- 1.1 Position-induced complications
To improve organ exposure in laparoscopic surgery, patients are often brought into extreme positions which may compromise long superficial nerves. Nerves particularly at risk include:
- Peroneal nerve
- Femoral nerve
- Ulnar nerve
- Brachial plexus
Prevention
- Padded shoulder rests if Trendelenburg position is expected
- In lithotomy position, the stirrups at the level of the head of the fibula should be padded with additional gel cushions
- When the arms are adducted, the elbow areas should be positioned on additional padding and loosely secured to the body pronated
- Abducted arms should always be positioned on padded supports and never abducted beyond 90°
1.2 Complications from trocar insertion
Insertion of the trocars, especially the first trocar, may result in injury to hollow viscera and vessels, which in many cases, requires rapid conversion to laparotomy for safe assessment and management of the injury. While it should be possible to manage accidental bowel injury laparoscopically, the possibility of other intraabdominal injuries not apparent at first glance must also be considered.
1.3 Pneumoperitoneum-induced complications
Pneumoperitoneum may trigger a variety of pathologic changes in hemodynamics, the lungs, kidneys, and endocrine organs. Depending on the intraabdominal pressure, type of anesthesia, ventilation technique, and underlying disease, the following severe complications may arise:
Cardiovascular complications
- Arrhythmia
- Cardiac arrest
- Pneumopericardium
- Hypotension/hypertension
Pulmonary complications
- Pulmonary edema
- Atelectasis
- Air embolism
- Barotrauma
- Hypoxemia
- Pneumothorax/pneumomediastinum
Immediate action
- Deflate the pneumoperitoneum
- If the anesthesiologist cannot manage the complication, consider conversion to open surgery or terminate the operation
Extreme subcutaneous emphysema
Up to 3% of all laparoscopies are complicated by collar skin emphysema; if left untreated it may threaten compression of the airways with secondary pneumothorax and pneumomediastinum and require CO2 deflation via a collar incision. If CO2 pneumothorax does not result in ventilation problems, watchful waiting is one possible option because the CO2 within the chest is rapidly absorbed. A chest tube is indicated in ventilation problems or extensive pneumothorax. Due to their flaccid tissue, elderly patients are particularly at risk.
1.4. Organ specific complications
Staple line failure
Positive leak test: if the leak is small and easily accessible, oversew it and consider a diverting ileostomy. When in doubt, refashion the anastomosis.
Organ injury
- Splenic injury: Bipolar RF coagulation: if necessary, apply hemostyptic agent or fibrin sealant. Laparotomy is needed only in exceptional cases.
- Pancreatic injury: In case of bleeding, proceed akin to injuries to the spleen. In this case it may be advisable to place a drain to evacuate secretions from any pancreatic fistula.
- Intestinal/duodenal injury: With adequate expertise, laparoscopic suturing is possible.
- Thermal damage from bipolar scissors or ultrasonic dissector
- Vascular injury: Most bleeding from smaller vessels can be stopped by bipolar energy devices or ultrasonic scissors and, if necessary, by clipping.
Injury to one of the large vessels (e.g., aorta, vena cava) mandates immediate laparotomy. - Ureteral injury In case of partial transection, laparoscopic suturing is an option; otherwise conversion to laparotomy and open ureteral repair. Such injuries always require ureteral double-J splinting.
- Vaginal injury: Iatrogenic trapping of the vagina when closing the stapler may result in rectovaginal fistula.