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20 Overcoming Technical Challenges: Reoperative Surgery
233
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Overcoming Technical Challenges: Prevention and Managing Complications
Bradley R. Davis
21
K e y P o i n t s
• The insertion of the initial trocar offers the biggest potential for injury, and reliance on only one technique has
potential for harm. Knowledge of an open technique and
a percutaneous technique will allow the surgeon the most
versatility in accessing the abdomen.
• Enterotomy, serosal, and thermal injuries are a part of
complex laparoscopy and a strategy must exist to deal
with them. For enterotomies, the decision should be made
immediately if the procedure needs to be converted to
minimize contamination. Serosal and thermal injuries
should be dealt with as soon as they are recognized, as
they may not be able to be found later in the case.
• While several anastomotic techniques are utilized, adhering to the traditional principles of proper tissue handling,
ensuring adequate blood supply, and avoiding tension
remain essential to optimizing outcomes.
• Methods for creating adequate length for a technically
sound left-sided bowel anastomosis include proper mobilization of the splenic fl exure and mesentery, division of
the inferior mesenteric vein near the ligament of Treitz,
ligation of the inferior mesenteric artery, and rectal mobilization (when applicable).
• You should have a stepwise and thorough algorithm for
troubleshooting the diffi cult anastomosis.
• With more operations being performed through minimally invasive approaches, laparoscopic techniques for
mobilizing the colon and maintaining optimal visualization are vital to minimizing complications.
Electronic supplementary material: Supplementary material is
available in the online version of this chapter at
1581-1_21
com/videos/978-1-4939-1580-4
B. R. Davis , M.D. (*)
Department of Surgery , University of Cincinnati Medical Center ,
231 Albert Sabin Way, ML 0058 , Cincinnati , OH 45267 , USA
e-mail:
. Videos can also be accessed at http://www.springerimages.
.
davisbd@ucmail.uc.edu; bradley.davis@uc.edu
10.1007/978-1-4939-
• Leak testing is a critical component to left-sided
anastomoses, and you should understand what to do with
a positive leak test or incomplete doughnuts.
Introduction
The practice of surgery requires a broad skill set with
ever- increasing demands on our technical abilities. The
application of advanced laparoscopic procedures in the management of colorectal disease has provided signifi cant opportunities for our patients while at the same time ongoing
challenges in the operating room. The development of new
technology is constant and pushes the surgeon to learn new
things regularly and perform procedures that may not have
been part of initial surgical training. As a result, there are
going to be instances when complications and technical misadventures occur, but insight into prevention of these complications remains the most effective strategy.
Trocar Insertion
Key Concept: The risk of injury is greatest with the initial
trocar insertion, and the operator should be an expert with
several different techniques for introduction of the initial
trocar into the abdomen.
One of the earliest opportunities for injury occurs during
trocar insertion into the abdomen. The initial trocar insertion
will provide the greatest opportunity for a bad outcome, and
as such several different techniques have been described [
These include an open technique, a blind technique using the
Veress needle, and an optical technique using specialized
trocars that allow visualization of the layers of the abdominal
wall using the laparoscope (Video 21.1 ). Mastery of one of
these techniques is essential for safe access to the abdomen,
and knowledge of more than one is essential to keep the
operating surgeon and the patient out of trouble; however, no
one technique has been shown to be superior with potential
1 ].
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_21, © Springer Science+Business Media New York 2015
235
236
B.R. Davis
Fig. 21.1 CT scan demonstrating a port-site hernia
pros and cons of each [ 2 , 3 ]. A recent review including 28
randomized controlled trials with 4,860 individuals undergoing laparoscopy demonstrated no advantage using any single
technique in terms of preventing major vascular or visceral
complications. Using an open-entry technique compared to a
Veress needle demonstrated a reduction in the incidence of
failed entry (OR = 0.12; 95 % CI 0.02 to 0.92). There were
three advantages with direct trocar entry when compared
with Veress needle entry, in terms of lower rates of failed
entry (OR = 0.21; 95 % CI 0.14 to 0.31), extra-peritoneal
insuffl ation (OR = 0.18; 95 % CI 0.13 to 0.26), and omental
injury (OR = 0.28; 95 % CI 0.14 to 0.55).
Advocates of the open technique regard this as the safest
and most effective means to place the initial trocar [ 4 ],
although there are some limitations. It is very diffi cult to
keep the skin incisions smaller than 1 cm, and larger trocars
(11 or 12 mm) are generally needed to prevent loss of pneumoperitoneum during the case. It is not always desirable or
necessary to have a 12 mm trocar, particularly in the midline,
and placing a trocar using an open technique off midline is
diffi cult in all but the thinnest patients. Additionally, while
acute and chronic herniation can occur through trocars as
small as 5 mm [ 5 ], it is generally acceptable to close the fas-
cial defect of trocars larger than 12 mm [ 6 , 7 ] resulting in
longer overall time using an open technique. Complications
associated with the open technique include enterotomy, vascular and solid organ injury, as well as acute and chronic
herniation, which in the immediate postoperative period
can result in bowel obstruction (Fig. 21.1 ) and need for
emergent repair. In the obese patient, it can be very diffi cult
to visualize the fascia through a small skin incision, and
if necessary, it should be enlarged to ensure an adequate
closure. It’s probably best to avoid this technique altogether
in the signifi cantly obese patients as the abdominal wall
thickness will preclude adequate fascial visualization without a generous skin incision.
