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30 The Intraoperative Consult
471
anastomotic insuffi ciency [ 24 , 25 ]. Often, the equipment
available will determine the method employed.
If, after all of these interventions, you are still unable to
determine if the bowel is viable, temporary closure and reevaluation in 12–24 h may allow better defi nition of nonviable bowel. For ostomies that appear ischemic, resection
back to healthy bleeding tissue is required as these rarely
improve after leaving the operating room.
Vaginal Delivery Complications
Key concept: Early repair may aid in repair of sphincter
injuries following childbirth.
During vaginal deliveries, third- and fourth-degree injuries involve the anal sphincter complex. Colorectal surgeons
have the detailed knowledge of the anatomy of the anal canal,
but rarely see the injuries acutely. This lends itself to a
multidisciplinary approach [ 26 ]. You may be called for these
consultations when the obstetrician has found a deformity
with which he/she is uncomfortable dealing. It is my personal
preference to be called early about these injuries involving
the sphincters and rectal wall because I think that the tissues
are healthier and that the planes are easier to identify. Contrary
to my preference for dealing with the injuries acutely, it has
been shown that if the repairs are done within 72 h or at 14
days, there are not any differences in the long- term functional
outcome [ 27 ]. There are typically two types of injuries. There
are lacerations that involve only the sphincter muscles, and
there are traumatic disruptions that lead to complete avulsion
of the rectovaginal septum resulting in a traumatic cloaca. For
the simpler sphincter injuries, two approaches have been
identifi ed: end-to-end repair and overlapping repair. These
are performed with interrupted sutures approximating the
ends of the muscle in four quadrants or overlapping the
sphincter mechanism. Studies have not shown any difference
in long-term outcomes with either repair [ 28 ]. It has been
shown that the incidence of fecal incontinence is higher in
women if the internal sphincter is not repaired [ 29 ]. If we are
called to the delivery suite, I make a point of demonstrating
the IS to the obstetrician (and residents) as I repair it separately. The internal sphincter (IS) is typically identifi ed as
(white) muscle tissue beneath the mucosa and separate from
the external sphincter. I repair the IS with interrupted Vicryl
suture. My management of the anterior external sphincter is
repair in an end-to-end fashion with interrupted PDS sutures.
Overlapping is certainly acceptable. In the acute situation, it
is rarely necessary to do much mobilization. The tissues are
often quite lax in the puerperal perineum. Other considerations are the importance of bowel-specifi c antibiotics and
performing the repair under optimal circumstances. The latter
often requires moving the patient to an operating room with
proper lighting, stirrups, and instruments. For the traumatic
cloaca, some believe that it is best to allow these patients to
heal over a 3- to 6-month period and then come back for
repair once the infl ammation has resolved and the tissues
soften [
30 ]. Again, I believe the tissues are easier to identify
and work with at an earlier time frame. In addition, women
with the cloaca-type injury are often miserable during the
period of waiting. An enema program using a cone-tip irrigator (used for colostomy irrigation) or even fecal diversion
may make their existence more tolerable.
Endoscopic Complications
Key concept: Endoscopic complications can often be treated
endoscopically, though operative intervention may be
required.
Complications of endoscopy include hemorrhage, perforation, and uncommon problems such as a snare imbedded
into a polyp that cannot be removed. Bleeding can often be
controlled with electrocautery, but this needs to be used with
caution given the potential for ischemia and necrosis with
delayed perforation. Additional methods include the placement of clips over the vessel and submucosal injection of epinephrine. Tattooing the area of bleeding, to allow rapid
localization, can be invaluable if operative control becomes
necessary. Bleeding that does not respond to local endoscopic
techniques may require angiography with embolization.
Perforation may be identifi ed during the endoscopy by direct
visualization of intra-abdominal contents. Tears can be noted
in the mucosa which allow escape of air into the submucosa,
creating the appearance of “bubbles.” If the perforation is full
thickness, placement of a clip for temporary control of contamination may be a useful technique. If the tear is not full
thickness, you may observe the patient clinically. Localized
perforations with minimal free air and localized peritoneal
tenderness may be treated similarly to diverticulitis with antibiotics and careful observation. Due to bowel preparation
prior to the colonoscopy, free perforation is usually associated with minimal contamination. It frequently requires operative intervention, but can usually be managed by primary
closure, with or without resection. If bleeding or perforation
occurs after polypectomy, it may be prudent to try to determine the histology of the polyp. If operation is necessary, it
may be reasonable to perform an oncologic resection.
