Reducing the risks of minimal invasive p

COMPLICATIONS : 

COMPLICATIONS Anaesthetic complications: Increased PaCO2 Pneumothorax Gas embolism

Laproscopic Entry Injuries: : 

Laproscopic Entry Injuries: Bowel injuries 0.4/1000 Vascular injuries 0.2/1000 THESE INJURIES MAY LEAD TO SERIOUS SEQUELAE, Laprotomy Bowel resection Vascular grafts Death

Vascular injuries : 

Vascular injuries Risk factors: Failure to note anatomical landmarks Position of the patient Inadequate pneumoperitoneum The depth of insertion of trocar or veress Lateral deviation of varess or trocar Excessive force Blunt trocars Failure to maintain perpendicular entry with secondary ports Obesity.

Surface anatomy : 

Surface anatomy It is important to identify the location of major blood vessels prior to insertion of instuments. Umbilicus is not a fixed landmark. Illiac crests are consistent surface landmarks for L4 and in 80% of the cases aortic bifurcation will lie within 1.25 cm of L4.

Position of the patient : 

Position of the patient In Trendelenberg position The angle of tilt may be difficult to judge once the drapes are in place. The angle of insertion is smaller than in supine position. The aortic bifurcation tends to be more caudal to the umbilicus.

Pneumoperitonium : 

Pneumoperitonium Intra abdominal pressure should be used as a reliable guide to insufflation. An intra abdominal pressure of 20mmHg is associated with a reliable elevation of anterior abdominal wall. The pressure should be reduced to 12-15mmHg once the trocars have been inserted.

Lifting the abdominal wall : 

Lifting the abdominal wall Increase the distance to the great vessels. May increase the risk of pre peritoneal insufflation.

Open laproscopy : 

Open laproscopy Reduces the risk of vascular injury during insertion of the primary trocar.

Secondary trocars : 

Secondary trocars Identification of inferior and superficial epigastric vessels. Should be inserted under direct vision. Secondary trocars should be inserted at 90 degrees to the skin. In the event of vascular trauma trocar sleeve should be left in place as a marker for the injured vessel.

7. Blood vessel injury : 

Minimal bleeding may usually be controlled by bipolar coagulation or a laparoscopic suture. BALLOON TEMPONADE. Laparotomy is not usually necessary except in the case of injury to the superior mesenteric artery. Such injury requires repair by a vascular surgeon 7. Blood vessel injury (Bassil et al, 1993)

Bowel injury during entry: : 

Bowel injury during entry: Classification Type I Damage by veress or trocar to normally located bowel. Type II Damage by veress or trocar to bowel adherent to abdominal wall.

Techniques to minimize bowel injury : 

Techniques to minimize bowel injury Saline tests: 2-3 ml of saline is injected down the veress needle and if the needle is intraperitoneal, no fluid should be withdrawn. Hanging drop test.

Saline mapping : 

Saline mapping Once pneumoperitoneum is established, prior to insertion of the primary port 10 ml of saline should be injected in an arc below umbilicus and only gas should be aspirated. If brown or turbid fluid is withdrawn the presence of bowel under the umbilicus should be suspected. In which case a 2-5 mm laproscope should be inserted through palmers point or the procedure should be abandoned.

Microlaproscopy : 

Microlaproscopy In patients with increased risk of adhesions a 2 mm minilaproscope can be introduced at palmers point. Open laproscopy: A slightly larger incision is required at the umbilicus with sharp dissection down to the peritoneum to allow direct entry. Reduces risk of type I injuries.

MANAGEMENT OF BOWEL INJURIES : 

MANAGEMENT OF BOWEL INJURIES May not be identified at the time of surgery(69%) Usually become apparent after 12-36 hr after surgery. Veress needle penetration with no tearing – conservative approach with antibiotcs and observation

Slide 29: 

In case of trocar pentration it is best to left in place to mark the site of injury. Some injuries may be managed by laproscopy whilst others will require a laprotomy. Post op pyrexia or worsening pain should be regarded with great suspician.

Minimizing exit complications : 

Minimizing exit complications During laproscopy , the pressure maintained in the abdominal cavity may produced a temponade effect on venous bleeding. After reducing the pressure the operating field should be observed before removal of the laproscope. Removal of all ports should be visualized.

Minimize thermal complications : 

Minimize thermal complications

THERMAL DAMAGE : 

Thermal injury to organs such as bowel may also result from leakage of current from the shaft of the instrument. This may result from : Insufficient or faulty insulation or from Capacitative coupling in which there is a build up of current in the shaft of the instrument because the normal escape route has been shut off. THERMAL DAMAGE

THERMAL DAMAGE : 

The bowel is the most commonly injured organ. The injury may range from minor blanching of the serosa to frank perforation. Perforation requires laparotomy, excision of the surrounding devitalized bowel and repair of the defect. THERMAL DAMAGE

THERMAL DAMAGE : 

It must always be remembered that electric current is potentially dangerous and all the safety rules for its use must be strictly obeyed. THERMAL DAMAGE

COMPLICATIONS OF HYSTEROSCOPY : 

COMPLICATIONS OF HYSTEROSCOPY

Complications may result from : 