The Veress needle is an alternative to the open technique
and can be used alone or in conjunction with an optical view
technique. Traditionally, Veress needles are 14 gauge in size
and are spring-loaded so that when resistance is met, the
blunt end retracts into the needlepoint and tissues such as
fascia and peritoneum can be traversed without signifi cant
trauma. The operator must feel the needle insert into the peritoneal cavity and discontinue advancing once the requisite
number of “pops” is felt and no further resistance is encountered. When centered on the midline, the operator will experience two points of resistance (the midline fascia and the
peritoneum), with the latter causing the spring mechanism to
“pop” as resistance is encountered and the needle abruptly
discontinued (corresponding to the needle traversing the
peritoneum and entering the peritoneal cavity). Confi rmation
of safe access is determined by water drop test in which
saline is introduced into the end of the Veress needle, which if
correctly placed will passively fl ow into the abdomen due to
the lower intraperitoneal pressure relative to the atmosphere.
I fi nd this test to be fi nicky and prefer to simply connect the
insuffl ation tubing set on a fl ow rate of 3 L/m and assess my
opening pressures as determined by the insuffl ator. The initial opening pressure should be low single digit or zero
mmHg but will correlate with the patient’s body mass index
[ 8 ]. Anything higher in a patient who is not morbidly obese
indicates that the needle is not in the correct location and
insuffl ation should be terminated immediately and the needle repositioned or an alternative method of initial access
should be pursued. Veress needles can be used in the midline,
but for re-operative surgery (in which the midline has been
used), an off-midline technique can be employed. Proponents
of this technique recommend the left upper quadrant
(Palmer’s point) as the preferred site [ 9 ] as there is relatively
little that can be injured here. In contrast, the liver edge often
obscures the right upper quadrant, while the lower quadrants
risk bowel and vascular injury and are less desirable locations. Many surgeons will want to elevate the abdominal wall
when using this technique, but this may make it more diffi cult by pulling up on the skin and creating a long distance
between the underlying fascia and the skin entry site. Many
bariatric surgeons recommend not elevating the skin and
simply inserting the needle. The same haptic feedback is
achieved irrespective of skin elevation, and it won’t be necessary to insert the full length of the needle to gain access into
the peritoneum in someone with a lot of subcutaneous fat.
Injuries associated with the Veress needle entry encompass the entire spectrum of bad things that can occur with
initial trocar injury—vascular, bowel, bladder, solid organ,
and air embolism have all been described [ 2 ]. The key to
success in using a Veress needle is experience and discipline.
Multiple passes should never be needed to gain access, and
the entire length of the needle (usually 12–15 cm) should
rarely be needed to reach the peritoneal cavity.
21 Overcoming Technical Challenges: Prevention and Managing Complications
237
The optical view technique or direct trocar insertion is
newer than either the Veress or open Hasson techniques and
relies on the clear plastic material of most modern trocars.
A zero-degree laparoscope should always be used inside the
trocar and the focus should be adjusted so that it is just
beyond the tip of the trocar. Elevating the abdominal wall is
not necessary and can be detrimental in an obese patient, as
the trocar length will not traverse the abdominal fat. The layers of the abdominal wall can be visualized as the bladeless
obturator passes through (Video 21.1 ). When used in conjunction with the Veress needle, the operator will have no
diffi culty identifying the peritoneal cavity as it will be insuffl ated with gas (Video 21.1 ). If the optical view technique is
to be used without establishing pneumoperitoneum beforehand, the surgeon must be experienced in identifying the
layers of the abdominal wall as seen through the trocar [
10 ].
Otherwise, even experienced surgeons who do not routinely
use this technique can fi nd themselves below the omentum or
pre-peritoneal (Video 21.2 ).
Enterotomy, Serosal, and Thermal Injuries
Key Concept: Enterotomies can and will occur during laparoscopy. Initial trocar entry is a risk as is lysing adhesions
in a re-operative abdomen. Immediate control and repair
or resection is necessary to limit contamination.
