Background & Risk Factors
Complications of gyn laparoscopy occur in ___ per 1,000 cases
3 to 6
10
Most bladder injuries occur at the bladder ___
2x points: what are 2 immediate intra-operative, extra-abdominal findings that a bladder injury has occurred?
Dome
2x points: blood and gas in Foley
This gynecologic disease is a major risk factor for intra-operative bowel and bladder injury
Endometriosis
When do the majority of vascular injuries occur?
Abdominal entry
At what point of the surgical process do complications most commonly occur?
Initial entry
Name the laparoscopic entry techniques
Closed (Veress needle) entry
Open (Hasson) entry
Direct trocar entry
Optical entry
What is the minimum volume of fluid to backfill when testing the integrity of a cystotomy repair?
250-300 mL
You decide to enter via Palmer's point. What do you ask from the anesthesiologist?
NG or OG tube
What is the first step in management when a major vessel is injured?
Apply pressure
Approximately __% of complications occur during initial entry
30-50%
What complication is usually self-limited and characterized by gas trapped under the skin?
Subcutaneous emphysema
Where is the ureter most commonly injured during a hysterectomy?
Uterine vessel transection (water under the bridge)
Vaginal cuff closure (ureter lies 1.2-1.3 cm from the lateral vaginal apex
Infundibulopelvic ligament transection
The (small/large) bowel is most commonly injured during entry. The (small/large) bowel is most commonly injured after entry.
2x points: this specific bowel segment is most commonly injured during the operative phase
1. small
2. large
2x points: rectosigmoid
Which 3 major retroperitoneal vessels are most at risk during primary entry?
Aorta
IVC
Iliac vessels
Name 3 risk factors for laparoscopic injury
Adhesions
Prior abdominal surgery
Endometriosis
Pelvic infection
Bowel distention
Large masses
Pelvic organ prolapse (ureter)
Which laparoscopic entry technique is best?
None
Insufficient evidence to support one technique over the others
Scenario: patient s/p urinary tract repair with intra-abdominal drain in place
What lab(s) can you run if you're concerned that the bladder repair is leaking?
Serum and peritoneal creatinine
Peritoneal Cr will be higher than serum levels
How do bowel injuries present?
Most present with 4 days of surgery, but delayed presentations can be up to 2 weeks (e.g. thermal injuries)
Abdominal pain/distention, tachycardia, fever, N/V, leukopenia/leukocytosis, septic shock
How would you manage a stable hematoma vs expanding hematoma?
Stable, non-expanding: observation
Expanding: may require exploration, suture ligation
This is the recommended annual volume of laparoscopies for a surgeon to maximize safety
Over 100
These two rare but fatal events can occur from excessive CO2 absorption
Gas embolism
Cardiac arrhythmia
How do you close a cystotomy?
Primary repair in 1-2 layers using absorbable suture followed by bladder decompression with foley catheter x 1-2 weeks
How do you close a bowel injury?
See table
Which vessel is most commonly injured during lateral trocar placement? Name at least 2 management options
Inferior epigastric vessels
Balloon tamponade via Foley catheter, suture ligation, fascial closure devices