Complications of laparoscopic and robotic-assisted surgery

Potential complications are an inevitable part of surgical practice from which not even the most experienced surgeons are immune. As such, the benefit of any surgical intervention must be weighed against the risk. Many of the complications that may occur with laparoscopic or robotic-assisted retroperitoneal surgery are similar to those encountered during traditional open surgery. However, controlling these events requires a unique skill set. Moreover, some complications are unique to laparoscopy. Complications from laparoscopic or robotic-assisted procedures may arise during every aspect of the operation, and when they do occur, early recognition and aggressive treatment are crucial to minimize subsequent morbidity to the patient. In this chapter, we review the potential complications and provide strategies aimed at prevention, recognition, and treatment.

Positioning injury

Attention to patient positioning on the operating table is of great import in avoiding postoperative orthopedic and neuromuscular injuries. Compression or stretch injuries can lead to complications including sensory and motor deficits, neuralgias, back pain, and rhabdomyolysis. Such injuries are more common after retroperitoneal surgery than after pelvic laparoscopic surgery, with an occurrence of 3.1% reported in the literature. Prevention includes using foam pads at pressure points, maintaining the head in the neutral position, and, when indicated, adding a properly placed axillary or chest roll. When the patient is in the dorsal lithotomy position or split-leg position, care must be exercised in maintaining a straight line from the patient’s heel to knee to contralateral shoulder while avoiding hip over extension.

Rhabdomyolysis can occur due to prolonged compression of the muscles of the back, flank, and proximal extremities. The incidence of clinical rhabdomyolysis after laparoscopic surgery in the flank position has been reported to be as high as 0.4% and is associated with several factors, including male gender, heavier weight, large muscle mass, longer operative times, and the use of a full flank or exaggerated lithotomy position. Management includes intravenous hydration with or without alkalization. Skin breakdown and pressure sores are also a potential complication secondary to patient positioning and are associated with the flank position and prolonged operating times.

Insufflation injury

Incorrect placement of a Veress needle can result in inadvertent insufflation of extraperitoneal spaces with subsequent extravasation of gas along tissue planes. The most common site of incorrect needle placement is the preperitoneal space ( Fig. 13.1 ), resulting in an increased distance between the skin and peritoneal cavity, which may necessitate open trocar placement to gain access. Moreover, preperitoneal or retroperitoneal insufflant can pass between diaphragmatic fibers or alongside the great vessels, causing pneumomediastinum, which, in turn, can lead to pneumopericardium or pneumothorax.

Insufflation of the subcutaneous space can be a result of incorrect Veress needle placement or secondary to leakage of gas around the trocars. The resultant subcutaneous emphysema is usually of no clinical consequence; once the procedure is complete, the gas is absorbed. However, extensive dissection of gas can lead to pneumothorax, pneumomediastinum, and hypercarbia. The risk of development of a pneumomediastinum increases when crepitus extending up to the neck is noted. Because of a continuum of fascial planes existing between the cervical soft tissue and mediastinum, the potential exists for gas to track upward into the neck and down into the mediastinum ^, ( Fig. 13.2 ). Subclinical thoracic air collections have been reported in 5.5% of urologic laparoscopic procedures, which can often be managed conservatively because of the high solubility of carbon dioxide (CO ₂ ). ^, However, if symptomatic pneumothorax or pneumomediastinum develops, the pneumoperitoneum should be discontinued and the ectopic gas evacuated.

A pneumothorax can also occur in the absence of subcutaneous emphysema. Insufflant can enter the pleural space through anatomic or congenital defects in the diaphragm. Complications of anesthesia and positive pressure ventilation, as well as patient conditions such as emphysematous bullae, can also lead to the entry of air into the pleural cavity.

After the pneumoperitoneum is successfully established, the presence of pressurized gas in the abdominal cavity has significant and varied physiologic consequences that can result in complications. The cumulative response of the cardiovascular system during laparoscopy with CO ₂ under moderate pressure (10–20 mm Hg) is usually sufficient for healthy individuals to tolerate pneumoperitoneum. However, patients with significant cardiovascular or pulmonary disease may not compensate sufficiently. In addition, careful attention to insufflation pressure is critical to avoid excessive tension and potential cardiovascular collapse.

Although appropriate ventilatory adjustments are usually sufficient to eliminate the increased CO ₂ load that results from laparoscopy, in some patients CO ₂ insufflation can produce profound hypercapnia. This can be exacerbated by subcutaneous emphysema and excessive intraabdominal pressures. If severe, hypercapnia and acidosis can have significant depressive cardiac effects. Initial management consists of lowering the intraabdominal pressure. If the anesthesiologist cannot adequately compensate, helium may be used or the procedure may need to be converted to open surgery. In individuals with chronic obstructive pulmonary disease, helium may be used initially as the insufflant to avoid hypercarbia; however, because of the smaller size of helium compared to CO ₂ , ectopic tracking of gas is more common, and it can take months for gas collections to spontaneously resolve.

