Endoscopic Surgery:

1
Endoscopic Surgery Risk Management and
Medico-Legal issues
2
Laparoscopic complications

• 1. Complications are less common than with
  laparotomy, but when they do occur, they are
  potentially more serious.
• 2. Patients assume key hole surgery is minor
  surgery and so should not be associated with
  major complications.

3
Possible laparoscopic complications
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
Medico-legal cases involving operative
laparoscopy I have given an opinion on
13
Risk management

• Identify risk
• Analyse risk
• - Publications
• - Incident reporting
• - Complaints
• - Medico-legal claims
• Modify practice to prevent, control or minimize
  risk in future

14
What factors increase the risk of laparoscopic
complications?

• Complex surgery
• Older patient
• Extremes of weight
• Previous abdominal surgery/adhesions
• Poor surgical technique/inexperience
• Faulty/incorrect equipment

15
(No Transcript)
16
(No Transcript)
17
What factors increase the risk of laparoscopic
complications?

• Complex surgery
• Older patient
• Extremes of weight
• Previous abdominal surgery/adhesions
• Poor surgical technique/inexperience
• Faulty/incorrect equipment

18
(No Transcript)
19
What factors increase the risk of laparoscopic
complications?

• Complex surgery
• Older patient
• Extremes of weight
• Previous abdominal surgery/adhesions
• Poor surgical technique/inexperience
• Faulty/incorrect equipment

20
(No Transcript)
21
(No Transcript)
22
What factors increase the risk of laparoscopic
complications?

• Complex surgery
• Older patient
• Extremes of weight
• Previous abdominal surgery/adhesions
• Poor surgical technique/inexperience
• Faulty/incorrect equipment

23
(No Transcript)
24
What factors increase the risk of laparoscopic
complications?

• Complex surgery
• Older patient
• Extremes of weight
• Previous abdominal surgery/adhesions
• Poor surgical technique/inexperience
• Faulty/incorrect equipment

25
(No Transcript)
26
(No Transcript)
27
Experienced surgeon
Trainee surgeon
28
(No Transcript)
29
What factors increase the risk of laparoscopic
complications?

• Complex surgery
• Older patient
• Extremes of weight
• Previous abdominal surgery/adhesions
• Poor surgical technique/inexperience
• Faulty/incorrect equipment

30
Endoscopy cart for laparoscopy
High flow insufflator
Video monitors
Electronic morcellator
Camera unit
Light source
Suction/irrigation unit
Electrosurgical generator
31
How to reduce laparoscopic complications

• Complications related to laparoscopic entry
• Complications related to the operative procedure
• Complications related to pneumoperitoneum
• Complications related to patient position
• Complications related to anaesthesia

32
How to reduce laparoscopic complications

• Complications related to laparoscopic entry
• Complications related to the operative procedure
• Complications related to pneumoperitoneum
• Complications related to patient position
• Complications related to anaesthesia

33
How to reduce complications related to
laparoscopic entry
34
Summary data for major laparoscopic complications
35
(No Transcript)
36
Remember, bowel injury during abdominal entry
also occurs with conventional surgery
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
Alternative entry techniques

• Optical Veress needle
• Microlaparoscopy
• Optical trocar
• Safety-shield
• ENDOTIP cannula
• Step Radial Expanding System
• Palmers point

50
(No Transcript)
51
(No Transcript)
52
(No Transcript)
53
Subumbilical insufflation and insertion of
primary trocar and cannula

• Palpate for aorta
• Elevate anterior abdominal wall (to increase
  distance between needle and bowel/major vessels)
• Aim Veress needle and trocar and cannula towards
  the hollow of the sacrum (away from major
  vessels)
• Create a high pressure pneumoperitoneum prior to
  inserting umbilical trocar and cannula (to
  increase distance between needle and bowel/major
  vessels)
• Insert trocar and cannula no more than a few
  centimetres into the peritoneal cavity (to reduce
  risk of bowel or vascular injury
• Avoid Trendelenburg tilt (head down) until
  laparoscope has been inserted (to avoid bringing
  major vessels closer to umbilicus)
• Avoid excessive force during insertion (to limit
  the distance the instruments advance into the
  peritoneal cavity.

54
Palpation for aortic bifurcation
55
(No Transcript)
56
(No Transcript)
57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
Palmers point laparoscopic entry site in high
risk cases
Midclavicular line below costal margin
Use in cases of Previous laparotomy Previous
peritonitis Large pelvic mass Inflammatory bowel
disease
61
(No Transcript)
62
Vessels of the lower anterior abdominal wall
63
Insert ancillary ports under direct vision
64
The inferior epigastric vessels are always
outside to the safe triangle
65
The inferior epigastric vessels are always
outside to the safe triangle
X
66
(No Transcript)
67
How to reduce complications related to the
laparoscopic procedure
68
Causes of laparoscopic operative injuries

• Cutting (eg. scissors, laser, monopolar
  electrosurgery)
• Burning (eg. electrosurgery, laser)
• Tearing (eg. blunt dissection)
• Ligating (eg. sutures, clips, staples)

69
Safe laparoscopic surgery

• Ensure structures are well visualised
• Do not tear tissue by applying too much force
  when probing or retracting
• Be careful during during sharp dissection (eg.
  division of adhesions)
• Be very careful using thermal energy (eg.
  electrosurgery, laser) near bowel, ureter and
  other vital structures.

70
(No Transcript)
71
Some complications are not recognised
72
(No Transcript)
73
(No Transcript)
74
(No Transcript)
75
(No Transcript)
76
GMC guidance Making and Using Visual and Audio
Recordings of Patients
77
Informed consent
78
Laparoscopic complications

• 1. Complications are less common than with
  laparotomy, but when they do occur, they are
  potentially more serious.
• 2. Patients assume key hole surgery is minor
  surgery and so should not be associated with
  major complications.

79
(No Transcript)
80
(No Transcript)
81
(No Transcript)
82
(No Transcript)
83
(No Transcript)
84
Electrosurgical generator
Cutting
Coagulation
Monopolar circuit
Bipolar circuit
Blend
85
Electrosurgical generator
Increasing voltage
Cutting
Coagulation
Monopolar circuit
Bipolar circuit
Blend
86
Management of laparoscopic vascular injury
87
Management of laparoscopic vascular injury
Call vascular surgeon!
88
Management of laparoscopic bowel injury
89
Management of laparoscopic bowel injury
Call G.I. surgeon!
90
Management of laparoscopic urinary tract injury
91
Management of laparoscopic urinary tract injury
Call urologist!