Occasionally, an electrosurgical snare may become imbedded in a polyp and not cut completely through and be unable
to be withdrawn. In my experience, this may occur with large
submucosal lipomas that have very different conduction
properties than “normal” polyps (Fig. 30.7 ). If additional
pressure on the snare or use of short bursts of “cutting” current does not succeed in removal, it may be best to cut through
the snare and leave it in the colon. This can be accomplished
by using another instrument to push the snare out of the chan-
472
H.R. Bailey and T.C. Isaacson
Fig. 30.8 Crohn’s stricture at the terminal ileum (left lower portion of
picture; Courtesy of Philip Y. Pearson, MD)
anastomosis, it has been shown in a randomized trial that
there were no differences in leak or complication rates with a
Fig. 30.7 Submucosal mass (i.e., lipoma) seen on endoscopy (Courtesy
of Philip Y. Pearson, MD)
side-to-side stapled versus a hand-sewn end-to- end anastomosis [ 31 ]. Most would agree that with abnormally thick-
ened bowel, hand-sewn techniques are safer than staplers. In
addition, the confi guration of the anastomosis has not been
shown to infl uence peri-anastomotic recurrence [ 32 ].
nel as the scope is removed. The plastic sheath can then usually be removed leaving only the wire. The patient can be
observed in the hospital with a tug on the wire once or twice
a day. After a few days, the wire will dislodge and be removed.
The lesson to be learned from this type of experience is not to
try to remove large lipomas with the snare!
Crohn’s disease can also involve other areas of the colon,
such as the sigmoid colon, through fi stulous communication.
Operative conduct depends on the degree of infl ammation in
the bystander organ. If the amount of infl ammation is minimal, disc excision of the fi stulous communication with primary closure can be done. Segmental resection of the ileal or
ileocecal disease then follows. If there is signifi cant infl ammation of the sigmoid, a double resection to reach grossly
Patients with Infl ammatory Bowel Disease
normal appearing (and feeling) tissue at the resection margins may be required.
Key concept: Resection is often required for patients with
Crohn’s disease. Pay attention to the status of any secondarily involved organs as they may require intervention.
Intraoperative Conditions
The diagnosis of right lower quadrant pain often leads to
an appendectomy, but the fi ndings can be unexpected and
Laparoscopic Approach Desired
result in a consultation with a colorectal surgeon. If an appendix is noted to be normal, but the terminal ileum is noted to
be infl amed, the decision about how to proceed centers on
the appearance of the colon. If the appendico-cecal junction
is normal, an appendectomy should be performed and the
patient referred for postoperative medical management of
presumed Crohn’s disease. If the colon is infl amed as well,
there are two options. If the disease is limited and the patient
is not extremely ill, there may be a role for closure and medical treatment. If the patient has extensive disease and is experiencing signifi cant clinical symptoms, resection of this area
is indicated (Fig.
30.8 ). In terms of the confi guration of the
Some surgeons focus on the initial approach of their surgery,
be it laparoscopic or robotic, and may be concerned about
giving the patient a signifi cant incision. This is an issue that
has to be discussed early in the consultation. If I feel that I
cannot do what is necessary without making a larger incision, I would offer the surgeon the opportunity to get another
consultant. It may also be important to discuss the issue of
making a larger incision with the patient’s family. They know
the patient well, and there may be ramifi cations if they wake
up with an incision larger than expected. It is best to include
as many people possible in this discussion.
30 The Intraoperative Consult
Fig. 30.9 Temporary closure of
an open abdomen with a negative
pressure device (Courtesy of
Matthew J. Martin, MD)
473
Not Marked for a Stoma
Key concept: Plan ahead when considering a stoma and do
whatever maneuvers you can to place it in the best possible
location.
