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Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Thomas Eakins. The Agnew Clinic, 1889
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
… why laparoscopy?
• Better recovery
• Shorter hospital stay
• Less post-operative pain
• Lower blood loss
• “Scarless surgery”
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Modified lithotomy position, with legs placed in the padded adjustable
stirrups and intermittent pneumatic compression system
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Surgeon: left side of the patient
First assistant: right side of the
patient
(Second assistant: between the legs
to use the manipulator)
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
1. Immobilize the umbilical area (our school uses two small towel clips
on the lateral margins of the peri-umbilical area)
2. Peri-umbilical incision of 10 mm (our school uses horizontal incision
at the inferior border of the umbilical ring)
3. Grasp the shaft of the Veress needle
like a dart and gently pass the needle
into the incision and reach the fascia.
Afterwards, lift abdominal wall below
the umbilicus and gently pass the
Veress needle at 45-degree caudal
angle. We use to lift the umbilical area
with the two small towel clips and then
go perpendicular.
Let’s enter into the abdomen in 10 steps:
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
5. Saline test (withdraw, instill,
withdraw). If no fluid, blood or feces
came out, you are in the right place.
6. Ask for insufflation: a pressure
below 6-7 mmHg is ok! You are inside
the peritoneum!
7. Wait until the intra-abdominal
pressure will be AT LEAST 10-15
mmHg (RCOG guidelines: 20-25
mmHg). Start with 1 L/min and then
you may increase the flow.
4. Two clicks: the first one will be the piercing of the fascia, the
second one of the peritoneum.
Let’s enter into the abdomen in 10 steps:
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
8. Insert the optical trocar through the umbilical incision and hear the
CO2 flow
Abdominal pressure= 8mmHg Abdominal pressure=25mmHg
9. Insert the laparoscope and ask for Trendelenburg.
10. Welcome to the abdominal cavity!
Let’s enter into the abdomen in 10 steps:
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Suprapubic trocar: 3-4 cm above
the symphysis pubis
Lateral trocars: 3 cm medial to
each anterior superior iliac spine
Inf epigastric
Ancillary trocars (under vision!)
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Complications (and how to manage them!)
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
• Vascular injury
• Bowel injury
• Urinary tract injury
• Incisional hernia
• Gas embolism
• Shoulder pain
• Pneumothorax
• Subcutaneous and pre-
peritoneal emphysema
• Cardiac arrhythmia
• Nerve injury
• Venous thrombosis
• Complications arising
from the use of electrical
energy
• Vulvar edema
• Port-Site Metastasis
Complications of gynecologic laparoscopy
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- know the anatomy!
- trans-illuminate the abdominal wall to identify superficial
epigastric artery
- put the ancillary trocars (5 mm?) laterally to the obliterated
hypogastric vessels
Recognition:
- it may not be apparent until after the trocar has been removed at
the end of the operation
Management:
- bipolar coagulation
- tamponade
- suturing
Abdominal wall vessels injury
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- use the safety checks before to insufflate!
Recognition:
- blood at the saline solution test
- direct laparoscopic visualization
- sudden drop of blood pressure
Management:
- if you are using the Veress needle or the optical trocar, leave it
inside (they produce a mechanical tamponade).
- compression over the aorta (no clamping!)
- conversion to laparotomy and immediate call of resuscitation
staff and vascular surgeons (emergency)
Large retroperitoneal vessels injury
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- risk of adhesions: insufflate from Palmer’s point; use
laparoscope-equipped optical trocars (layer-by-layer entry)
- bowel preparation
Recognition:
- fecal material from Veress needle or optical trocar
- direct laparoscopic visualization
- sometimes it may occur few days after the surgery (signs of
peritonitis)
Management:
- injury by “cold” instruments: closure by two-layers suture
(consider conversion to laparotomy)
- electrosurgical damage: consider resection before to suture
Bowel injury
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- be careful in case of previous c-section
- put a Foley catheter before to start the surgery (empty bladder)
- careful dissection of anterior peritoneum between the uterus
and the bladder (Retzius space)
Recognition:
- in case of suspected injury, instill methylene blue dye into the
bladder
- pelvic drainage
- cystoscopy
Management:
- suture in a single layer, followed by bladder drainage for 7–10
days
Bladder injury
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- stent positioning before the surgery
- Hydroprotection: 10–20 ml of normal saline solution injected just
beneath the parietal peritoneum
Recognition:
- in case of suspected injury, indigo carmine may be injected
intravenously to verify if there is any leakage of the dye through the
ureter
- delayed presentation: increase of creatinine, nausea, vomiting,
pain, abdominal distension, ileus
Management:
- call the urologist
- “cold” damage: stent and suture in single layer
- electrosurgical damage: consider resection and re-implantation
Ureteral injury
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- careful closure of the fascia
- use of 5 mm trocars as much as possible
Recognition:
- tender swelling over the hernia site, often within 2 weeks of the
operation
- nausea, vomiting, signs of bowel obstruction
Management:
- laparoscopic or laparotomic confirmation and repair
Incisional hernia
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Recognition:
- sudden circulatory collapse
- cyanosis
- increase of jugular venous pressure
- characteristic ‘millwheel’ murmur
- high arterial pCO2
- drop in end tidal carbon dioxide concentration.
