© Springer International Publishing AG 2018
Jennifer T. Anger and Karyn S. Eilber (eds.)The Use of Robotic Technology in Female Pelvic Floor Reconstruction https://doi.org/10.1007/978-3-319-59611-2_1515. Complications of Robotic Urologic Surgery
(1)
Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98101, USA
Keywords
Pelvic prolapseComplicationsPreventionPelvic floor reconstructionRobotic surgeryMinimally invasive surgeryIntroduction
Urinary incontinence and pelvic organ prolapse are prevalent conditions that affect millions of women worldwide. Approximately 23.7% of women report at least one pelvic floor disorder (PFD ) [1], and it has been estimated that 10% of women undergo surgery for urinary incontinence or pelvic prolapse in their lifetime [2]. However, with the increased awareness of PFDs, these numbers likely represent an underestimate.
As more attention has been placed on PFDs and their treatment, newer techniques have been introduced into the armamentarium of therapeutic options. Among the newer approaches that have been implemented are minimally invasive techniques , including robotic surgery, which have become a mainstay of reconstructive therapy. Given this evolution, it is imperative for surgeons to be familiar with the risks, benefits, and alternatives of these newer procedures. While robotic surgery provides many advantages, including increased visibility due to magnification, ease of performance over laparoscopic surgery, shorter hospital stays, and decreased postoperative pain and recovery time, complications related to the approach can occur. This chapter will focus on complications of robotic surgery and prevention strategies that can be applied to several techniques performed robotically to treat PFDs.
Types of Complications
Though robotic surgery is considered to be a minimally invasive approach, complications may occur—some that are similar to the risks of open surgery and others that are unique to robotic and laparoscopic surgery. Laparoscopy in urologic surgery has a reported complication rate of up to 13% [3] and a mortality rate of 0.2–0.97% [3, 4]. The rate of conversion from laparoscopy to an open procedure in a series of a variety of laparoscopic urological cases was 1.2–1.5% in two large single-institution series [3, 5]. Regarding pelvic floor reconstruction specifically, a meta-analysis of robotic sacrocolpopexy revealed an intraoperative and serious postoperative complication rate of 3% (range 0–19%) and 2% (range 0–8%), respectively [6]. Patients should be thoroughly and carefully counseled on the potential complications that include, but are not limited to, hemorrhage, infection, neurovascular or visceral injury (that may occur outside of the field of view and therefore be missed), failure to progress, necessity to convert to an open procedure, cardiopulmonary events, and complications specific to the robotic approach, including mechanical problems and issues related to trocar placement and insufflation. Failure of the surgery to progress can occur when there are dense adhesions or other anatomic or technical issues that prevent the surgery from advancing toward the goal.
Minimizing the Risk of Complications
Patient Selection
The main keys to minimizing complications in robotic surgery are careful patient selection and surgeon preparedness. Surgeons should anticipate the potential risks as they pertain to each individual patient, with meticulous attention to detail and, whenever possible, minimize avoidable pitfalls. Past medical and surgical history and a careful physical examination should be performed, keeping in mind the numerous factors that can have specific implications in robotic surgery. Contraindications to robotic and laparoscopic surgery include coagulopathy, active bowel obstruction, hemoperitoneum or hemoretroperitoneum, intra-abdominal or abdominal wall infection, and suspected malignant ascites [7]. It is imperative to keep patients informed about all the known risks, benefits, and alternatives of treatment for their condition.
History
A history of chronic obstructive pulmonary disease (COPD) places patients at risk for hypercarbia due to the pneumoperitoneum. Elevated carbon dioxide (CO2) levels can be arrhythmogenic due to the effects of CO2 on the myocardium. Accordingly, patients with COPD should be evaluated with preoperative arterial blood gas and pulmonary function tests, and patients with cardiac arrhythmia should be treated preoperatively.
Prior abdominal or pelvic surgery or history of peritonitis can result in challenges with safe entry into the abdomen. Other concerning history would include benign ascites, abdominal hernia, and aortic or iliac arterial aneurysms .
Physical Examination
Overall performance status should be considered, particularly in the case of elective surgery such as that related to the treatment of pelvic floor dysfunction. Morbid obesity can render robotic surgery difficult due to the need for longer instruments, limited range of motion of the instruments, and challenges with obtaining and maintaining pneumoperitoneum. Morbid obesity can also result in elevated airway pressures that result in the need for abandonment of laparoscopy. Surgical scars may offer insight into the potential difficulty of trocar placement, and it has been suggested that when intra-abdominal adhesions are a concern, the abdomen is best entered subcostally at the left midclavicular line.
