Complications of Laparoscopy Including Robotics

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Complications of Laparoscopy Including Robotics

Friedrich‐Carl von Rundstedt,¹ Marcelo Chen,² & Richard E. Link³

¹ Department of Urology, University Hospital Jena, Germany

² Department of Medicine, MacKay Medical College, Taipei, Taiwan

³ Division of Endurology and Minimally Invasive Surgery, Scott Department of Urology, Baylor College of Medicine Medical Center, Houston, TX, USA

Introduction

With the increasing utilization of laparoscopy and robotics in urologic surgery over the past two decades, we have observed a shift in the type and frequency of surgical complications that can occur. Although minimally invasive surgery (MIS) provides great morbidity advantages when performed skillfully, the surgical approach differs greatly from the open alternatives. A surgeon transitioning to MIS must learn to recognize and treat a specific set of typical problems associated with this surgical method.

The management of surgical complications truly begins with the anticipation of a potential event. Without anticipation of these critical micro‐events, complication prevention cannot occur. Preparing for surgery is the most important step in this process and will lay the groundwork for a safe, high‐quality operation. Reviewing the medical history and relevant imaging immediately prior to surgery and identifying steps of the operation that may be particularly challenging for an individual patient are common sense but critical. Taking this disciplined approach, even to routine procedures highly familiar to the surgeon, will help avoid preventable complications.

Many of the techniques fundamental to complication avoidance in surgery have been developed and applied successfully by the aviation industry. The implementation of a presurgical checklist and timeout is familiar to most surgeons. These steps ritualize the presurgical review and improve communication among members of the operating room team. Their value has been well demonstrated in various studies [1–6], with the World Health Organization promoting its use in a global healthcare initiative [7, 8]. Beyond the checklist, a very impressive tool in modern aviation safety is called Crew Resource Management (CRM) [9]. The captain and crew of American Airways Flight 1549, who saved all passengers by landing in the Hudson River, referred to CRM as the key to successfully managing a potentially catastrophic complication. CRM aims to optimize the effort of the team in utilizing all resources and information available to a flight crew. A core component of CRM is communication, with the goal of facilitating cooperation. Pilots are encouraged to learn from errors, be willing to accept help from the crew, and use all available resources to make decisions. Many of these skills can be adapted for professional interactions in the operating room (OR) [10, 11]. The surgeon should be open‐minded and pay attention to concerns brought forward by surgical assistants, anesthesiologists, or OR nurses. Likewise, the surgeon’s instruction should be followed efficiently. Although implementation of such safety methodology has been shown to improve surgical outcomes, the current lack of standardized measurement tools limits possible conclusions [8].

Laparoscopy and robotic‐assisted surgery have critically altered the interaction in the OR between the surgeon and other team members. On the positive side, the situation awareness of all team members is improved as everyone can see the surgical field on the video monitor and follow the progress of the operation. Conversely, a robotic procedure poses a unique challenge as the surgeon is not physically present at the bedside and has to rely on continuous feedback from the assistant. Without effective communication by vigilant bedside personnel, the surgeon may be completely unaware of a potentially dangerous evolving situation while his or her head is buried in the robotic console. Alas, even a highly experienced operating robotic surgeon can no longer single‐handedly monitor and control all activity at the operative field. This distributes some of the responsibility for identifying and preventing intraoperative complications onto the shoulders of potentially less experienced or knowledgeable OR staff, possibly increasing risk.

If a complication does occur in the OR, there is great value in providing a debriefing afterwards with all the team members involved. Direct feedback will help prevent avoidable mistakes in the future. Likewise, regular reporting of complications in a morbidity and mortality conference provides an opportunity for valuable peer review and education, which may decrease future complication rates.