Enterotomies can and will occur during the conduct of
laparoscopic abdominal surgery. There is a risk of bowel
injury associated with the initial trocar access which has
been estimated between 0.5 and 0.7 % [ 11 , 12 ]. Re-operative
surgery also increases the risk of an enterotomy, and during
re-operative colectomies, the risk is estimated to be less than
1 %; however, this is still signifi cantly higher than the incidence when operating on a virgin abdomen [ 13 ]. When deal-
ing with inter-loop small bowel and pelvic adhesions, the use
of sharp dissection technique is preferred to avoid injury
resulting from energy and heat (Video 21.3 ). Inadvertent
bowel or serosal injuries can often be repaired if a result of
sharp dissection when the true extent of the injury can be
determined. It is imperative that once an enterotomy is made,
it is identifi ed and repaired immediately (Video 21.4 ). This
will avoid any unnecessary contamination and spillage as
well as the risk of not being able to fi nd it later in the procedure. If the surgeon is not comfortable evaluating and closing
the enterotomy laparoscopically, a small abdominal incision
can be made and it can be repaired extracorporeally. Prior to
exteriorization, the bowel should be tagged to facilitate identifi cation of the injury.
Intestinal injury can also occur off-camera, and great care
should be taken to avoid forcing an instrument into the operative fi eld as it may be caught up in the small bowel. This is
particularly true when the patient is positioned in either
Fig. 21.2 A thermal injury is identifi ed on the small bowel antimesenteric surface. Notice that there is a degree of blanching with some very
small visible burn formation. This may not have created any problems
but it is safer to be proactive when dealing with these types of injuries
extremes of Trendelenburg or airplaned in either direction.
In addition, when using energy sources, heat is generated on
the blade of the instrument that can cause small bowel injury
both on and off the camera as the instrument is withdrawn.
Care should be taken when removing any instrument that is
potentially hot, and it is good practice to allow the instrument to cool prior to removing.
A relatively common scenario during laparoscopy is an
inadvertent serosal or thermal injury. It is our practice to
repair serosal injuries irrespective of laparoscopy using a 3-0
Vicryl Lembert suture. It is important that this be done as
soon as they are recognized, as they can be diffi cult to relocate after even a few minutes (Video 21.4 ). This is particularly true during a laparoscopic case where inspecting the
entire bowel can be much more labor intensive than in open
surgery. The utility of oversewing serosal injuries is not well
studied, but animal models have failed to identify any benefi t
[ 14 ]. It is likely that very superfi cial injuries occur frequently
and go unrepaired without detriment to the patient, but in
the absence of demonstrable harm, we suggest repairing
recognized serosal injuries for fear of delayed intestinal perforation and leaks. It is also important to recognize thermal
injuries (Fig. 21.2 ), which can occur during use of electro-
surgical devices and bipolar and ultrasonic energy devices.
It is estimated that such injuries occur between 0.6 and
3 times per 1,000 cases [ 15 ]. Electrothermal injury may
result from direct application, insulation failure, direct coupling, and capacitive coupling. Direct application is probably
the most common and easiest to recognize. Once again, it is
important to immediately evaluate the injury and decide if it
necessitates repair. Finding the injury at a later time will
prove diffi cult irrespective of laparoscopy. The decision to
oversew these injuries will depend on the operator’s judgment
238
B.R. Davis
as to whether the bowel wall integrity has been compromised.
Coagulation burns are deeper than those caused by a blended
or cutting current [
16 ], and injuries that blanch white have
usually gotten hot enough to cause protein denaturation, but
may not result in full-thickness injury. As a rule, if the injury
is a result of a very short burst of energy and there is minimal
tissue change, no further intervention is required.
Bleeding: Intra-abdominal and Pelvic
Key Concept: There are a variety of options for ligating
blood vessels intracorporeally, and the surgeon should
master one of these instruments and then have a plan for
when they fail. All methods for ligating blood vessels are
capable of failing.
The development of reliable energy sources to ligate
major vascular pedicles has been a critical step in moving
laparoscopic colorectal surgery toward the mainstream.
Surgeons now have a reliable method of dividing large (up to
7 mm) vessels and with this the opportunity to encounter
major bleeding, both during and following surgery which
may challenge the laparoscopist more so than during open
surgery. When major bleeding occurs, the laparoscopic surgeon must rely not only on their skill but also those of a
talented assistant. Certainly, silk and Vicryl ties can fall off
of major arteries and veins, but controlling bleeding during
an open surgery is generally less diffi cult when compared to
laparoscopy, and the operator will need to have a skill set and
a plan of action when major bleeding occurs during the conduct of a laparoscopic case.
The current choices for vascular ligation include laparoscopic staplers, clip appliers, bipolar energy, and radiofrequency (ultrasonic) shears or some variation of these
themes. In general, the bipolar products have similar performance characteristics and are approved for 7 mm vessel ligation [ 17 ]. Many authors have favorably compared ultrasonic
devices with bipolar energy, although the vessel indication is
smaller (5 mm) and may result in longer operative time
and greater blood loss when compared to bipolar devices
[ 18 – 20 ].
The use of monopolar electrocautery is appropriate for
dissecting in the avascular anatomic planes, but will not be
effective in dealing with any vessel of signifi cant size. The
use of clips on mesentery and vascular pedicles has largely
been abandoned, as they are inferior to the other readily
available options [ 19 , 21 , 22 ].