Abdominal wall hernias, organomegaly, or a pulsatile mass suggestive of an abdominal aortic aneurysm should be investigated preoperatively to ensure the safest route of entry for the patient.
Perioperative Preparation
Equipment Failure
Complications related to equipment malfunction are largely preventable with meticulous attention to detail. One series of 8,240 robotic surgeries at eleven institutions reported an equipment malfunction rate requiring cancellation of the case at 0.4%, with malfunction of the robotic arms or optics as the most commonly reported reason [8]. Proper training of the surgeon and operating room staff to familiarize the team with the equipment, including its capabilities and limitations, is imperative. Knowledge of troubleshooting techniques and partnership with the technical assist team are also important in order to minimize complications related to the equipment failure.
Patient Positioning
Proper positioning and padding of pressure points are critical to ensure safety in robotic surgery. Generally, in pelvic floor reconstruction, patients are placed in the lithotomy or low lithotomy position. Care must be taken to avoid excessive flexion of the hips or outward rotation of the legs, the latter of which can cause stretching of the femoral nerve. For pelvic floor surgery, the arms may be tucked by the patient’s sides, and the hands and wrists should be placed in neutral position and pronated to avoid brachial plexus injury. Compressions stockings and sequential compression devices should be placed on the lower extremities to minimize the risk of deep vein thrombosis. All pressure points and bony prominences, including elbows, heels, and calves, should be padded to minimize the risk of rhabdomyolsis, compartment syndrome [9], or venous thrombotic events. The patient should be secured to the table using well-padded safety belts or tape across the chest, particularly given the frequent use of the extreme Trendelenberg position in pelvic floor reconstructive cases. Shoulder braces should not be used in this circumstance due to the risk of brachial plexus injury. Gel pads or beanbags can be helpful in preventing cephalad migration of the patient.
Neurologic complications may not be recognized until the postoperative period when the patient has difficulty with ambulation or describes sensory changes. Careful neurologic examination should be performed, and a neurologic consultation obtained. While nerve palsies can resolve within the first few postoperative days, recovery can also be slow, requiring prolonged physical therapy .
Intraoperative Complications
Complications During Abdominal Access
Complications related to entry into the abdomen are critical to understand. Irrespective of whether access is obtained via insertion of a Veress needle or open Hassan technique, injury to viscera or vasculature can occur during this step or during the subsequent insertion of the trocars.
Veress Needle Insertion
Improper positioning of the Veress needle into the abdominal wall can initially be difficult to detect. In fact, 1–2 L of carbon dioxide (CO2) can be instilled with misleading abdominal distention and tympany that appear normal before incorrect placement is realized. However, if initial pressures exceed 10 mmHg, one should consider the possibility that the Veress needle is not located intra-abdominally. Assymetric abdominal distention or a sudden rise in insufflation pressure should also alert the surgeon to malposition of the needle. If incorrect needle placement is suspected, the Veress needle must be repositioned. In the event of multiple unsuccessful needle placement attempts, CO2 evacuation and conversion to the Hasson technique should be considered.
Incorrect Veress needle placement can be avoided by confirmation of proper placement of the Veress needle prior to insufflation of the abdomen using the “aspiration, irrigation, aspiration”, or “drop” technique as well as confirming that the needle can be easily advanced 0.5–1.0 cm without resistance. Upon entry into the abdomen, aspiration should not return blood, urine, or bowel contents; irrigation with sterile fluid should pass easily without resistance; repeat aspiration should return nothing; removal of the syringe should result in a prompt “drop” of the fluid level .
Hasson Technique
The rate of complications related to entry via the open technique is rare compared with that using the Veress technique, though the complications are generally similar. Bowel that is adherent to the underside of the abdominal wall can present a problem during access.
Vascular or Visceral Injury
When aspiration though the Veress needle returns blood, urine, or bowel contents, entry into a vessel, the bladder, or bowel, respectively, should be suspected. Typically, the needle can simply be removed, but once proper entry into the abdomen has been accomplished, the area of concern should be carefully inspected for hemostasis and integrity of the viscera. When initial insufflation pressures are elevated, consideration of entry into a solid organ or the abdominal wall should be considered, the latter described in the section above.
For vascular injuries, application of pressure to the area of concern can facilitate hemostasis. If hemodynamic instability ensues, a general surgery or vascular consultation should be obtained. The risk of vascular complications can be minimized by entry into the abdomen in avascular areas such as subcostally at the midclavicular line or supero-medial to the anterior superior iliac spine. When entering at the umbilicus, the needle should be pointed toward the pelvis. Making a small incision through which the fascia can be grasped, pulled up, and stabilized can also facilitate safe entry.
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