If you have any concern that a stoma may be required, this
is something that you should mention early on in your consultation. If the requesting surgeon thinks you should be able
to avoid a stoma altogether and you disagree, a similar discussion as mentioned previously should be undertaken.
Discussion with the family is also of extreme importance. If
the decision is made to proceed and the patient has not been
marked preoperatively, attention to aspects of creating a
proper stoma should be followed. Inspection of the abdomen
should be undertaken to avoid scars, skin creases, and other
disorders of the skin including psoriasis. Although diffi cult,
it is possible to sit the patient upright on the operating table
to observe the abdominal creases. This becomes especially
important in an obese patient to avoid the stoma being hidden below a large pannus or in a valley. Stomas should be
placed through the rectus sheath to reduce the incidence of
hernia formation [ 33 ]. Siting a stoma in the umbilicus is
another alternative described by Raza and colleagues [ 34 ].
Damage Control: How Do You Bail?
There will be situations where the pathology encountered is
so complex, the patient is not doing well, or the bowel has
become too edematous and you will need to make a decision
to control the situation as best possible. If there are multiple
areas of injured bowel, these will typically need to be resected
or closed to prevent further contamination. The “damage control” approach used in trauma may be applicable. The injured
intestine can be removed and the ends closed with staples or
umbilical tape, leaving the bowel in discontinuity for return
when the patient is stable. The abdomen can be closed quickly
using a negative pressure device and the “open abdomen”
technique (Fig. 30.9 ). Additional methods of managing intes-
tinal injury are exteriorization or tube drainage. Injuries can
be brought up through the incision, or a tube can be placed
into the bowel and brought out through the abdominal wall.
Communication with Family
The intraoperative consult frequently leads to other issues outside the operating room. Due to the fact that the operative consent likely did not encompass the procedure you were called
to perform, informed consent must be addressed. Unless the
patient is unstable or my role primarily involves adhesiolysis,
I attempt to breakout and meet with the patient’s family. I
explain the situation, what my plans are, and the risks of the
proposed operation. At this juncture it is important to focus on
doing the right thing for the patient. Once the case is complete
and you know the extent of what you needed to do and the
implications of the unplanned operation, you can address further concerns. They may have questions about what happened
and if this was a mistake. This is also true when talking with
the patient. It is important to try and give the consulting sur-
474
H.R. Bailey and T.C. Isaacson
geon as much credit as is reasonable and still be honest with
the patient and family. Be courteous to the consulting surgeon
as you are now on a team taking care of the patient.
Legal Issues and Documentation
In terms of documentation and legal issues, the previous discussion still holds. Clearly explain the circumstances surrounding your consultation. Give the primary surgeon
recognition for the observation of an issue that was out of
his/her scope of practice, and state without judgment the
fi ndings. Sometimes a less than ideal outcome is due to either
something that you do which does not succeed or your
inability to fi x the problem. When the outcome is poor, continue to be honest, and explain the situation clearly accepting
responsibility for some of the outcome when appropriate.
Above all else, do the safe thing for the patient regardless of
the concerns of the primary surgeon.
Summary Pearls
The ability to properly manage consultations that occur during another surgeon’s case makes you an invaluable resource.
There are many unusual and unique circumstances that can
present, but with proper identifi cation of the problem and
adherence to the surgical principles you have learned, most
can be appropriately and safely managed. Communication
with the requesting surgeon and the family is very important
and will help achieve the best outcome for the patient.
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Laparoscopic Complications
Joongho Shin and Sang W. Lee
Key Points
• Understanding anatomy, tissue planes, the steps of the
operation, and how to prevent potential complications
associated with laparoscopic colectomy is critical.
• Having a consistent, systematic approach is essential in avoiding complications during laparoscopic
colectomy.
• In re-operative laparoscopic colectomy, early proactive conversion is likely to result in favorable outcome. Reactive conversion in response to
intraoperative complications should be avoided.
3 1
As “novice” laparoscopic colon surgeons embark on
mastering the skills of laparoscopic colon surgery, it is crucial that they are cognizant of common complications associated with a laparoscopic approach. It is not only important to
immediately recognize complications and appropriately treat
them when they do occur, but also it is imperative to have a
consistent and systematic approach to each case in order to
avoid them.