Management:
- stop CO2 insufflation
- roll the patient on the left side
- call immediately cardiopulmonary resuscitation
Gas embolism
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
(In case of congenital defect of the diaphragm)
Recognition:
- cyanosis
- Increase of jugular venous pressure
- Increase in airway pressure
Management:
- stop CO2 insufflation
- thoracostomy
Pneumothorax
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Very common, it is caused by irritation of the
diaphragmatic nerves by residual CO2 trapped
inside the abdominal cavity
Prevention:
- remove all the CO2 from the abdominal cavity at
the end of the surgery
Shoulder pain
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- perpendicular insertion of Veress needle and optical
trocar in obese patients
- use Hasson technique
Recognition:
- bubbling from the peri-umbilical incision during
insufflation
- direct laparoscopic visualization
Management:
- use the ancillary access to go between the fascia and
peritoneum and remove the CO2 from this area, before to
enter into the peritoneal cavity
Pre-peritoneal emphysema
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- do not increase the flow immediately after the insufflation
Management:
- stop the CO2 insufflation
- anticholinergic agents
Cardiac arrhythmia
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Prevention:
- correct positioning of the patient, especially when
undergoing prolonged laparoscopic surgery
Nerve injuries
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
It is relatively uncommon following laparoscopic
surgery because of earlier mobilization.
Prevention:
- use of stockings and subcutaneous heparin for
prophylaxis in women having major laparoscopic
surgery
- set intra-abdominal pressure below 15 mmHg, in
order to allow a proper venous return from the vena
cava
Venous thrombosis
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
“You must believe in your hands”
Helena Ban Frangež, Ass. Prof.
Department of Human Reproduction
Univerzitetni Klinični Center Ljubljana
Complications of Laparoscopic Gynecologic Surgery
Antonio Simone Laganà, M.D.
Department of Human Pathology in Adulthood and
Childhood “G. Barresi” - University of Messina (Italy)
Thanks for your attention!

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Complications of Laparoscopic Gynecologic Surgery

  • 1. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Thomas Eakins. The Agnew Clinic, 1889
  • 2. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) … why laparoscopy? • Better recovery • Shorter hospital stay • Less post-operative pain • Lower blood loss • “Scarless surgery”
  • 3. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Modified lithotomy position, with legs placed in the padded adjustable stirrups and intermittent pneumatic compression system
  • 4. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Surgeon: left side of the patient First assistant: right side of the patient (Second assistant: between the legs to use the manipulator)
  • 5. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) 1. Immobilize the umbilical area (our school uses two small towel clips on the lateral margins of the peri-umbilical area) 2. Peri-umbilical incision of 10 mm (our school uses horizontal incision at the inferior border of the umbilical ring) 3. Grasp the shaft of the Veress needle like a dart and gently pass the needle into the incision and reach the fascia. Afterwards, lift abdominal wall below the umbilicus and gently pass the Veress needle at 45-degree caudal angle. We use to lift the umbilical area with the two small towel clips and then go perpendicular. Let’s enter into the abdomen in 10 steps:
  • 6. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) 5. Saline test (withdraw, instill, withdraw). If no fluid, blood or feces came out, you are in the right place. 6. Ask for insufflation: a pressure below 6-7 mmHg is ok! You are inside the peritoneum! 7. Wait until the intra-abdominal pressure will be AT LEAST 10-15 mmHg (RCOG guidelines: 20-25 mmHg). Start with 1 L/min and then you may increase the flow. 4. Two clicks: the first one will be the piercing of the fascia, the second one of the peritoneum. Let’s enter into the abdomen in 10 steps:
  • 7. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) 8. Insert the optical trocar through the umbilical incision and hear the CO2 flow Abdominal pressure= 8mmHg Abdominal pressure=25mmHg 9. Insert the laparoscope and ask for Trendelenburg. 10. Welcome to the abdominal cavity! Let’s enter into the abdomen in 10 steps:
  • 8. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Suprapubic trocar: 3-4 cm above the symphysis pubis Lateral trocars: 3 cm medial to each anterior superior iliac spine Inf epigastric Ancillary trocars (under vision!)
  • 9. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Complications (and how to manage them!)
