Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_232_библиотеки_им_акад_М_И_Перельмана
.pdf
3. Laparoscopic Entr
y
Techniques: Consensus 2
3
O
pen Versus Closed Laparoscopy
H
asson-Sty
l
e Access Versus Verres
N
eedle
/
Trocar Acces
s
Sa
f
et
y
F
ourteen stu
d
ies in t
h
e
l
iterature provi
d
e in
f
ormation on t
h
e comparative
s
a
f
ety o
f
Hasson-sty
l
e access versus Verres nee
dl
e / trocar access [25–37],
inc
l
u
d
ing 2 a
b
stracts [38,39], 2 series representing t
h
e Hasson tec
h
nique in a
tota
l
o
f
2506 patients [40,41], an
d
8 series using t
h
e nee
dl
e/trocar tec
h
nique
on a tota
l
o
f
80,785 patients [42–49].
A
review o
f
wor
ld
wi
d
e experience re
l
ate
d
to comp
l
ications o
f
gyneco
l
ogic
l
aparoscopic operations invo
l
ving 1,549,360 patients s
h
owe
d
an overa
ll
com-
plication rate ranging from 0.2% to 10.3%. Various complications described
are detailed in the following paragraphs
.
Mortal
i
ty
N
o deaths are reported as a consequence of primar
y
-access complications
in either the open or closed laparoscop
y
g
roups in an
y
of the 4 randomized
controlled trials [25–28]. No deaths are reported in open-laparoscop
y
patients
in the nonrandomized controlled trials; however, 1 closed-laparoscop
y
patient
died as a consequence of an unreco
g
nized trocar in
j
ur
y
to the bowel, leadin
g
to several laparotomies and eventuall
y
death b
y
m
y
ocardial infarction [33]. In
a case series usin
g
closed laparoscop
y
, reportin
g
on predominantl
y
lar
g
er
s
ample sizes, 2 deaths were reported in 1 stud
y
[43]—due to an epi
g
astric vein
in
j
ur
y
in one case and an unreco
g
nized
g
astrointestinal in
j
ur
y
in the other
case—and a further death was caused b
y
needle in
j
ur
y
to the iliac arter
y
in
another stud
y
[48].
Bowel In
j
ur
i
es
Ab
out one t
h
ir
d
to one
h
a
lf
o
f
b
owe
l
in
j
uries are re
l
ate
d
to entr
y
, an
d
t
h
e
rest are cause
d
d
urin
g
t
h
e operative proce
d
ure. A
l
t
h
ou
gh
operative
b
owe
l
in
j
uries are uncommon (0%–0.5%), t
h
e
y
occur more
f
requent
ly
t
h
an ma
j
or-
vesse
l
in
j
uries. In t
h
e Unite
d
Kin
gd
om, t
h
e inci
d
ence o
f
b
owe
l
in
j
ur
y
is on t
h
e
or
d
er o
f
0.4 per 1000 cases. W
h
i
l
e t
h
is
l
ow rate is reassurin
g
, it sti
ll
imp
l
ies
t
h
at a
b
out 50 women in t
h
e Unite
d
King
d
om wi
ll
su
ff
er
l
aparoscopic entry-
re
l
ate
d
b
owe
l
d
amage eac
h
year. T
h
e co
l
on an
d
sma
ll
b
owe
l
are invo
l
ve
d
at
a
b
out t
h
e same rate. However, most intestina
l
in
j
uries are not reco
g
nize
d
intraoperative
ly
, an
d
peritonitis or possi
bly
d
eat
h
su
b
sequent
ly
occurs. For
t
h
is reason,
b
owe
l
injuries are one o
f
t
h
e most common causes o
f
postopera
-
tive
d
eat
h
re
l
ate
d
to
l
aparoscopy
.
A
compoun
d
ing
f
actor in t
h
e
d
e
l
aye
d
d
iagnosis is t
h
at most patients wit
h
a
l
aparoscopic intestina
l
injury
d
o not present wit
h
t
h
e typica
l
f
eatures o
f
per
f
orate
d
viscus
b
ut present wit
h
vague
f
eatures suc
h
as
l
ow-gra
d
e
f
ever,
https://t.me/med1917
2
4 S. Lalchandani and K. Philli
p
s
l
eucopenia, or a norma
l
l
eu
k
oc
y
te count. Nausea, vomitin
g
, i
l
eus, an
d
severe
abd
omina
l
p
ain are uncommon
f
eatures.