Pneumoperitoneum – considerations and complications

The insufflation of CO₂ for the maintenance of a pneumoperitoneum or inflated retroperitoneal space is generally performed at a pressure of 15 mmHg. At the initiation of pneumoperitoneum, severe bradycardia can occasionally be observed and should be anticipated by the anesthesia staff. Bradycardia may occur regardless of the patient’s age and health status and is most likely an effect of a vagal stimulation caused by peritoneal stretch and irritation [12]. This can be seen more commonly during rapid abdominal insufflation through a large‐bore trocar. Prompt desufflation of the abdomen combined with anticholinergic agents will resolve this in most cases, although in rare circumstances this phenomenon can lead to arrhythmias and cardiac arrest [12, 13]. The safest approach is to insufflate slowly at a low flow rate to a pressure of 12–15 mmHg. We also routinely notify the anesthesiologist verbally at the onset of insufflation, communicate actively during this phase concerning the patient’s heart rate, and respond rapidly with desufflation if significant bradycardia develops. If the patient stabilizes swiftly and the anesthesiologist can rule out other potential causes of bradyarrhythmia, the case can generally be resumed without further restrictions.

CO₂ embolus is a rare but potentially lethal complication of peritoneal or retroperitoneal insufflation. Both the laparoscopic surgeon and anesthesia staff must maintain a low threshold to suspect CO₂ embolus if problems develop with intraoperative hemodynamics and/or oxygenation. Although CO₂ embolus can occur at any point in a laparoscopic procedure, the period of initial abdominal insufflation is a high‐risk step. Malposition of either a Veress needle or primary trocar into a vessel or parenchymal organ can result in CO₂ embolus. The risk can be mitigated by using an optical trocar for initial access and by utilizing good Veress needle technique. In particular, aspiration from the Veress needle prior to insufflation is critical to assure that the needle tip does not lie within a vessel with attendant blood return. The incidence of CO₂ embolism during laparoscopy is exceedingly low but can have a fatal outcome with a reported mortality of 28% [14]. Clinical symptoms include systemic hypotension, dyspnea, cyanosis, tachycardia or bradycardia, arrhythmia or asystole [15]. Treatment entails desufflation, ventilation with 100% oxygen, head‐down and left lateral decubitus (Durant’s) position. In severe cases, an attempt to aspirate gas bubbles from the right atrium through a central line may be indicated.

Laparoscopic and robotic surgery are regularly performed with CO₂ insufflation pressures of 12–15 mmHg. However, elevation of the insufflation pressure to 20 mmHg is a common response to venous bleeding during a procedure. This increase in pressure can be remarkably effective in controlling bleeding and facilitating visualization. An increased insufflation pressure does have the potential to worsen venous return, renal blood flow, cardiac output and myocardial function, restrict diaphragmatic excursion, and increase CO₂ absorption, leading to hypercapnia and metabolic acidosis [16, 17]. Metabolic acidosis is compensated through hyperventilation and elimination of CO₂ through the lungs as well as by recruitment of endogenous buffer systems. Patients with limited pulmonary reserve will have less capacity to compensate for prolonged or high‐pressure insufflation and need to be closely monitored for their reduced ability to eliminate excessive CO₂. Some authors have documented the safety of performing laparoscopic surgery under prolonged insufflation pressures of 20 mmHg in patients with normal pulmonary function [18]. It is important to recognize that traditional insufflators allow substantial fluctuation in abdominal pressure throughout surgery in response to leaks, suctioning, and instrument exchanges. More sophisticated modern insufflation systems, such as the AirSeal® device (Conmed, Utica, NY, USA), hold a very steady insufflation pressure at whatever value is selected and can withstand continuous suctioning without dropping pressure. Therefore, prolonged pressure at 20 mmHg using an AirSeal may be significantly more disruptive to normal hemodynamics, oxygenation, and acid–base balance than standard insufflation. We recommend elevating insufflation pressure to 20 mmHg as needed for bleeding but making a conscious effort to return to pressures of 12–15 mmHg as soon as it is feasible to do so during the case.

Abdominal insufflation can result in impaired renal function and low urine output during a laparoscopic procedure. These effects are believed to result from increased intra‐abdominal pressure as well as hormonal changes from activation of the renin–angiotensin–aldosterone system [19]. Hemodynamic changes have a direct effect on parenchymal microperfusion and can lead to acute tubular necrosis and reduced glomerular filtration rate [20, 21]. Although these effects usually do not impair long‐term renal function, patients with underlying chronic kidney disease may experience more significant transiently reduced urine output. Individual cases of irreversible kidney damage have been reported but these are relatively rare events [22]. Decreased urine output during insufflation should be anticipated and anesthesia staff should avoid overaggressive fluid resuscitation, which can lead to fluid overload and pulmonary complications [23].

