General risks due to pneumoperitoneum and adhesiolysis, if necessary: Injuries to vessels and hollow organs are possible during the blind puncture with the Veress needle as well as with the optical trocar. However, the optical trocar should be preferred for previously operated patients with prior abdominal surgery.
During adhesiolysis, thermal injury to the intestinal wall must be kept in mind and definitively ruled out for certain.
If laparoscopic visualisation is not possible, immediately convert to open surgery.
Place additional working trocars under visualisation to avoid intraabdominal injuries.
Bleeding:
- Watch out for epigastric vessels; bleeding from the trocar insertion sites is preferentially treated with U sutures-stitches, using suture aids for fascial closure devices.
- Bleeding from the staples line → suture ligation or clips
- Bleeding from retroperitoneal vessels (vena cava or aorta)
- Bleeding from the omentum
- If laparoscopic visualisation is not possible, immediately convert to open surgery. Adhesions increase the risk of injury to retroperitoneal vessels.
Injury to adjacent organs:
- Spleen: Compression, hemostyptics, thermal procedures, as a last resort → splenectomy
- Tears of the liver parenchyma caused by the retractor → hemostasis with monopolar current, compression, hemostyptics
- Injury to the pancreas → oversewing, targeted drainage
- Injury to the esophagus caused by the large-caliber gastric tube: Endoscopic procedure intervention with Endo-Clips in combination with injection of epinephrine.
Too short alimentary loop:
Not expected as a result of the pouch shape that is similar to a sleeve gastrectomy due to the primarily sleeve-like shape of the gastric pouch, retrocolic elevation reconstruction if necessary.
Loop rotation:
To avoid loop rotation (“blue loop syndrome”), guide the loop under visualization direct view (the mesentery points to the left). If a rotation still occurs, it is lifted and corrected. If the loop is rotated nevertheless, correct and refashion the anastomosis.