O
n
ly
1 ran
d
omize
d
contro
ll
e
d
tria
l
provi
d
es
d
ata on t
h
e ris
k
o
f
b
owe
l
i
n
j
ur
y
, an
d
it
f
oun
d
no
d
i
ff
erence
b
etween open an
d
c
l
ose
d
access [27],
b
ut
again a wide confi
de
n
ce
in
te
rv
al
could
be
a
r
easo
n
fo
r
a
n in
co
n
clus
iv
e
r
esult.
C
onversel
y
, a metaanal
y
sis of nonrandomized controlled trials demonstrates
t
wice t
h
e ris
k
o
f
b
owe
l
in
j
ur
y
in open
l
aparoscop
y
compare
d
to c
l
ose
d
l
apa-
r
oscop
y
[
29,33–35
].
ascular In
j
uries
M
ajor vascu
l
ar injuries t
h
at occur a
f
ter entry are muc
h
l
ess
f
requent t
h
an
th
ose t
h
at occur
d
uring t
h
e
bl
in
d
-entry p
h
ase o
f
t
h
e operation. T
h
e rate o
f
v
ascu
l
ar injury is reporte
d
to range
f
rom 0.003% to 1.33% w
h
en access occurre
d
th
roug
h
t
h
e nee
dl
e/trocar tec
h
nique [27]. A
l
arge Dutc
h
review compare
d
t
h
e
i
nci
d
ence o
f
vascu
l
ar injury in t
h
e c
l
ose
d
tec
h
nique in 489,335 patients wit
h
th
at o
f
12,444 patients in w
h
om open
l
aparoscopy was per
f
orme
d
[33]. In t
h
at
c
o
h
ort, t
h
e inci
d
ence o
f
major vascu
l
ar injury using t
h
e c
l
ose
d
tec
h
nique was
0
.075%, an
d
0% w
h
en open
l
aparoscopy was per
f
orme
d
. Catastrop
h
ic
h
emor
-
rhage may occur if the sharp tip or edge of a laparoscopic trocar or insuffl
at
i
on
n
ee
dl
e injures one o
f
t
h
e major vesse
l
s, w
h
ic
h
inc
l
u
d
e t
h
e aorta, t
h
e in
f
erior
v
ena cava, an
d
t
h
e common, interna
l
, an
d
externa
l
i
l
iac arteries an
d
veins. In
a
review o
f
8 intraoperative major vascu
l
ar injuries, one
h
a
lf
o
f
t
h
e patients
r
equire
d
l
aparotomy,
b
ut
l
aparoscopic repair was possi
bl
e in t
h
e ot
h
er
h
a
lf
49]. Major vascu
l
ar injuries t
h
at occur intraoperative
l
y,
l
i
k
e t
h
ose t
h
at occur
d
uring entry, are associate
d
wit
h
a
h
ig
h
morta
l
ity rate (12.5%), an
d
a
b
out one
h
a
lf
o
f
t
h
e patients require trans
f
usion [49]
.
r
i
nar
y
In
j
ur
i
es
U
rinary injuries
h
ave
b
een o
b
serve
d
in 0.02%-1.7% o
f
l
aparoscopies,
w
hich is not different from the number observed in open gynecologic surgery.
B
ladder injuries are more common than ureteral accidents and also are more
c
ommon
l
y recognize
d
intraoperative
l
y t
h
an are uretera
l
l
esions. A review o
f
5
8 bladder and 47 ureteral injuries showed that bladder injuries were not
d
iagnosed intraoperatively in only 9.2% of laparoscopic operations, but ure-
t
eral injuries, like intestinal injuries, were not noticed in 93.7% of cases [50].
I
n a series of 953 major laparoscopic procedures, 15 urinary injuries (4 ureteral
a
nd 11 vesical) were observed, for an overall urinary complication rate of 1.6%
51]. However, in this series, intraoperative diagnosis was established in onl
y
5
3.3% of patients, and 46.6% of patients required reparative laparotomy
.
Careful identifi
cation of the ureters in areas where the pelvic ureter is
e
asily exposed should prevent injuries above and near the uterine vessels
.