The specific parameters of abdominal insufflation may also influence the degree of postoperative pain following laparoscopic surgery. Lower insufflation pressures have been clearly associated with decreased postoperative shoulder pain after laparoscopic cholecystectomy [24, 25]. Likewise, a prospective randomized trial demonstrated improved postoperative pain after laparoscopic gynecologic surgery when insufflation pressures were kept to 8 mmHg as compared to 12 or 15 mmHg [26]. In summary, we recommend keeping the duration of abdominal insufflation as brief and the pressure as low as possible for adequate surgical visualization to minimize the risk of intraoperative and postoperative sequelae.

Patient positioning – considerations to prevent complications

Patient positioning must meet several requirements. The first, and most critical, consideration is assuring patient safety. The patient should be secured adequately to the table and all bony prominences and potential pressure points should be well padded. These considerations are especially critical in obese patients. Initial abdominal laparoscopic access often occurs in the supine position and the bed will often need to be moved prior to robot docking (i.e. tipped to the side). Testing the stability of the patient during bed movement is an important step before surgical draping. The anesthesia team must also have access to invasive lines and noninvasive monitoring sites (such as a blood pressure cuff) to allow troubleshooting during intraoperative care.

The second consideration in positioning is to provide acceptable access to the operative field for the surgeon so that the procedure can progress appropriately. The limited operating envelope of the da Vinci™ S and Si systems (Intuitive Surgical, Inc., Sunnyvale, CA, USA) constrains some of these choices for individual procedures unless redocking is planned. Patient positioning should take into account the docking path and position of the robot. The da Vinci Xi system provides substantially more flexibility in defining the operating envelope, allowing all four quadrants of the abdomen to be accessed from a single docking position. Likewise, potential conflicts of the robotic arms outside the patient should be factored into both patient and port positioning. These options may be limited in very thin patients or those of small stature. Even for laparoscopic procedures without robotic assistance, positioning the patient such that gravity can act to retract bowel is generally advantageous. This often means modified flank position for kidney cases and lithotomy with Trendelenburg position for pelvic cases. In all cases, the possibility of conversion to open surgery should be considered in positioning, particularly early in a minimally invasive surgeon’s learning curve.

We position our laparoscopic and robotic kidney cases in a modified flank position (lateral decubitus) (Figure 88.1a). The side of the surgical site is elevated (left kidney–left side up) and the patient rests on a gel roll supporting the shoulders and the hip. The ipsilateral arm is brought over the contralateral side and is supported by pillows (Figure 88.1b) to pad all possible pressure points while avoiding overextension at the shoulder or elbow joints. Some surgeons prefer to place the ipsilateral arm along the patient’s side to minimize potential contact with the cephelad robotic arm when working low in the retroperitoneum. The skin is covered with surgical foam and the patient is secured to the table with 3‐inch (7.5 cm) silk surgical tape at the level of shoulders, hips and feet. We always test the position of the patient by turning the table sideways before the surgical skin preparation. For obese patients, we prefer to use extra tape and padding at the level of the hips and shoulders. Testing of the secure position prior to applying the drapes can help to reveal any weak points.

Image described by caption and surrounding text. — **Figure 88.1** (a, b) Example of patient positioning for laparoscopic and robotic renal surgery.

Patient positioning for pelvic surgery with the da Vinci S or Si systems requires Trendelenburg with the head down (30–40°) and the legs in lithotomy position. Since the da Vinci Xi system allows the arms to pivot on an overhanging boom, lithotomy position can be omitted for pelvic procedures with this system. To prevent the patient from shifting, the arms are usually secured on the sides with or without metal or plastic sleds. We use surgical foam and tape across the chest to prevent shifting toward the head. Custom‐made support systems are available, providing additional support of the shoulders and holding the body in place (TrenGuard™, Pink Pad™) without tape across the chest. For obese patients undergoing pelvic surgery, assuring that the patient can be adequately ventilated when in steep Trendelenburg position should be confirmed with the anesthesia team prior to skin incision.

