injury is suspected during the operation, \nintestinal integrity may be tested. In this test, after pelvis is filled \nwith isotonic, air is given into rectum by 60 ml catheter type injector. \nAlso the proximal sigmoid colon is compressed laparoscopically and \nobserved whether there is an air bubble on behalf of a possible leakage \nin the rectum. However, the injury may not always be determined \nclearly and morbidites may be observed due to delayed diagnosis. \nClinical findings are generally nonspecific in the postoperative period \nand may be presented as mild abdominal pain, subfebrile fever, and \nnausea. However, the overall diagnosis time of occult injuries range \nbetween 1‒21 days.\nUrinary injuries:  The incidence of urinary injuries during \nlaparoscopic procedures is approximately 0.2% and this rate is very \nsimilar with that of observed in laparotomic procedures. Mainly, ureter \nand bladder injuries may occur. In order to avoid these complications, \nit is crucial to clarify the pelvic anatomy, especially the trace of ureter \nin the pelvis. In laparoscopic procedures, the bladder is most likely to \nget injured and these injuries are recognized more rapidly compared \nto ureter injuries.18 Previous pelvic surgeries, infections, the presence \nof endometriosis, pelvic tumors and all kinds of factors impairing \nanatomical integrity may contribute to iatrogenic ureter injuries.\nUreter is one of the common sites of laparoscopic complications. \nBecause of increasing numbers of laparoscopic hysterectomy \nprocedures, ureter injuries are encountered more often when compared \nto abdominal hysterectomies. Ureter injury risk is determined as \n2.6‒35 times higher with laparoscopic hysterectomy compared to \nlaparotomy.19 The part, which is adjacent to the infindibulo‒pelvic \nligament in the pelvic inlet of the ureter, is the common injury \nsite especially in laparoscopic‒assisted vaginal hysterectomy \noperations.16 Injuries are generally secondary to thermal energy \nrelated transsection, ligation, retraction, contusion, devascularization \nand are frequently not noticed. Patients may apply within the first 3 \ndays due to injury‒induced symptoms and sometimes it takes couple \nof weeks after the operation. The majority of injuries (70%) are \ndetected in the postoperative period; however 20% of these injuries \nmay not be recognized.\nBladder injuries are generally observed during suprapubic trocar \npenetration, in the bladder dissection or as a result of excessive thermal \nenergy use. However, as the majority of these injuries are detected \nduring the operation (90%), morbidity rates are low. In suspicious \ncases, the bladder can be filled with methylene blue and the presence \nof leakage could be examined. In the presence of an injury, observation \nwithout any intervention or primary repair can be considered. In small \ninjuries, repair with single‒layer 2/0‒3/0 absorbable sutures along \nwith continuous urine drainage (7‒10 days) is generally adequate. \nEspecially in larger injuries (>1cm) or in thermal energy injuries, 2‒\nlayer repair is suggested.19\n\nLaparoscopic complications of gynecologic procedures\n10\nCopyright:\n©2016 Pabuccu\nCitation: Pabuccu EG. Laparoscopic complications of gynecologic procedures. Obstet Gynecol Int J. 2016;4(1):7‒10. DOI: 10.15406/ogij.2016.04.00092\nPostoperative complications\nHernia formation in trocar region: When compared to laparatomic \nsurgery, one of the most significant advantages of laparoscopy is to \nenable decrease in postoperative hernia formation. The incidence is \nbetween 0.06 and 1% and this rate is approximately 10‒100 times \nlower when compared with laparotomy. 