H
em
a
t
o
m
a
A
n a
bd
omina
l
wa
ll
h
ematoma may
b
e note
d
postoperative
l
y in a patient
i
n w
h
om no
bl
ee
d
ing occurre
d
intraoperative
l
y; t
h
e inci
d
ence o
f
t
h
is injur
y
r
anges
f
rom 0.1% to 2.1% wit
h
t
h
e open tec
h
nique compare
d
to 0%–0.5% wit
h
https://t.me/med1917
3. Laparoscopic Entr
y
Techniques: Consensus 2
5
t
h
e c
l
ose
d
tec
h
nique [29,32,33,41,42,44]. Occasiona
lly
, an a
b
scess ma
y
d
eve
l
op
due
to
a
n in
fected
he
m
ato
m
a
of
the
a
n
te
ri
o
r
abdo
min
al
w
all.
Herni
a
a
t the Site
o
f A
bdo
min
a
l W
a
ll Tr
o
c
a
r
A
major a
d
vantage o
f
l
aparoscopic surgery is t
h
at t
h
e inci
d
ence o
f
ventra
l
h
ernia
f
ormation is
l
ower t
h
an t
h
at wit
h
a
l
aparotomy incision. A review o
f
l
iterature suggests t
h
at t
h
e inci
d
ence o
f
incisiona
l
h
ernia associate
d
wit
h
l
apa
-
roscopic gyneco
l
ogic surgery is 0.06%-1%, an
d
t
h
at associate
d
wit
h
genera
l
s
urgery is 0.8%-1.2%,
b
ot
h
o
f
w
h
ic
h
are 10 to 100 times
l
ower t
h
an t
h
e inci
-
d
ence a
f
ter
l
aparotomy incision [33,45]. Hernias t
h
at
d
eve
l
op at t
h
e trocar site
usua
ll
y resu
l
t
f
rom t
h
e
l
ac
k
o
f
c
l
osure or improper c
l
osure o
f
trocar woun
d
s
an
d
, in most instances, are a preventa
bl
e comp
l
ication.
W
ou
n
d
Infect
io
n
W
ound infection at the primar
y
access site is uncommon; most wound
infections are minor skin infections that can be treated successfull
y
with
expectant mana
g
ement, draina
g
e, or antibiotics. Severe necrotizin
g
fasciitis
can occur. Co
g
liandolo et al. showed hi
g
her incidence of wound infection at
the primar
y
access site associated with open method compared to closed
method [27]. Conversel
y
, Si
g
man et al. showed hi
g
her incidence of wound
infection at the primar
y
access site associated with closed method compared
to o
p
en method [29].
Compl
i
cat
i
ons Related to Pneumoper
i
toneum
Extra
p
eritoneal Insufflation. The most common causes of extra
p
eritoneal insuf-
ation are preperitoneal placement of the insuffl
ating needle or leakage of
carbon dioxide around the cannula sites. The amount of retro- or
p
re
p
erito
-
nea
l
d
issection ma
y
a
l
so
b
e a
f
actor. Usua
lly
t
h
is con
d
ition is mi
ld
an
d
is
l
imite
d
to t
h
e a
bd
omina
l
wa
ll
. Su
b
cutaneous emp
hy
sema can
b
ecome exten
-
s
ive, invo
l
vin
g
t
h
e extremities, t
h
e nec
k
, t
h
e me
d
iastinum, an
d
even t
h
e peri
-
car
d
ium, an
d
can resu
l
t in
hy
percapnia an
d
car
d
iovascu
l
ar co
ll
apse. Most
s
tu
d
ies reportin
g
on nee
dl
e/trocar
l
aparoscop
y
h
ave rates o
f
extraperitonea
l
insuffl
ation ranging from 0.05% to 10.7%. Only 1 study reported the occur-
rence of extraperitoneal insuffl
ation using the open technique [28].
G
a
s Em
bo
lism
.
Gas embolism is a complication resultin
g
from the direct entr
y
of the
g
as into the arterial or venous s
y
stem. This usuall
y
occurs durin
g
or
shortly after insuffl
ation, but it may result from the direct intravascular insuf-
ation of argon or other gases during the operation. It is an uncommon com-
plication but is associated with hi
g
h mortalit
y
rate. In a recent metaanal
y
sis
of nearl
y
500,000 closed-entr
y
laparoscopies, the incidence of carbon dioxide
embolism was 1 (0.0014%) in 71,428 la
p
arosco
p
ies [33]. Two deaths occurred
in a series of 7 cases of
g
as embolism, for a mortalit
y
rate of 28.5% [52].