Nerve injuries

The most common complications in laparoscopy are vascular, bowel, or adjacent organ injuries but peripheral nerve injuries related to positioning can have a substantial impact on postoperative quality of life. Nerve injuries result in up to 16% of anesthesia‐related malpractice claims [27]. A recent analysis of >380,000 anesthesia cases across all surgical specialties revealed only 112 cases of true perioperative nerve injury (0.03%) but 13% of the detected injuries occurred during urologic surgery [28, 29]. Moreover, a review of 2775 urologic laparoscopic cases reported postoperative neuromuscular pain in 5.4% of patients [30]. Knowledge of the most sensitive pressure points can help to reduce the incidence of these type of injuries. The most common injuries arise from overstretching the brachial plexus, or compression of the peroneal or ulnar nerves.

Rhabdomyolysis

Careful padding is also warranted to prevent postoperative rhabdomyolysis, a pressure‐induced tissue injury leading to necrosis of muscle cells. Multiple factors associated with rhabdomyolysis, including hypovolemia, myoglobinuria, and metabolic acidosis, may cause acute kidney injury or renal failure [31]. Rhabdomyolysis is a relatively rare complication of urologic surgery. A recent outcome analysis reported only 870 events out of more than one million urologic cases [32]. However, a known risk factor for rhabdomyolysis is prolonged operative time [33]. This can be a significant risk in laparoscopic and robotic cases early in a surgeon’s learning curve. The incidence of rhabdomyolysis in urologic laparoscopic cases has been reported to be as high as 1% [33, 34]. Immediate postoperative muscular pain, particularly in the buttock, hip, or flank should raise concern for potential rhabdomyolysis. Treatment consists of aggressive hydration and diuresis. Hemodynamic support and temporary dialysis may be required in more severe cases.

Extremity compartment syndrome

Compartment syndrome of an extremity is increased pressure within a closed fascial compartment resulting in perfusion compromise and tissue injury [35]. This most frequently occurs in the trauma setting but can be diagnosed after surgery. In the setting of urologic procedures, compartment syndrome much more commonly involves the lower extremities. The terminology for cases in the lower limb is “well leg compartment syndrome” (WLCS) and will typically occur after prolonged surgery in the lithotomy position. Modifiable factors including heel support, modified lithotomy, avoidance of Trendelenburg and ankle dorsiflexion, as well as the use of intermittent compression devices may reduce the incidence. Extremity compartment syndrome is a clinical diagnosis and should be considered in cases of severe leg pain, lower limb swelling, plantar hypoesthesia, absence of pulse, and pallor. Confirmation of compartment pressures can be performed using a needle inserted into the compartment and connected to a pressure transducer [36, 37]. The treatment is immediate surgical decompression with fasciotomy.

Infectious complications

The risk of urinary tract infection following laparoscopic surgery should not exceed that following open surgery. Clearly documenting a negative urine culture prior to any procedure in which the urinary tract will be violated is appropriate surgical practice. For laparoscopic nephrectomy, the rate of postoperative urinary tract infection has been reported to be 1.4% [38]. Even though some laparoscopic procedures may have significantly longer operative times than their open equivalents, this does not appear to result in an increased risk of sepsis, pneumonia, or surgical site infection [38].

Thromboembolic complications

Thromboembolic complications, including deep venous thrombosis and pulmonary embolus, are some of the most common complications occurring after major surgery. A full description of risk mitigation and management of these complications is outside the scope of this chapter and the reader is referred to detailed recent reviews on this topic [39–42]. Several lines of evidence suggest that thromboembolic complications are less common in minimally invasive urologic, colorectal, and gynecologic procedures as compared to their open counterparts [43–45]. This is despite longer operative times and the negative influence of pneumoperitoneum on venous return for laparoscopic procedures.