14 This complication is due \nto improper and inadequate closure of trocar penetration sites and is \nsomehow preventable. Hernia formation generally occurs in trocar \ninlets that are larger than 5 cm, however they may also be observed \nin small trocar sites. Small intestine, rarely colon and omentum are \nfound as content in hernias that are observed in extraumbilical regions \nwhere a large trocar is used. Especially in undetected hernias, the risk \nfor intestinal incarceration may be as high as 20%.20 In order to avoid \nhernia formation, using 10 mm trocar instead of 12mm, preferring \nthose with blunt‒conic tip instead of sharp tip, repairing fascias, \nremoving small trocars in guidance of a camera, and closing the valve \nmechanism while removing are recommended. Hernia repairs are \ngenerally performed laparotomically; however, laparoscopy may also \nbe used.\nConclusion\nAs a result of increasing request for minimal invasive procedures, \na growing number of laparoscopic procedures are carried out today. \nThe essential principle should be to increase the expertise in order \nto protect from these complications. This can also be possible by \nassistant training programs and post‒graduate courses. In this context, \nusing and promoting simulators for training can be attributed as a \nsimple but effective step for laparoscopic experience.\nAcknowledgments \nNone.\nConflicts of interest \nThe authors declare there is no conflict of interests. \nFunding\nNone.\nReferences\n1. Magrina JF. Complications of laparoscopic surgery. Clin Obstet \nGynecol. 2002;45(2):469‒480.\n2. Makai G, Isaacson K. Complications of gynecologic laparoscopy. Clin \nObstet Gynecol. 2009;52(3):401‒411.\n3. Lehmann‒Willenbrock E, Riedel HH, Mecke H, et al. Pelviscopy/\nlaparoscopy and its complications in Germany, 1949‒1988. J Reprod \nMed. 1992;37(8):671‒677.\n4. Hulka J, Peterson HB, Phillips JM, et al. Operative laparoscopy: \nAmerican Association of Gynecologic Laparoscopists’ 1993 membership \nsurvey. J Am Assoc Gynecol Laparosc. 1995;2(2):133‒136.\n5. Roy GM, Bazzurini L, Solima E, et al. Safe technique for laparoscopic \nentry into the abdominal cavity. J Am Assoc Gynecol Laparosc . \n2001;8(4):519‒528.\n6. Teoh B, Sen R, Abbott J. An evaluation of four tests used to ascertain \nVeres needle placement at closed laparoscopy. J Minim Invasive \nGynecol. 2005;12(2):153‒158.\n7. Sogc Clinical Practice Guideline. Laparoscopic Entry Review of \nTechnique, Technologies and Complications. 2007;No:193.\n8. Yuzpe AA. Pneumoperitoneum needle and trocar injuries in laparoscopy. \nA survey on possible contributing factors and prevention. J Reprod Med. \n1990;35(5):485‒490.\n9. Hashizume M, Sugimachi K. Needle and trocar injury during \nlaparoscopic surgery in Japan. Surg Endosc. 1997;11(12):1198‒1201.\n10. Hasson HM. A modified instrument and method for laparoscopy. Am J \nObstet Gynecol. 1971;110(6):886‒887.\n11. Chandler JG, Corson SL, Way LW. Three spectra of laparoscopic entry \naccess injuries. J Am Coll Surg. 2001;192(4): 478‒490.\n12. Tarik A, Fehmi C. Complications of gynaecological laparoscopy—a \nretrospective analysis of 3572 cases from a single institute. J Obstet \nGynaecol. 2004;24(7):813‒816.\n13. Baggish MS. Analysis of 31 cases of major‒vessel injury associated with \ngynecologic laparoscopic operations. J Gynecol Surg. 2003;19(2):63‒73.\n14. Chapron C, Pierre F, Harchaoui Y , et al. Gastrointestinal injuries during \ngynaecological laparoscopy. Hum Reprod. 1999;14(2):333‒337.\n15. Crist DW, Gadacz TR. Complications of laparoscopic surgery. Surg Clin \nNorth Am. 1993;73(2):265‒289.\n16. Peterson HB, Hulka JF, Phillips JM. American Association of \nGynecologic Laparoscopists’ 1988 membership survey on operative \nlaparoscopy. J Reprod Med. 1990;35(6):587‒589.\n17. Brosens I, Godron. A Bowel injuries during gynaecological laparoscopy: \na multinational survey. Gynaecol Endosc. 2001;10(3):141‒145.\n18. Hasson HM, Parker WH. Prevention and management of urinary \ntract injury in laparoscopic surgery. J Am Assoc Gynecol Laparosc . \n1998;5(2):99‒114.\n19. Härkki‒Siren P, Sjoberg J, Kurki T. Major complications of laparoscopy: \nA follow‒up Finnish study. Obstet Gynecol. 1999;94(1):94‒98.\n20. Berker B, Taskın S, Taskın E. Complications of Laparoscopic \nGynecologic Surgery. In: Michael S, editors. Prevention and \nManagement of Laparoendoscopic Surgical Complications. 3rd edn. \nSociety of Laparoendoscopic Surgeons, USA; 2012.","source_license":"CC0","license_restricted":false}