Com
p
lications Related to Anesthesi
a
F
or
l
aparoscopy, t
h
e major comp
l
ications re
l
ate
d
to anest
h
esia are not
d
i
ff
erent
f
rom t
h
ose t
h
at occur in open-access cases. Car
d
iac arrest
h
as
b
een
https://t.me/med1917
2
6 S. Lalchandani and K. Philli
p
s
r
eporte
d
in 0.002%-0.003% o
f
l
aparoscopies, usua
lly
b
ecause o
f
a pro
f
oun
d
v
asova
g
a
l
response to rapi
d
peritonea
l
d
istension, t
h
e patient’s position,
i
ncrease
d
a
bd
omina
l
pressure, or air em
b
o
l
ism [53]. Car
d
iac arr
hy
t
h
mias
h
ave
b
een reporte
d
in 27% o
f
patients un
d
ergoing
l
aparoscopy [53].
C
onversions/Complications Requiring Laparotom
y
T
wo randomized controlled trials su
gg
ested an increased risk of laparo-
s
copic cases being converted to laparotomy as a consequence of closed-access
c
omplications, demonstratin
g
a 68% protective effect for open laparoscop
y
25,27]. In a review of literature comprising 411,139 patients, the overall rate
o
f conversion to laparotomy was 2.1%. For minor laparoscopic procedures,
t
he conversion rate was 1.2%, and for ma
j
or operations, the rate was 2%
25,35,43,48,54]. The 2 most common reasons for conversion to laparotom
y
w
ere major vascular injury and major intestinal injury.
H
ospital Readmission
s
Ab
out 0.4%-0.5% o
f
t
h
e tota
l
num
b
er o
f
patients w
h
o
h
a
d
l
aparoscop
y
w
ere rea
d
mitte
d
to t
h
e
h
ospita
l
a
f
ter
d
isc
h
arge [55].
iti
g
ation
W
here do we stand in relation to complications related to Laparoscopic
p
rocedures? Retrospective claim reviews from Canada, the United States, and
A
ustralia indicate that the primar
y
port entr
y
leadin
g
to bowel in
j
ur
y
and
d
ela
y
in its reco
g
nition constituted the leadin
g
cause of successful claims.
S
imilarly, vascular injuries associated with Verres needle or primary port entr
y
leading to signifi
cant morbidity or mortality were another cause of litigation.
I
n all the above cases, the payment ranged between $7,500 and $4,980,086 in
t
he United States and $1,500 and $315,955 outside the United States, depend
-
i
ng upon incremental disability or death incurred to the patient [56–58].
ow to Minimize the Risk of Com
p
lications
Ident
i
f
i
cat
i
on of R
i
sk Factors
. Previous abdominal sur
g
er
y
: The use of an alternative access site
should be considered, for example, right upper quadrant
.
2. Patient weight: In obese patients it may be more diffi
cu
l
t
to
estab
li
s
h
p
neumo
p
eritoneum due to the increased distance between the
p
eri
-
t
oneum and the surface of the abdomen. In very thin patients, the
r
isk of complications is higher due to the reduced distance between
t
he surface of the abdomen and the large blood vessels.
https://t.me/med1917
3. Laparoscopic Entr
y
Techniques: Consensus 2
7
3. Patient
p
osition: T
h
ere is consi
d
era
bl
e
d
e
b
ate w
h
et
h
er su
p
ine or
T
ren
d
e
l
en
b
ur
g
position is sa
f
e
f
or primar
y
trocar entr
y
. It is possi
bl
e
th
at Tren
d
e
l
en
b
ur
g
position ma
y
cause
l
oss o
f
orientation
d
urin
g
n
ee
dl
e/trocar insertion an
d
increase t
h
e ris
k
o
f
comp
l
ications. A
l
so,
the benefi
t of having the abdominal organs drop away from the
i
nsertion site ma
y
re
d
uce t
h
e ris
k
o
f
b
owe
l
comp
l
ications
b
ut expose
th
e major vesse
l
s an
d
t
h
ere
f
ore increase t
h
e ris
k
o
f
vascu
l
ar injury
.