Complications may result from Anesthesia Positioning the patient The distension media The surgery: Uterine perforation Haemorrhage Delayed complications: Infection Adhesion formation Failure of resolution of the presenting symptoms

THE DISTENSION MEDIA : 

The nature of the complications depend on the type of medium in use. The medium may be carbon dioxide (CO2) in the case diagnostic hysteroscopy or fluid in both diagnostic and operative procedures. The fluid may be of high or low molecular weight. THE DISTENSION MEDIA

1. Carbon dioxide. : 

1. Carbon dioxide. Cardiac arrhythmia may occur with diagnostic hysteroscopy. The complication should be extremely rare if the correct insufflator is used. The hysteroflator delivers CO2 at a rate of not more than 100ml per minute whereas the laparoflator can deliver 1-6 litres in the same time.

Slide 43: 

Dextran is popular in some countries for both diagnostic and operative hysteroscopy when mechanical instruments are used. It may produce an: Anaphylactic reaction, Adult onset respiratory distress syndrome (ARDS) or Pulmonary oedema. 2. High molecular weight fluids:Dextran

3. Low molecular weight fluids. : 

3. Low molecular weight fluids. Saline may be used with the laser But only non-electrolytic fluids should be used with electrosurgery because of the risk of producing burns to other organs. All low molecular weight fluids may produce fluid overload.

Fluid Overload : 

Fluid Overload Usually occur in the immediate post-operative period. The surgeon and/or anesthetist have the responsibility to begin resuscitative procedures and seek appropriate advice and help from their colleagues in internal medicine. If such complications should occur during the procedure, surgery must be abandoned.

Prevention of Fluid Overload : 

Prevention of Fluid Overload May be accomplished by: Using appropriate distension media and delivery systems Keeping operating times to a minimum Avoiding entering the vascular channels Keeping fluid pressures below 80mmHg and gas pressures below 100mmHg. Meticulous accountancy of fluid balance. The procedure must be abandoned if the deficit rises to 2 litres or there is evidence of venous congestion..

1. Uterine Perforation : 

1. Uterine Perforation The incidence of perforation is about 0.8% In the British Mistletoe study perforation occurred in 0.64% and 0.65% of cases respectively with roller ball and laser but in 1.29% and 2.47% of cases when roller ball and loop or loop alone were used

1. Uterine Perforation Simple perforation : 

Simple perforation may be made with a cervical dilator or with the hysteroscope. Perforation should be suspected if the dilator passes to a depth greater than the length of the uterine cavity. Perforation with the hysteroscope should be avoided by always introducing the telescope under direct visual control. 1. Uterine Perforation Simple perforation

Slide 50: 

Simple perforation rarely causes any further damage and may be treated conservatively by observation and appropriate broad spectrum antibiotics. Laparoscopy may be considered to exclude bleeding. 1. Uterine Perforation Simple perforation

Slide 51: 

Complex perforation caused by electrosurgical instruments or laser may be associated with thermal injury to adjacent structures including bowel or large vessels. 1. Uterine Perforation Complex perforation

1. Uterine Perforation : 

In the majority of cases of electrical injury, and in all cases where laser has been used : Laparotomy and Detailed examination of the bowel, pelvic blood vessels and aorta is mandatory. 1. Uterine Perforation

2. Haemorrhage : 

Intrauterine bleeding occurring during the procedure should be immediately obvious and can usually be controlled by spot electrocoagulation. 2. Haemorrhage

2. Haemorrhage : 

If coagulation fails to control the bleeding, the procedure may have to be abandoned and tamponade performed by inserting a Foley catheter and distending the balloon. The catheter should be left in situ for a few hours after which the bleeding nearly always stops. 2. Haemorrhage

2. Haemorrhage : 

Occasionally these simple measures fail to control haemorrhage. This may occur if resection has been carried out too deep into the myometrium and a plexus of vessels opened. In this case: Hysterectomy, Ligation or Ultrasound guided embolization of the anterior branches of the internal iliac arteries may be necessary. 2. Haemorrhage

LATE ONSET COMPLICATIONS : 

LATE ONSET COMPLICATIONS 1. Infection Acute pelvic inflammatory disease is rare following hysteroscopic surgery. This may be prevented by prophylactic antibiotics. The diagnosis is made by the presentation of the classic symptoms and signs and Treatment should be by appropriate antibiotics following culture of vaginal swabs and blood.

LATE ONSET COMPLICATIONS : 

2. Vaginal Discharge Vaginal discharge is common after any ablative procedure and is usually self limiting. LATE ONSET COMPLICATIONS

LATE ONSET COMPLICATIONS : 

3. Adhesion Formation An intrauterine device and Administration of oestrogen and progestogen therapy may help to prevent adhesion formation following: Resection, Adhesiolysis or Division of a septum. LATE ONSET COMPLICATIONS

FAILURE OF RESOLUTION OF THE PRESENTING SYMPTOMS : 

FAILURE OF RESOLUTION OF THE PRESENTING SYMPTOMS The procedure may fail to cure the presenting symptoms. This may be because of poor patient selection or failure of the surgery.

THANK YOU : 

THANK YOU