Complications of Gynecologic Laparoscopic Surgery
Sep 2009 – by R. Schenken, MD
Complications of laparoscopy in gynecologic patients are reported to occur in 0.1 to 10 percent of all cases.1 Over one-half of these occur at entry in to the abdominal cavity. Approximately one-fourth of all injuries and one-half of bowel injuries are recognized postoperatively.2 Risk factors include prior abdominal surgery, endometriosis, pelvic infection, bowel distention, large pelvic masses, adhesions, cardiopulmonary disease and diaphragmatic hernias.
Complications related to pneumoperitoneum include extra-peritoneal gas insufflation, mediastinal and omental emphysema, and pneumothorax. Extraperitoneal insufflation requires evacuation of as much gas as possible and replacement of the insufflation needle or resorting to an open technique. Mediastinal emphysema and pneumothorax may occur even with excessive insufflations and ventilation pressures or with direct insertion through the pleura. This may result in cardiac embarrassment. The gas should be evacuated and the laparoscopy abandoned with close observation of the patient until the gas has been absorbed. Pneumothorax may require placement of a chest tube and assisted ventilation. Omental emphysema usually resolves spontaneously. Gas embolism from direct vessel insufflations and cardiac arrhythmia from excessive absorption of CO2 are rare, but potentially fatal.
The reported incidence of vascular injuries is 0.1 to 6.4 per 1000 laparoscopies.3 Injuries may involve vessels in the abdominal wall, omentum, mesenteric vessels, middle sacral artery, iliac artery and vein, vena cava and aorta. Several techniques are available to suture abdominal wall vessels such as the inferior epigastric which is the most common vessel injury during placement of lateral trocars. Cauterization of these vessels is usually ineffective. Delayed bleeding from trocar sites occasionally occurs because the trocar itself and the pneumoperitoneum may tamponade the vessel during the procedure. Clinically stable ecchymoses and hematomas may be observed, but expanding hematomas require exploration and suture ligation. Minimal bleeding from omental and pelvic vessels may be controlled with fulguration or suturing. Injury to major vessels may be avoided by midline insertion through the umbilicus at a 45 degree angle while lifting the abdominal wall and direct visualization of lateral trocar placement. Major vascular trauma requires immediate removal of the insufflations needle or trocar to avoid further tearing of the vessel and immediate laparotomy to control hemorrhaging. Damage to major vessels requires repair by a vascular surgeon.
Gastrointestinal tract injuries may involve the stomach, and small or large intestines. They may be caused by the insufflations needle, trocars, cautery, and other laparoscopic instruments. Perforation of the stomach may occur with an upper abdominal or umbilical site insertion especially when a nasogastric tube has not been used to decompress the stomach. No surgical treatment is necessary if the stomach has not been torn. Otherwise the injury requires surgical repair by laparoscopy or laparotomy with postoperative antibiotics and nasogastric suction. Bowel injury is a more serious complication because they are often missed intraoperatively and a delayed diagnosis increases the risk of peritonitis and death. This is especially true for thermal injuries that may not result in perforation for several days. Bowel injury should be suspected when the patient's postoperative discomfort doesn't steadily improve, especially in the presence of fever, tachycardia, and absence of flatus. Free intra-abdominal air is present in a large percentage of patients after laparoscopy and may persist for up to a week postoperatively; therefore it alone is not a helpful radiographic sign to make an early diagnosis of bowel perforation. Repeat laparoscopy or laparotomy should be considered when there is a suspected bowel injury.
Urinary tract injury usually occurs to the bladder with the insufflations needle, secondary trocars, laparoscopic hysterectomy, and resection of endometriosis. Routine drainage of the bladder should avoid most needle and trocar injuries. Signs of a bladder injury include blood and gas in the Foley bag and injuries may be confirmed by retrograde filling of the bladder with dye. Punctures by the insufflation needle only require bladder drainage with an indwelling catheter. Larger injuries require suturing that can be accomplished laparoscopically. Thermal and mechanical ureteral injuries usually occur during laparoscopic hysterectomy or treatment of endometriosis. Identification of the ureter is the primary means of preventing damage. Intravenous dye may be necessary to confirm the injury. Mobilization and repair are usually required. Resection of thermal injuries and reimplantation may be necessary.
The incidence of trocar site bowel herniation is .02 percent.4 The use of trocars larger than 10 mm at extra-umbilical site increases the risk and fascial closure is recommended. However, herniation may still occur despite attempts to close the fascia at the original surgery.5 (34). Symptoms include the presence of a bulge that may be painful, nausea, vomiting, and abdominal distention. Treatment is surgical correction of the defect.
- Magrina JF. Complications of laparoscopic surgery. Clin Obstet Gynecol 2002; 45:469.
- Chandler JG, Corson SL, Way LW. Three Spectra of Laparoscopic Entry Access Injuries. American College of Surgeons 2001; 192: 478.
- Shirk GJ, Johns A, Redwine DB. Complications of laparoscopic surgery: How to avoid theman and how to repair them. J Minim Invasive Gynecol 2006; 13:352.
- Montz FJ, Holschneider CH, Munro MG. Incisional hernia following laparoscopy: a survey of the American Association of Gynecologic Laparoscopists. Obstet Gynecol 1994; 84: 881.
- Boike GM, Miller CE, Spirtos NM, et al. Incisional bowel herniations after operative laparoscopy: a series of nineteen cases and review of the literature. Am J Obstet Gynecol 1995; 172:1726.