  • 10. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) • Vascular injury • Bowel injury • Urinary tract injury • Incisional hernia • Gas embolism • Shoulder pain • Pneumothorax • Subcutaneous and pre- peritoneal emphysema • Cardiac arrhythmia • Nerve injury • Venous thrombosis • Complications arising from the use of electrical energy • Vulvar edema • Port-Site Metastasis Complications of gynecologic laparoscopy
  • 11. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - know the anatomy! - trans-illuminate the abdominal wall to identify superficial epigastric artery - put the ancillary trocars (5 mm?) laterally to the obliterated hypogastric vessels Recognition: - it may not be apparent until after the trocar has been removed at the end of the operation Management: - bipolar coagulation - tamponade - suturing Abdominal wall vessels injury
  • 12. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - use the safety checks before to insufflate! Recognition: - blood at the saline solution test - direct laparoscopic visualization - sudden drop of blood pressure Management: - if you are using the Veress needle or the optical trocar, leave it inside (they produce a mechanical tamponade). - compression over the aorta (no clamping!) - conversion to laparotomy and immediate call of resuscitation staff and vascular surgeons (emergency) Large retroperitoneal vessels injury
  • 13. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - risk of adhesions: insufflate from Palmer’s point; use laparoscope-equipped optical trocars (layer-by-layer entry) - bowel preparation Recognition: - fecal material from Veress needle or optical trocar - direct laparoscopic visualization - sometimes it may occur few days after the surgery (signs of peritonitis) Management: - injury by “cold” instruments: closure by two-layers suture (consider conversion to laparotomy) - electrosurgical damage: consider resection before to suture Bowel injury
  • 14. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - be careful in case of previous c-section - put a Foley catheter before to start the surgery (empty bladder) - careful dissection of anterior peritoneum between the uterus and the bladder (Retzius space) Recognition: - in case of suspected injury, instill methylene blue dye into the bladder - pelvic drainage - cystoscopy Management: - suture in a single layer, followed by bladder drainage for 7–10 days Bladder injury
  • 15. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - stent positioning before the surgery - Hydroprotection: 10–20 ml of normal saline solution injected just beneath the parietal peritoneum Recognition: - in case of suspected injury, indigo carmine may be injected intravenously to verify if there is any leakage of the dye through the ureter - delayed presentation: increase of creatinine, nausea, vomiting, pain, abdominal distension, ileus Management: - call the urologist - “cold” damage: stent and suture in single layer - electrosurgical damage: consider resection and re-implantation Ureteral injury
  • 16. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - careful closure of the fascia - use of 5 mm trocars as much as possible Recognition: - tender swelling over the hernia site, often within 2 weeks of the operation - nausea, vomiting, signs of bowel obstruction Management: - laparoscopic or laparotomic confirmation and repair Incisional hernia
  • 17. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Recognition: - sudden circulatory collapse - cyanosis - increase of jugular venous pressure - characteristic ‘millwheel’ murmur - high arterial pCO2 - drop in end tidal carbon dioxide concentration. Management: - stop CO2 insufflation - roll the patient on the left side - call immediately cardiopulmonary resuscitation Gas embolism
  • 18. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) (In case of congenital defect of the diaphragm) Recognition: - cyanosis - Increase of jugular venous pressure - Increase in airway pressure Management: - stop CO2 insufflation - thoracostomy Pneumothorax
  • 19. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Very common, it is caused by irritation of the diaphragmatic nerves by residual CO2 trapped inside the abdominal cavity Prevention: - remove all the CO2 from the abdominal cavity at the end of the surgery Shoulder pain
  • 20. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - perpendicular insertion of Veress needle and optical trocar in obese patients - use Hasson technique Recognition: - bubbling from the peri-umbilical incision during insufflation - direct laparoscopic visualization Management: - use the ancillary access to go between the fascia and peritoneum and remove the CO2 from this area, before to enter into the peritoneal cavity Pre-peritoneal emphysema
  • 21. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - do not increase the flow immediately after the insufflation Management: - stop the CO2 insufflation - anticholinergic agents Cardiac arrhythmia
  • 22. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Prevention: - correct positioning of the patient, especially when undergoing prolonged laparoscopic surgery Nerve injuries
  • 23. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) It is relatively uncommon following laparoscopic surgery because of earlier mobilization. Prevention: - use of stockings and subcutaneous heparin for prophylaxis in women having major laparoscopic surgery - set intra-abdominal pressure below 15 mmHg, in order to allow a proper venous return from the vena cava Venous thrombosis
  • 24. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) “You must believe in your hands”
  • 25. Helena Ban Frangež, Ass. Prof. Department of Human Reproduction Univerzitetni Klinični Center Ljubljana Complications of Laparoscopic Gynecologic Surgery Antonio Simone Laganà, M.D. Department of Human Pathology in Adulthood and Childhood “G. Barresi” - University of Messina (Italy) Thanks for your attention!