It is preferable to be facile with one technology, as repetitive use will result in less bleeding from erroneous application. The cost-effectiveness of staplers vs. energy devices
has been evaluated [ 20 ], and it is my practice to use staplers
to divide the pedicle only if I plan to divide the bowel intracorporeally—a situation in which I would not open any
energy device. All energy devices generate heat and have
some degree of thermal spread. It is important to be mindful
of this when exchanging instruments or when dividing tissue
near important structures that are being preserved. It is also
critical to avoid tension when ligating major vessels, as this
can result in inadequate tissue sealing and bleeding. Arteries
that are heavily calcifi ed may not seal with energy due to the
inability of the proteins to coagulate and an alternate
approach may be preferable in this situation. Fortunately
when energy devices fail, they tend to do so immediately and
delayed bleeding and take backs for vessels that were clearly
sealed at the initial operation are rare [ 23 ].
When bleeding does occur, the most important initial step
is to gain proximal control—an attempt to clip or ligate a
bleeding mesenteric or named arterial vessel without fi rst
controlling the source will be unlikely to work and can result
in injury to important structures (Video 21.5 ). A Maryland
grasper works well for this purpose and it is a good instrument
to have on the Mayo stand at all times. It is good practice to
abandon the technique that resulted in the bleeding and
to proceed directly to an ENDOLOOP
®
(3-0 PDS™ II works
well in this situation, Ethicon Endo-Surgery, Cincinnati,
OH). Reattempting to seal a vessel that is bleeding using
energy may work, but if the proximal side is short and near
the mesenteric root, the stakes for failure can be very high.
This is particularly true when dealing with bleeding venous
structures, as they can be very unforgiving. It is my practice
to always divide the inferior mesenteric vein a few centimeters distal from the duodenum in the event that if it does
bleed, it can be controlled. If it is ligated very short, it may
retract behind the pancreas and can rarely be salvaged
laparoscopically.
When bleeding is somewhat diffuse and the source is
diffi cult to identify, the operator has a few options—the laparoscopic suction irrigator can be diffi cult to use for this purpose, as it will often become occluded with tissue. Vaginal
packing works well in this situation—cut to 15–20 cm strips,
it can be introduced through a 12 mm trocar and act as a
sponge and can be used in concert with the suction irrigator
(Video 21.6 ). Additionally, nasal packing strips are a similar
size and can be easily placed down a standard size trocar.
Care should be taken to remove either right away. A sponge
can also be used but will be more likely to fray and may not
retain its radiopaque strip when cut. A laparotomy pad can be
introduced through a hand port without much diffi culty and
is also a nice way to clear the fi eld. It is imperative to remain
calm during bleeding that is diffi cult to control. It is appropriate to attempt laparoscopic control because the time
required to turn the lights on, get the nursing staff oriented,
open the patient, and isolate the bleeding will typically result
in more blood loss. Therefore, compress the site of bleeding
with a sponge, and if it is not possible to isolate, then maintain the pressure to stem the bleeding during conversion.
21 Overcoming Technical Challenges: Prevention and Managing Complications
239
Pelvic bleeding can be a source of considerable
hemorrhage in both open and laparoscopic surgery. Control
of presacral bleeding can be accomplished laparoscopically
[ 24 ] through a variety of techniques (Video 21.7 ) including a
welding technique using the rectus muscle of epiploic fat.
The use of bovine pericardium has also been described
applied to the bleeding site with a spiral tacker. The best
strategy is to stay in the correct planes posteriorly and use an
energy device laterally to divide the lateral stalks and peritoneum. This will keep the fi eld dry and maintain the critical
exposure, which can be diffi cult in a narrow pelvis.
On rare occasions when pulsatile bleeding strikes the
camera, the operative fi eld will be totally obscured— creating
a situation that is particularly unnerving. It is important to
determine the signifi cance of the bleeding (omental vessel
vs. IMA) and to deal with it as quickly as possible. Typically
the camera operator is the least experienced surgeon or student involved in the case, and the senior surgeon must
quickly take control of the situation. There is no point in proceeding until the visualization of the fi eld can be restored;
therefore, the fi rst priority is to clear the lens by removing
the laparoscope. Blood in the trocar will frustrate any
attempts at good visualization, and if it cannot be cleared
quickly, therefore, an alternate trocar should be chosen for
the camera as long as it provides good exposure to the bleeding vessel. Alternatively, a 5 mm trocar can be upsized to
accommodate a 10 mm laparoscope, which will be less temperamental in the face of blood and debris. Once the operative view has been restored, an assessment of the bleeding
can be made and dealt with appropriately. When necessary,
an additional 5 mm trocar can be inserted to provide a point
of entry for additional instruments or an ENDOLOOP
®
.
Never allow the lack of an additional 5 mm or 10 mm trocar
to result in a conversion, advice that is often lost in the stress
of the situation.