Intraoperative surgical complications

Vascular injuries and intraoperative bleeding (see Video 88.1)

The most common type of intraoperative complication in urologic laparoscopic surgery is vascular injury, which has been reported to occur in 1.7–1.9% of cases [30, 46]. Urologic procedures in the retroperitoneum and the pelvis require identification, dissection, and preservation of major vessels including the aorta, vena cava, renal arteries and veins, superior mesenteric artery, inferior mesenteric artery, and iliac arteries and veins. The frequency of vascular injuries during urologic surgery differs from gynecologic surgery, when the most common vascular injuries occur during trocar insertion [47, 48]. Placement of trocars into a desufflated abdomen is strongly discouraged and has been associated with serious vascular injuries [49, 50]. During closed insufflation, placement of a Veress needle should not be limited only to the umbilicus. However, the surgeon should be aware of which structures are at risk for injury when placing the needle elsewhere in the abdomen (Figure 88.2).

2 Illustrations of human body depicting structures at risk during placement of a Veress needle for insufflation throughout the abdomen, with parts labeled retroperitoneum, epigastric vessels, etc. — **Figure 88.2** Structures at risk during placement of a Veress needle for insufflation throughout the abdomen.

The most effective way to avoid injury to major vessels is to anticipate the micro‐events that lead to these complications in advance. One critical step is a thorough review of the relevant imaging preoperatively to identify any vascular anomalies and establish the relationship of the pathology in question to vascular structures. Early in a surgeon’s experience, the use of multi‐plane reconstructions and CT‐angiograms may aid in defining this anatomy.

For nephrectomy procedures, prior knowledge of the number of arteries and veins serving the kidney facilitates a safe procedure. For retroperitoneal surgery on the left side, critical anatomic factors to anticipate include the presence of a large lumbar vein behind the renal artery, the location of the adrenal vein and the presence or absence of a retroaortic renal vein component. (Figure 88.3) The surgeon also needs to recognize the often intimate relationship of the superior mesenteric artery to the renal hilum to prevent a catastrophic complication [51]. On the right side, the junctions of the gonadal and adrenal veins to the vena cava are weak points that should be treated with caution. In pelvic surgery, the iliac vessels and branches are the primary source of major bleeding. Laparoscopic and robotic surgery provide less tactile feedback to aid in dissection, so these approaches demand the surgeon to maintain proper orientation and use visual cues to identify and preserve major vessels [52]. This is particularly critical in robotic cases where shifting orientation by 90° requires only a twist of the surgeon’s wrists and may go unrecognized by both the console surgeon and bedside assistant. The robotic arms are also very strong and can inadvertently avulse major vessels if not monitored visually by the console surgeon [53]. In the case of a large renal mass, parasitic vessels due to neoplastic angiogenesis should be taken into consideration as well as the presence of regional lymphadenopathy that may limit safe access to the hilar vessels. In rare cases with bulky retroperitoneal lymphadenopathy, presurgical embolization of the renal artery may be advantageous [54–56]. Finally, for complex cases requiring vena caval thrombectomy, anatomy and the urologic surgeon’s experience level should determine whether preoperative vascular or cardiothoracic surgery consultation is indicated. It is important to recognize that vascular surgeons facile with laparoscopic or robotic surgery are uncommon so their involvement may require open conversion at many institutions.

Illustration of kidney with 2 boxed area linked by lines to 2 photos displaying danger zone for small arterial branches and adrenal vein and danger zone for venous anomalies (retroaortic renal vein, large lumbar veins). — **Figure 88.3** Example of anticipating micro‐events during left renal dissection that can result in preventable vascular injury.

It makes sense to differentiate between two types of vascular injuries: (i) those intraoperative injuries that are immediately recognized and definitively dealt with during surgery; and (ii) unrecognized injuries that result in bleeding requiring blood transfusion, surgical exploration, or endovascular intervention in the postoperative period. A single institutional analysis from the Cleveland Clinic in 2007 reported intraoperative hemorrhage in 2.3% and postoperative bleeding events in 2.7% of 1867 laparoscopic oncologic cases [57]. Access‐related vascular injuries most often involve the epigastric arteries or superficial vessels of the abdominal wall [58].

The minimally invasive surgeon should have a regimented plan in place to address bleeding during laparoscopic and robotic surgery. This process can be broken down into two phases: an initial “damage control” phase and a subsequent “definitive control” phase (Figure 88.4

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