In this chapter, we will review most commonly encountered, as well as unique, complications, which are associated
with laparoscopic colon surgery. In addition, we will outline
a systematic approach that focuses on steps to avoid common
pitfalls that can lead to potential complications.
Introduction
Key Concept: Whether you are early in your learning curve or
performing more complex cases laparoscopically, you need to be
aware of the potential complications and how to manage them.
Now that we have multiple large randomized controlled
clinical trials clearly demonstrating equivalent oncologic and
superior perioperative outcomes after laparoscopic colectomies, more colectomies are being performed laparoscopically
[ 1 , 2 ]. Despite proven benefi ts of laparoscopic colectomy,
only about 20–30 % of all elective colon resections are being
performed laparoscopically in the United States [ 3 ]. Although
multiple factors contribute to this tepid gain, a steep learning
curve remains as one of the most important factors.
J. Shin , MD
Department of Surgery , New York-Presbyterian/Weill Cornell
Medical Center , New York, NY, USA
e-mail: jos9071@med.cornell.edu
S. W. Lee , MD, FACS, FASCRS (
Department of Surgery, Division of Colon and Rectal Surgery ,
Weill Cornell Medical College , 525 East 68th Street, 172,
New York, NY 10065, USA
e-mail: sal2013@med.cornell.edu
*)
Tips to Avoiding Complications at the Beginning
Positioning
Key Concept: Ideal positioning provides an optimal surgical
access while minimizing a risk of injury to the patients.
Our preference is to place all patients in the modifi ed
lithotomy position with both arms tucked to the sides. This
provides an excellent access, which allows surgeons to work
in line with the pathology and avoids any confusion among
OR staff members about positioning. By resting both arms to
the sides of the patients, crush injury to digits can occur during replacement of the leg section of the table. We use a combination of a Kerlix bandage roll, an arm board, and a
protective wrap (pediatric diapers) around the hands and
wrists to protect fi ngers and to avoid hyperextension of the
wrist (Fig. 31.1 ). According to American Society of
Anesthesiologist Closed Claim Project database, perioperative nerve-related injuries are one of the most common
The online version of this chapter (doi: 10.1007/978-1-4614-9022-
) contains supplementary material, which is available to
7_31
authorized users.
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_31, © Springer Science+Business Media New York 2014
477
478
Fig. 31.1 Protecting hands with
Kerlix roll and diaper
Fig. 31.2 Patient positioning.
Notice the padding and the
degree of fl exion at the hip
J. Shin and S.W. Lee
complications related to positioning [ 4 ]. Careful positioning
and padding can prevent injuries to upper extremities caused
by stretching or compression.
The angle between the body and the thighs of the patients
should be kept at near 180°, in order to avoid clashing of
instruments with patient’s thighs when working in the upper
quadrants of the abdomen (Fig. 31.2 ). Care should be taken
to avoid hyperextension of the legs at the hips, which can
lead to damage to the sciatic and obturator nerves. This is
best avoided by lowering both legs to the appropriate level
without hyperextending them before draping the patients; a
blind positioning of the legs after draping can potentially
cause injury.
Dealing with the Small Bowel
Key Concept: Gravity is your friend in keeping the small
bowel out of the way and often requires steep changes in
position.
Gaining an adequate exposure away from the small intestines can be a challenge. In general, the working quadrant of
the abdomen should be positioned higher than the other
quadrants, so that the small intestines fall away from the
operative fi eld (Fig. 31.3 ). Although extreme positioning
with routine use of a beanbag and tapes can be helpful, this
time-consuming and cumbersome practice is not necessary,
though admittedly up to individual surgeon preference. More
31 Laparoscopic Complications
Fig. 31.3 Steep positioning will
allow gravity to move the small
bowel out of the way when
working in the pelvis
479
often, a commonly available gel pad placed on the operating
room table provides enough support and traction to keep the
patients from sliding in almost all instances. The use of
shoulder braces, which can cause brachial nerve injury,
should be avoided. In cases where gravity and positioning
are not enough, placing an additional retractor, a moist gauze
pad placed through a larger trocar, a moist laparotomy pad,
or a radiologically tagged surgical towel placed through a
hand-access incision can be helpful in retracting the small
intestines away from the fi eld [ 5 ].