Anastomotic Leak
Key Concept: The most important intraoperative predictors
of a healthy anastomosis are adequate blood supply and
absence of tension. In the event that either of these is not
achieved, the laparoscopic surgeon will need to decide
if converting the case will offer a better chance of success.
A technically perfect anastomosis requires intimate knowledge of the tools being used.
There are innumerable studies looking at the risk factors
and strategies to prevent anastomotic complications with
some general themes that are consistent. Prevention of leak
starts with a meticulous surgical technique, and surgeons can
have the biggest impact on prevention of anastomotic complications by ensuring that the blood supply to the anastomosis is intact and that there is no tension across the anastomosis.
While there is little in the way of data to support the latter
assertion, there is a host of newer data correlating the oxygen
tension in the mucosa of the bowel with rates of anastomotic
leak. Testing the effect of tension across anastomosis has
been done in animal models with demonstration of decrease
of mucosal blood fl ow in the face of increasing tension. The
presence of mechanical forces attempting to disrupt anastomosis does not require a study to demonstrate poor outcomes. The surgeon should do whatever is necessary to make
sure that the bowel that is being joined together does so easily and without tension. The risk of leak for a right colon
anastomosis should be very low, as blood supply and tension
should never be an issue. Care should be taken to avoid the
“180-degree twist” that is unfortunately easier to do than
believed with side-to-side anastomosis and can result in
kinking in the blood supply. For a left colectomy, both blood
supply and tension can be problematic. The surgeon’s decision to ligate the inferior mesenteric artery at its origin will
have an impact on the blood supply to the subsequent conduit. If the descending colon or transverse colon is to be used
as the conduit, the impact is mitigated. With the sigmoid
colon, the marginal blood supply off of the middle colic may
not be adequate to perfuse such a long conduit [ 25 , 26 ]. If it
is necessary to use the sigmoid colon as part of the colorectal
or coloanal anastomosis, the left colic artery should be preserved [ 27 , 28 ]. Length can be achieved by completely mobi-
lizing the attachments of the left colon to the retroperitoneum
and fl exure. The other critical aspect to obtaining adequate
bowel length is mobilizing the mesentery, which will tether
the left colon into the abdomen unless it is freed. To gain
additional length, the inferior mesenteric vein (IMV) must
be ligated adjacent to the IMA and a second time at the inferior border of the pancreas just lateral to the ligament of
Treitz (Fig. 21.3 ). Ligating the vein twice while carefully
preserving the marginal artery at the splenic fl exure will add
several centimeters to the length of the conduit while preserving arterial blood supply. A common error in an effort to
gain length is to divide the colonic mesentery up toward the
splenic fl exure of the colon, with the end result cutting off
the blood supply to the distal conduit, which is now based on
the middle colic artery. If the marginal blood supply is compromised due to inadvertent injury while mobilizing the fl exure or wandering too close the mesenteric border during
ligation of the mesentery, the conduit will become ischemic
and very likely unusable. As a general rule, if the cut edge of
the mesentery traversing the pelvic brim is too tight to allow
a fi nger (or a laparoscopic 5 mm grasper) to easily slip underneath (Fig. 21.4 ), the anastomosis is at risk since the blood
supply is under tension—even if the bowel ends appear to
approximate easily without tension. Every effort should then
be made to lengthen the mesentery, even if this has already
been attempted, as often reassessment will identify a small
adhesion to release. In general, if the mesentery is lax, there
240
B.R. Davis
Fig. 21.3 The inferior mesenteric vein terminate in the splenic vein
and will not be paired with the artery close to this location which can
tether the conduit making it diffi cult for the anastomosis to be created
without tension. The vein can be located in this location near the ligament of Treitz and ligated with clips, staplers, or energy
Fig. 21.4 In this fi gure the conduit can be seen traversing the pelvic
inlet and a grasper can easily slip below without tension
is likely no tension at the anastomosis. In those cases where
only a few centimeters would allow less tension on the anastomosis, distal mobilization of the rectum to elevate it out of
the pelvic hollow can also be a useful maneuver.
There are unfortunately times when despite fully mobilizing both the mesentery and the left colon, the conduit simply
won’t reach the pelvis. This can be due to a number of factors
but is usually associated with a short fatty mesentery. You
then fi nd yourself in a situation where gaining length means
dividing more mesentery (often the transverse mesocolon),
which can result in further ischemia to the conduit and need
for more length. There are limited options when this occurs—
perform a total colectomy and an ileorectal anastomosis or
rotate the right colon 180 degrees around the ileocolic
pedicle in an effort to preserve the ileocecal valve. The latter
option referred to as the Deloyers procedure [ 29 ] has proven
successful, although a comparison to an ileorectal anastomosis has not been reported (Fig. 21.5a,b ). Presumably the sim-
plicity of an ileorectal anastomosis in cases where the entire
rectum is preserved would outweigh the benefi ts of preserving the right colon. However, if part of the rectum has been
resected, then the functional results of an ileorectal anastomosis are likely to be poor, and the Deloyers procedure
would obviate the need for a permanent ostomy. The blood
supply for this procedure is dependent on the ileocolic artery,
and all mesenteric attachments of the ascending colon should
be divided, being careful to preserve the marginal vessel
adjacent to the right colon. The colonic segment is then
rotated clockwise and anastomosed to the rectum. A window
in the ileal mesentery has also been described, but is not necessary, as the colon will be situated anterior to the small
bowel with this maneuver. Manceau et al . described their
experience with this procedure in 48 consecutive cases [ 30 ]
with a median follow-up of 26 months. There were no anastomotic leaks in this series, although 65 % of the patients had
a temporary diverting ileostomy.