Insufflation can also produce significant cardiac arrhythmias, including bradycardia (the most common), tachycardia, ventricular extrasystoles, atrioventricular dissociation, and nodal rhythms. Hypercapnia, as well as a vagal response to abdominal distention and peritoneal irritation, has been implicated. The use of atropine before insufflation may prevent these vagal reactions.

A rare but potentially fatal complication related to the pneumoperitoneum is a gas embolism, which is most commonly seen during the induction of pneumoperitoneum. Although intravasation of gas as a result of the increased intraabdominal pressure has been suggested as a cause, the most reported cause is direct placement of a needle or trocar into a vessel or abdominal organ. ^, In a meta-analysis of nearly 500,000 laparoscopic procedures with closed access, the incidence of gas emboli was 0.0014%.

Patient survival after gas embolism depends on rapid diagnosis and treatment. The diagnosis can be difficult, and there is often no warning before acute cardiovascular collapse, particularly during insufflation. When the size of the embolus increases, tachycardia, arrhythmias, hypotension, and increased central venous pressure may be noted. Hypoxia, hypercapnia, and cyanosis may also be evident. Electrocardiographic changes can include a right heart strain pattern, and auscultation may reveal the classic “mill wheel” murmur just before the acute event. Also, an acute decrease in measured end-tidal CO ₂ is noted as the embolism occludes the pulmonary trunk ( Fig. 13.3 ). When an embolism is suspected, release the pneumoperitoneum and administer 100% oxygen. Place the patient in the left lateral decubitus position with the head down to move the gas away from the pulmonary artery ( Fig. 13.4 ). Institute cardiopulmonary resuscitation and place a central venous catheter in an attempt to aspirate the gas. Percutaneous or open evacuation of the gas have also been reported as an effective treatment.

Dissection injury

Injury can occur during dissection due to mechanical or thermal forces being inadvertently applied to tissue. Past pointing during cutting, forcing instruments through trocars, and aggressive retraction all can mechanically disrupt tissue. If this occurs outside of the visual field, injury may not be noted until the postoperative period. As such, it is important to perform a visual sweep of the entire operative space at the conclusion of procedures to assess for bleeding and visceral injuries. If possible, it is helpful to have staff in the operating room to observe the video at this point as multiple individuals can better survey for subtle findings.

Thermal injury

Several common devices that achieve hemostasis or incise tissue produce significant heat. Although this energy is focused on the tip of the instrument, heat scatter or unintentional activation outside of the operative field can lead to injury. A focal burn to the liver, muscle, or soft tissue is of little consequence; however, an unrecognized thermal injury to bowel can evolve into a serious complication. As visceral wall integrity remains intact, patients may not show symptoms for 48 hours until a perforation evolves. Even at that point, diagnosis may be challenging. Prevention of burns depends on the careful use of electrocautery. Before using electrocautery, inspect all instruments, including robotic manipulators, to be certain that insulation is intact. Insulation defects can result in arcing of the electrocautery current between instruments. Moreover, when current is applied, the entire tip of the instrument must be kept within the visual field. Finally, be certain that the tissue to be cauterized is isolated from the surrounding tissue to prevent inadvertent injury secondary to thermal conduction through tissue.

Vascular injury

Vascular injuries are among the most common and challenging complications of urologic laparoscopy, occurring in 2.8% of procedures. Vascular injury can result from Veress needle and trocar placement or from trauma sustained during dissection. Many of these injuries are minor and are easily managed, whereas others have catastrophic potential. A thorough understanding of vascular anatomy and constant attention to maintaining orientation are critical to avoid vascular complications, and early recognition of such an event is key to minimizing the extent of injury.

Slight bleeding from the trocar or Veress needle access often resolves without intervention, though several maneuvers are available to control bleeding from abdominal wall vessels. If the bleeding is minor, apply electrocautery under direct vision. If the bleeding is brisk, pass a Foley catheter down the trocar, then inflate the balloon and put on traction to tamponade the bleeding vessel ( Fig. 13.5 ). More significant bleeding may require sutures to achieve hemostasis. Pass a figure-of-eight suture using a Carter-Thomason needlepoint fascial closure device (Cooper Medical, Trumbull, CT) ( Fig. 13.6 ). If this maneuver is unsuccessful, open exploration may be indicated.