4
. Access site: Access in a perium
b
i
l
ica
l
area is more
l
i
k
e
l
y to
b
e associ
-
a
te
d
wit
h
severe vascu
l
ar in
j
ur
y
(e.
g
., aorta, vena cava) t
h
an access
th
roug
h
t
h
e upper a
bd
omina
l
qua
d
rants, w
h
ere pneumot
h
orax or
h
epatic
l
esions may
b
e more common.
5
. Surgica
l
expertise: Patients o
f
a we
ll
-traine
d
an
d
experience
d
surgeon
a
re
l
i
k
e
l
y to
h
ave a
l
ower ris
k
o
f
comp
l
ication
.
Use of Newer Instruments
. Blunt-tipped trocars ma
y
provide less risk of in
j
ur
y
, althou
g
h sharp,
s
afet
y
-shielded trocars have not been associated with lower compli
-
cat
i
o
n r
ates.
2
. O
p
tical trocars and o
p
tical Verres needle are also new instruments
a
nd are safe and eas
y
to handle. The
y
offer several advanta
g
es over
t
he use of the ordinar
y
Verres needle and the minilaparatom
y
.
3. The sin
g
le-use Step Radial Expandin
g
S
y
stem (Innerd
y
ne, Salt Lake
C
it
y
, Utah) should prevent most t
y
pe 1 in
j
uries. This s
y
stem ma
y
a
lso sometimes dis
p
lace rather than
p
enetrate tissue when bowel is
a
dherent to the entr
y
site, and thereb
y
also reduce the incidence of
ty
pe 2 in
j
uries. There is less tissue trauma and less pain. This s
y
stem
uses a Verres needle with a polymeric sleeve. Following insuffl
ation
,
t
he needle is removed, leavin
g
the outer sleeve in situ. Direct dilation
o
f the sleeve and therefore the track is obtained b
y
the use of a sin
g
le
a
ppropriatel
y
sized dilator (up to 12 mm). This s
y
stem has a Food &
D
ru
g
Administration (FDA) approval with re
g
ard to its safet
y.
4
. The reusable EndoTIP s
y
stem (Endoscopic Threaded Ima
g
in
g
Port,
K
arl Storz Endoscop
y
, German
y
) is desi
g
ned in such a wa
y
that it is
i
nserted without a trocar, allowin
g
the laparoscope to be positioned
t
o
g
ive visualization of the la
y
er-b
y
-la
y
er entr
y
into the peritoneal
cavity. The potential benefi
ts
wi
t
h
t
hi
s
de
vi
ce
in
c
l
ude
n
o
t
r
oca
r
use
a
nd endoscopic visualization of the tissue bein
g
penetrated. The
e
xternal threads of the cannula cause the la
y
ers of the abdominal
w
all to be lifted u
p
, rather than
p
ushed down toward the viscera,
w
hich limits the risk of visceral or blood vessel in
j
ur
y
[59,60]. As the
c
annula is rotated down to obtain access, it is su
gg
ested that in
j
ur
y
i
n the muscle, fascia, and peritoneum is not ali
g
ned, thereb
y
reduc
-
i
n
g
the incidence of incisional hernia.
These may be some of the logical benefi
ts of these systems, but large-scale
trials would be required to prove their effi
ciency before widespread use can be
recommended. However, the number of procedures required ma
y
be prohibi-
tive in the desi
g
n of such trials.
https://t.me/med1917
2
8 S. Lalchandani and K. Philli
p
s
ec
o
mmen
da
t
io
ns
A
s wit
h
an
y
sur
g
ica
l
tec
h
nique, t
h
e
l
aparoscopic approac
h
is associate
d
with complications, which must be offset against the expected clinical benefi
ts.
A
number of com
p
lications of the la
p
arosco
p
ic a
pp
roach, as described above,
e
it
h
er
d
o not occur or occur muc
h
l
ess
f
requent
ly
wit
h
conventiona
l
approac
h
es.
Th
ese comp
l
ications are t
h
e su
bj
ect o
f
a consensus
d
ocument concernin
g
l
aparoscopic entr
y
tec
h
niques: Mi
ddl
es
b
rou
gh
[61]. T
h
e
y
h
ave
f
ormu
l
ate
d
c
ertain
g
ui
d
e
l
ines
f
or c
l
ose
d
/open
l
aparoscop
y
, secon
d
ar
y
ports, an
d
proper
p
atient selection and counselin
g
, which could form a basis for safe practice.