An immediate test of an anastomosis to assess for an air
leak is easily performed for colorectal and left-sided resections and may help prevent or identify anastomotic leaks
[ 31 – 33 ]. Some authors advocate endoscopic evaluation as
bleeding from the staple line can also be identifi ed [ 34 ],
although the clinical signifi cance of this intervention is less
clear than an air leak test [ 35 ]. The advantage of the endo-
scopic evaluation of the anastomosis during laparoscopy is
the confi rmation that the bowel is in fact distended—this can
be more diffi cult when occluding the bowel with a laparoscopic grasper as the haptic feedback will be missing and it
is not always evident that the bowel is distended under pressure. If an air leak is identifi ed or some other problem with
the anastomosis (serosal separation, bleeding), then a laparoscopic repair is feasible [
34 , 35 ] if the surgeon has the skill
sets (Video 21.8 ). Intracorporeal suturing can be accomplished more easily if the anastomosis is in the upper rectum
and can be attempted before converting to an open or handassisted case. In addition to the air leak test, the anastomotic
doughnuts should be inspected for completeness. Although
the correlation between incomplete doughnuts and anastomotic integrity is uncertain, it will help the surgeon in the
decision-making process when an air leak does occur.
Regardless of the manufacturer, all of the staplers have a
failure rate, and more importantly, when device failure
occurs, the surgeon must have a plan to salvage the anastomosis. The exact incidence of failure is diffi cult to establish,
but in 2007 Mardestein et al. reported on 1,188 stapler
misfi res reported to the FDA during a 12-month period [
36 ].
Of the misfi res, 588 occurred during colorectal procedures
with failure to form staples and an inability to remove the
21 Overcoming Technical Challenges: Prevention and Managing Complications
Fig. 21.5 Deloyers procedure.
( a ) The attachments to the right
colon are taken down and the
vessels are divided as shown.
( b ) The right colon is rotated
180 degrees around the ileocolic
pedicle in an effort to preserve
the ileocecal valve, and
anastomosis is performed
241
stapler as the most common problem. From these adverse
events, 266 occurred during rectal resections and 80 were
considered major, resulting in 23 unplanned permanent ostomies. Stapler misfi re during a laparoscopic procedure was
associated with a 43 % conversion rate. This high rate of
conversion to open surgery following stapler misfi re was
confi rmed by Pandya et al. in their analysis of 200 consecutive laparoscopic colectomies [ 37 ].
It is unknown how many of these failures were surgeonrelated, but it is imperative that everyone involved in the case
has intimate familiarity with the proper use of the device. The
primary surgeon may not be the person deploying the stapler,
and errors can occur when there is an assumption that a cosurgeon or assistant knows how to properly deploy a given
stapler. In our operating room, the surgery resident is often
responsible for deploying the stapler, and it is not unusual for
him or her to be doing so for the fi rst time. We have avoided
this situation by focused education on the proper use of the
various staplers prior to the operating room for trainees. This
information can also be included into the time-out or preoperative briefi ng procedure so that proper orientation can occur.
Strictures
Key Concept: Strictures usually result from an ischemic
conduit following an anastomosis; however, the use of
improperly sized staplers can also contribute to their development. Recurrence of IBD can also result in stricturing
and may be mitigated by a stapled anastomosis.
Anastomotic stricture following a colon anastomosis is a
well-known, but poorly defi ned, complication. What may
be a “small” narrowing to some is a tight stricture or even
“wide open” to others. Furthermore, outside of symptoms or
scheduled endoscopic follow-up, the anastomosis may not
be evaluated for months or years. As such, it is diffi cult to
determine the actual rate of stricture formation for colorectal
anastomoses. In 2012, Neutzling and colleagues updated
their Cochrane review that consisted of 9 randomized controlled trials with 1,233 patients (622 stapled, 611 handsewn) undergoing a colorectal anastomosis [ 38 ]. While there
were no other signifi cant differences in evaluated metrics
between the two methods, the authors did fi nd stricture was
more common in a stapled anastomosis [risk difference
(random- effects model) 4.6 %, 95 % CI; 1.2–8.1 %)].