Trocar- and Instrument-Related Injuries
Key Concept: Not only can poor trocar placement lead to a
more diffi cult operation, but trocar and instrument-related
injuries (though rare) can lead to overt or missed injuries to
almost all intra-abdominal structures with devastating
consequences.
Trocar-related injuries might occur regardless of the
type of entry method used. Overall, the incidence of bowel
injury during laparoscopy is relatively small (0.13 %).
According to a meta-analysis performed by Van der Voort
and colleagues [
caused by trocar insertion is the small intestines (55 %)
followed by the colon (38 %). Small bowel injury during
6 ], the most common site of bowel injury
laparoscopic surgery may happen in several ways: (1)
Veress needle injury, (2) thermal injury, (3) crush injury, or
(4) laceration by laparoscopic instrument or ports. Thermal
injury can occur by either lateral thermal spread or stray
currents generating heat along the path between the active
and the ground electrodes (Video 31.1 ). Lateral thermal
spread is less of a concern for bipolar energy device. In a
study using porcine muscles, only the monopolar energy
device increased the temperature of the tissue higher than
the safe level of 42 °C when measured 1 cm away from
the tip of the instruments on 5–15 s applications [
7 ]. More
importantly, for all different types of energy devices (monopolar, bipolar, ultrasonic), the tip remained above the safe
temperature (42 °C) for several seconds. After 5-s application at highest settings, it took monopolar diathermy, ultrasonic, and bipolar device, 35, 10, and 5 s, respectively, for
tips to cool down below the safe working temperature. In
general, it is a safe practice to minimize the use of monopolar diathermy in laparoscopic colectomy and to not touch
any surrounding tissues with energy devices immediately
after prolonged energy activation. Inadvertent currents can
spread by either insulation failure or by direct coupling
[ 8 ]. Direct coupling occurs when an energy device touches
another metallic instrument. To avoid and detect inadvertent energy device-induced thermal injury, it is important
to keep the entire length of the instrument in laparoscopic
480
J. Shin and S.W. Lee
view during energy application whenever it is possible.
Additionally, use of plastic trocars (versus older metal trocars) will minimize the risk of capacitive coupling.
A crush injury to the small intestines happens when a
laparoscopic instrument, such as a bowel grasper, forcibly
pulls in a loop of the small intestines into a trocar. In order to
avoid this type of injury, the instrument should only be
removed after a confi rmation that the jaw of instrument is
empty and closed. A penetrating injury to the small intestines
can occur during a blind insertion of a sharp laparoscopic
instrument. Laparoscopic instruments should be inserted in
the ventral direction away from the internal organs under
direct visualization. The instrument should not be advanced
if any amount of resistance is encountered. Finally, one of
the most common laparoscopic instrument injuries is an
inadvertent serosal tear or wall injury from grasping the
bowel too hard or tearing the bowel while “running” or moving the bowel. Unfortunately, this is often a missed injury as
the instrument and affected bowel are off screen. To minimize this, you should always keep both instruments in plain
view, along with gentle handling of the bowel with atraumatic bowel graspers.
Although rare, a trocar-related vascular injury can result
in a fatal complication. In a review of 696,502 laparoscopic
procedures [
9 ], Azevedo et al., found the incidence of major
vessel injury to be 0.006 %. In order to avoid a major vessel
injury during closed entry, precaution and vigilance need to
be maintained at all times. The patient should be in a fl at
supine position rather than the Trendelenburg position, as the
latter decreases the distance between the sacral promontory
and the abdominal wall, leading to an increase in the risk of
major vessel injury. One of the ways to avoid potential complications related to Veress needle insertion is to limit its use
in re-operative cases. An insertion technique which has
worked very well for us is a technique in which we create a
negative intraperitoneal pressure by pulling up on the stalk
of umbilicus with a Kocher clamp while inserting a Veress
needle through the base of the umbilicus, the thinnest portion
of the abdominal wall. It is important to keep the stopcock of
a Veress needle open to air during insertion, so that a rush of
air into negatively pressured peritoneal cavity will cause the
small intestines to fall away from the abdominal wall immediately upon entry (Fig. 31.4 ).