I
n closed laparoscop
y
, the primar
y
incision should be made in the base of
t
he umbilicus. If there is an
y
suspicion of adhesions, then the alternative entr
y
c
hoice is Palmer’s
p
oint. The umbilicus should be elevated or stabilized in such
a
wa
y
that the Verres needle can be inserted at a ri
g
ht an
g
le to the skin. A
c
orrect positionin
g
of the needle should be checked b
y
either Palmer’s aspira
-
tion technique or observation of gas-fl
ow
p
ressure rates. The intraabdominal
p
ressure should be up to 25 mm H
g
at the time of trocar insertion. This pro
-
v
ides a lar
g
e bubble, and with the tension of the anterior abdominal wall, a
g
reater
d
istance
b
etween t
h
e anterior a
bd
omina
l
wa
ll
an
d
t
h
e intraa
bd
omina
l
o
r
g
ans is maintaine
d
d
urin
g
trocar insertion, w
h
ic
h
ma
y
re
d
uce t
y
pe 1 in
j
u
-
r
ies. The primar
y
trocar should be inserted throu
g
h the thinnest part of the
a
bdominal wall in the base of the umbilicus, and the la
p
arosco
p
e should be
r
otated throu
g
h 360° to check visuall
y
for an
y
evidence of adhesions, bowel
d
ama
g
e, or hemorrha
g
e. At the end of the procedure, the primar
y
trocar
sh
ou
ld
b
e remove
d
un
d
er
d
irect visua
l
ization to exc
l
u
d
e an
y
previous
ly
unno
-
t
i
ced
bo
w
e
l l
es
i
o
n
s.
O
pen laparoscop
y
ma
y
reduce or avoid t
y
pe 1 lesions, but it does not
el
iminate t
y
pe 2
b
owe
l
l
esions. To minimize t
h
e ris
k
o
f
d
ama
g
e, t
h
e
d
eep
f
ascia
sh
ou
ld
b
e e
l
evate
d
wit
h
suita
bl
e c
l
am
p
s to se
p
arate t
h
e a
bd
omina
l
wa
ll
f
rom
i
ts contents a
f
ter t
h
e
pl
acement o
f
a s
k
in incision at t
h
e
l
ower
b
or
d
er o
f
t
h
e
u
mbilicus. The fascial ed
g
es should be ta
gg
ed with an adequate suture. The
entry should be confi
rmed by visualizing bowel or omentum before inserting
th
e
bl
unt-ti
pp
e
d
cannu
l
a into t
h
e a
bd
omen. T
h
e trocar insertion s
h
ou
ld
b
e
g
uided between thin retractors to prevent displacement of the cannula. Gas
should be insuffl
ated directly through the cannula. At the end of the proce-
d
ure
,
t
h
e
f
ascia
l
d
e
f
ect s
h
ou
ld
b
e c
l
ose
d
to minimize t
h
e ris
k
o
f
h
erniation.
A
secon
d
ar
y
trocar s
h
ou
ld
b
e intro
d
uce
d
un
d
er
d
irect
l
aparoscopic
g
ui
d
-
a
nce, in or
d
er to precise
ly
contro
l
t
h
e
d
ept
h
an
d
d
irection o
f
t
h
e trocar
i
n
se
r
tio
n
.
C
ounsel
i
n
g
A
s in all sur
g
er
y
, the avoidance of some complications can be achieved b
y
p
roper patient selection, use of
g
ood-qualit
y
, well-maintained instruments,
a
nd
p
ro
p
er techni
q
ue. Patients should be made aware that not all com
p
lica-
https://t.me/med1917
3. Laparoscopic Entr
y
Techniques: Consensus 2
9
tions can
b
e avoi
d
e
d
. In counse
l
in
g
f
or a
l
aparoscop
y
, a
ll
patients s
h
ou
ld
pro-
vi
d
e
d
wit
h
t
h
e
f
o
ll
owin
g
in
f
ormation
:
. T
h
ere is a possi
b
i
l
it
y
o
f
in
j
ur
y
to
b
owe
l
,
bl
a
dd
er, an
d
bl
oo
d
vesse
l
s.
Th
e ris
k
o
f
eac
h
t
y
pe o
f
in
j
ur
y
is in t
h
e ran
g
e o
f
1–4 per 1000 cases.