While little evidence exists to support one staple diameter
over another, it is our practice to use the largest stapler that
will safely fi t into the conduit and negotiate the rectal stump.
For most adults this is usually 29 mm, and we rarely use the
33 mm or 25 mm diameter stapler. There is some evidence to
suggest that when stapling an ileal pouch to the anus, symptomatic strictures occur more frequently when a 29 mm stapler is used compared to a 33 mm [ 39 ]. Others have suggested
that stenosis is a function of mechanical circular stapling
regardless of the diameter [ 40 ]. We have not seen this in our
practice and maintain like others that symptomatic stenosis
is rare following stapled end-to-end anastomoses [ 41 , 42 ] or
side-to-end anastomosis, especially when careful attention to
preservation of blood supply is maintained.
Converting: How and When
Key Concept: Conversions are a part of every laparoscopic
case and surgeons should understand their personal rate of
conversion and their outcomes. Converting proactively is
242
B.R. Davis
always the best strategy to preserve better patient outcomes.
A hand port can often be used to bridge a straight laparoscopic case and a laparotomy.
Conversions are a part of every practice and will occur
for different reasons including equipment malfunction,
bleeding, obscure anatomy, advanced malignancy, and intraabdominal adhesions. The overall experience of the operator
also infl uences the incidence of conversion with a learning
curve estimated between 30 and 50 cases [
to convert is always diffi cult but should be made as expeditiously as possible as a proactive conversion made early in
the procedure will minimally affect the outcome when compared to the patient who underwent an open procedure [ 44 ].
It is when the surgeon struggles for prolonged periods of
time creating injury and bleeding that the patient will have an
adverse outcome which will be worse than if the procedure
had just been done open [
to open is usually accomplished through a midline laparotomy; however, for surgeons with experience using handassist techniques, alternatives to performing a midline
laparotomy do exist. For many left-sided and pelvic procedures, a Pfannenstiel incision can provide adequate to excellent exposure when used in combination with hand-assisted
laparoscopic techniques. However, the surgeon should be
certain that the lower transverse incision will adequately
accomplish what needs to be addressed. For instance, it
would be risky to attempt to control bleeding from the inferior mesenteric artery pedicle or upper abdominal sources
using this approach. There will be times when a hand port
placed in this location will require a midline extension, and
based on very limited experience, it is advisable to maintain
at least a 2 cm skin bridge between the Pfannenstiel and the
midline incision to prevent total breakdown of the wound.
When faced with a situation in which previous surgery
increases the risk of conversion, the procedure should progress with minimal disposable equipment opened, and then a
single trocar can be inserted to evaluate for suitability so that
the amount of time and money spent for the laparoscopic
procedure is minimized. An alternate approach would be a
hand port placed in the midline to assess adhesions, again
done with care to avoid opening a lot of disposables and
avoiding unnecessary cost. The so-called “peek” port has
been reported in the literature and was found to signifi cantly
limit the number of unnecessary conversions to a totally
open approach [
46 ].
45 ]. Converting from laparoscopy
43 ]. The decision
Pearls and Pitfalls: The Fatty Omentum, Small Bowel, and Maintaining Pneumoperitoneum
Key Concepts: Performance of colorectal laparoscopy requires
unobstructed views of some very important structures.
The establishment and maintenance of pneumoperitoneum,
displacing the omentum and small bowel, and proper
patient positioning are all critical to achieve this level of
visualization.
Omentum
The omentum can be problematic when performing laparoscopy due to its penchant to adhere to anything that has been
infl amed or previously operated on as well as its capacity to
store fat [ 47 , 48 ]. It should be expected that when accessing
the abdomen on a re-operative case, the omentum will adhere
to any previous incision and can be broadly attached to the
abdominal wall. This can result in the initial trocar insertion
being through the omentum and will confuse the novice when
the camera is inserted. Withdrawing the trocar and attempting
to establish a plane between the abdominal wall and the
omentum either through an open technique or an alternate
trocar insertion can usually manage this (Video 21.2 ).
Obese patients can have very thick and stiff omentum
making it diffi cult to get the perfect exposure. Given the
increasing obesity problem in North America, surgeons will
need to be able to deal with these obstacles if a laparoscopic
approach is to be pursued. The basic problem is the competition for space within the insuffl ated abdomen with a fatty
omentum occupying much more of the space that a surgeon
needs to adequately visualize important structures. As an
example, many surgeons approach a right colon by placing
the patient in Trendelenburg with the intention of using gravity to allow the small bowel to occupy the upper abdomen
while the ileocolic pedicle is being exposed and ligated.
However, with a fatty omentum the upper abdomen becomes
congested and space is limited. The small bowel has nowhere
to go and the visualization is impaired. My approach to the
obese patient for a right colectomy is to take advantage of
gravity and the cephalad location of the ileocolic pedicle.