Unique Complications: Right Colectomy
Fig. 31.4 Veress needle enters the thinnest portion of the abdominal
wall, while negative pressure is being created by pulling up the umbilical stalk with Kocher clamp
Exposure
Obtaining an adequate exposure is a prerequisite to avoid complications in any types of surgery. To achieve this during laparoscopic right colectomy, the patient is placed in the Trendelenburg
position with the right side of the patient tilted up. The transverse colon along with the greater omentum is retracted in the
cephalad direction. Loops of the terminal ileum are gently swept
into the pelvis, and the rest of small bowel is allowed to fall to
the patient’s left side. In diffi cult cases, use of moist gauze
placed through a trocar can be helpful in retracting.
Key Concept: Right colectomy poses the potential for unique
complications including damage to the duodenum, ileocolic/
middle colic vessels, and right ureter. A systematic approach,
knowledge of the pertinent anatomy, and achieving the correct plane of dissection from the start will keep you out of
trouble.
Identifying the Correct Dissection Plane
Embryologically, the colon starts as a midline structure.
As the fetus develops, the colon rotates and fuses laterally to the retroperitoneum. The “white line” of Toldt
31 Laparoscopic Complications
481
a
b
c
Fig. 31.5 ( a ) Entering correct plane from lateral to medial approach.
( b ) Entering correct plane from medial-to-lateral approach. ( c ) Entering
wrong plane from medial-to-lateral approach by dissecting too deep
into retroperitoneum
Fig. 31.6 Strong upward tension of colon mesentery using bowel
grasper with its jaw open allows surgeon to see the interface better
represents the most lateral fusion line between the colon
and the retroperitoneum. The mobilization of the colon
during the resection essentially reverses the fusion process that took place during embryologic development by
surgically separating the two planes. In one sense, it is
more natural to perform this dissection using the lateral to
medial approach. By incising just medial to the Toldt fascia, the potential space between the colon and the retroperitoneum is accessed directly (Fig. 31.5a ). During this
approach, a dissection should not be carried out lateral to
the Toldt fascia as this will likely lead to entry deep into
the retroperitoneum and potential injuries to the retroperitoneal structures.
During the medial-to-lateral dissection, the major vessels
are usually divided fi rst (Fig. 31.5b ). Because the major
(ileocolic, IMA) vessels are located medial to the embryologic fusion plane, there is a natural tendency to delve into
the retroperitoneum (Fig. 31.5c ). This can result in unneces-
sary bleeding and/or injury to retroperitoneal structures such
as the ureter or the duodenum. To avoid getting into the
wrong plane, the right colon and its mesentery should be
tented upward with strong retraction while bluntly separating the retroperitoneum away. This upward tension is best
achieved by bowel grasper with its jaw open wide (Fig. 31.6 ).
The correct plane is usually one superfi cial layer above the
perceived plane. The mantra “the purple goes down” well
describes the process of separating the colon mesentery
away from the retroperitoneum (Fig. 31.7 ).
Fig. 31.7 “Purple goes down.” Medial approach to a right colon demonstrates the yellow undersurface of the right colon mesentery and
“purple” retroperitoneal fascia left down
Identifying/Handling the Duodenum
Identifi cation of the duodenum is the key step in performing
a laparoscopic right colectomy. The relationship between the
ileocolic vessels and the duodenum is constant in all patients.
The ileocolic artery is the fi rst branching artery off of the
superior mesenteric artery below the duodenal sweep.
A gentle anterolateral retraction of the mesentery near the
ileocolic junction will tent up the ileocolic vessels. A wide
mesenteric window is then created below the ileocolic vessels. The duodenum must be identifi ed before ligating the
ileocolic pedicle in all cases (Fig.
common mistakes that can be made early in the experience is
to create a window too distally away from the duodenum. If
31.8 ). One of the most