The patient is placed in steep reverse Trendelenburg and the
small bowel passively hangs into the lower abdomen and
pelvis. To allow visualization of the bare area of the right
colon and the vascular pedicle, the omentum is literally
stuffed into the upper abdomen and held there by the assistant (on the patient’s right side). This is accomplished by lifting directly up on the transverse colon toward the abdominal
wall which then acts as a gate to keep the omentum tucked
upward. An additional trocar may be necessary which is generally a good advice when dealing with diffi cult anatomy or
obese patients.
It is generally less of a problem when dealing with
left- sided anatomy. However, the omentum can become
problematic in attempting to mobilize the splenic fl exure,
especially if attempting to do so by fi rst entering the lesser
sac between the colon and the omentum. The same problem
of limited space seen on the right will come into play when
trying to lift the omentum out of the left upper quadrant.
21 Overcoming Technical Challenges: Prevention and Managing Complications
243
An alternate approach, which again relies on gravity, is to
leave the omentum on the colon by dividing it along the
greater curve of the stomach and letting it hang down in the
lower abdomen.
While it is generally desirable to preserve the omentum
during a total colectomy, there are times when its size will
become such a liability in terms of completing the procedure
safely without converting to open surgery, that it is necessary
to remove it. This can be done easily in the era of effective
laparoscopic energy devices. This will likely prove to be necessary in a very limited number of cases usually involving
obese men who carry their weight centrally. These patients
also tend to be shorter, which can signifi cantly limit the
amount of space available to safely visualize the mesentery,
the major vascular pedicles, and the at-risk retroperitoneal
structures such as the duodenum and left ureter.
Small Bowel
Like the omentum, the small bowel can also be problematic
when performing a laparoscopic colectomy and can be the
difference in terms of being able to complete the procedure
without converting to either hand-assist or open. It is often
the obese patient that poses the biggest diffi culty in terms of
the small bowel obscuring the operative fi elds due to the
short nature of their mesentery. This is usually worse in men
due to their tendency to deposit fat stores intra-abdominally.
For right-sided procedures, the small bowel can be
directed toward the pelvis by placing the patient in steep
reverse Trendelenburg, and this is usually not a problem. The
lateral-to-medial approach will also be easier in cases when
the small bowel is problematic, but my preferred approach
for dealing with this particular issue is a hepatic fl exure down
approach. The omentum can either be left on the colon or
dissected off (it usually can be done even with the patient in
this position) and the hepatic fl exure attachments can be
divided using a bipolar or other energy device from the
patient’s left side. The duodenum will be quickly identifi ed,
and the remaining ascending colon can be mobilized from
top down. It is not until the appendix and ileal attachments
need to be mobilized that the patient will need to be tilted
into Trendelenburg. Once the right colon is completely
mobilized off the retroperitoneum, the decision can be made
to take the vascular pedicle intra- or extracorporeal as it will
be somewhat easier to identify once the colon can be lifted to
the abdominal wall.
For left colectomies, the small bowel will need to go
cephalad and the only good way to make this happen is steep
Trendelenburg. It is often the distal ileum that obscures the
visualization of the window below the inferior mesenteric
artery. If this is a problem, take a moment to assess whether
there are any adhesions that can be divided of the ileum and
the right pelvic sidewall. Often patients have congenital
Fig. 21.6 When the small bowel will not passively fall into the upper
abdomen, the operator must assess whether there are any adhesions
from the ileum to the right pelvic sidewall that may be tethering the
bowel into the lower abdomen. Dividing these adhesions should free up
the ileum enough to fall away passively with gravity
adhesions of the ileum into the pelvis that will hinder your
ability to completely displace the small bowel into the upper
abdomen (Fig. 21.6 ). If the view remains compromised
despite these maneuvers, then the operator has limited
choices. My approach is to proceed with a lateral-to-medial
approach and work the colon and fl exure in this way. The
small bowel will rarely hamper your ability to mobilize the
splenic fl exure. Alternatively, a hand-assisted left colectomy
can be attempted as the proper use of the operator’s hand can
signifi cantly increase the ability to retract the small bowel.
In addition, a sponge can be brought in through the hand port
and used to shield the small bowel from potential injury from
cautery or energy.
Airway Problems
One unique situation that can be very diffi cult to deal with
is that of an inadvertent esophageal intubation. Just a few
squeezes of an Ambu bag in the esophagus can completely
fi ll the small bowel with air and little can be done to dissipate
it. If a diffi cult airway is anticipated, a discussion with the
anesthetist is warranted to minimize the chances of this complication. With modern tools such as the glide scope, this
type of complication should be minimal.
Pneumoperitoneum
Pneumoperitoneum is an essential part of every laparoscopic
procedure, and while physiologic derangements occur in
every patient subjected to positive intra-abdominal pressure,
the clinical consequences are generally limited. These effects
may be exacerbated by the use of steep head-down positioning [ 49 , 50 ] and obesity [ 50 , 51 ]. Decreasing the insuffl ation