2
. T
h
ere is a possi
b
i
l
it
y
t
h
at conversion to
l
aparotom
y
ma
y
b
e require
d
,
a
nd on ver
y
rare occasions a temporar
y
colostom
y
ma
y
be
r
e
q
uire
d.
3. Patients an
d
t
h
eir
d
octors s
h
ou
ld
expect a pro
g
ressive an
d
main-
t
aine
d
improvement a
f
ter
l
aparoscopic sur
g
er
y
. Increasin
g
pain or
v
omitin
g
s
h
ou
ld
a
l
ert t
h
e patient or
d
octor to t
h
e ris
k
o
f
comp
l
ica-
t
ion. Increasin
g
pain s
h
ou
ld
raise t
h
e suspicion o
f
b
owe
l
d
ama
g
e
u
nti
l
prove
d
ot
h
erwise.
4
. T
h
e patient an
d
f
ami
l
y s
h
ou
ld
l
eave t
h
e
h
ospita
l
wit
h
written in
f
or
-
m
ation a
b
out reco
g
nition o
f
comp
l
ications an
d
t
h
e action to
b
e
t
a
k
en in t
h
e event o
f
t
h
ese
d
eve
l
opin
g.
C
onclus
i
on
T
he need to
p
erforate the abdominal wall to
p
erform la
p
arosco
p
ic intraab
-
dominal sur
g
er
y
is associated with the risk of dama
g
in
g
the structures beneath.
T
h
e
p
otentia
l
com
pl
ications associate
d
wit
h
p
eritonea
l
access are o
f
ten over-
l
oo
k
e
d
,
l
ar
g
e
ly
b
ecause t
h
e
y
are re
l
ative
ly
uncommon; in
f
act, most sur
g
eons
wi
ll
see or experience re
l
ative
ly
f
ew, i
f
an
y
, o
f
t
h
e serious
l
i
f
e-t
h
reatenin
g
varieties in t
h
eir pro
f
essiona
l
careers. C
l
ear
ly
, vascu
l
ar an
d
viscera
l
in
j
uries
comprise t
h
e most sinister o
f
t
h
e comp
l
ications, an
d
t
h
e
d
ia
g
nosis o
f
eac
h
ma
y
not
b
e ma
d
e unti
l
some time a
f
ter t
h
e en
d
o
f
t
h
e
p
roce
d
ure, a situation t
h
at
o
f
ten compoun
d
s t
h
e severit
y
o
f
t
h
e situation. T
h
e ris
k
o
f
t
y
pe 1 in
j
uries ma
y
be reduced b
y
use of the Hasson technique, but some t
y
pe 2 in
j
uries are inevi
-
ta
bl
e, re
g
ar
dl
ess o
f
t
h
e met
h
o
d
o
f
access. Patients must
b
e
f
u
lly
in
f
orme
d
o
f
t
h
e nature an
d
extent o
f
t
h
ese ris
k
s an
d
t
h
e importance o
f
ta
k
in
g
prompt
action s
h
ou
ld
a com
pl
ication arise
.
eferences
1. Cuschieri A. Whither minimal access surgery: tribulations and expectations.
A
m
J
S
ur
g
.
995;1
6
9:9–19.
2. Merlin T, Scott D, Rao M, et al.
S
ystematic Review of Laparoscopic Live Donor
N
ephrectomy—Update and Re-appraisal
.
ASERNIP-S Report No. 15. 2nd ed. Ade-
l
ai
d
e, Sout
h
Austra
l
ia: ASERNIP-S; Ma
y
2000.
3. Ker
bl
K, C
l
a
y
man RV, McDou
g
a
ll
EM, et a
l
. Transperitonea
l
nep
h
rectom
y
f
or
b
enign
d
isease o
f
t
h
e
k
i
d
ney—a comparison o
f
l
aparoscopic an
d
open surgica
l
t
ec
h
niques. Uro
l
og
y
.
994
;
43:607–613
.
https://t.me/med1917
3
0 S. Lalchandani and K. Philli
p
s
4. Parra RO, Perez MG, Boullier JA, Cummin
g
s JM. Comparison between standard
fl
ank versus laparoscopic nephrectomy for benign renal disease.
J
Uro
l
.
5;
1
5
3
:
7
1
–
11
7
3.
5. Lujan JA, Sanc
h
ez-Bueno F, Pari
ll
a P, Ro
bl
es R, Torra
lb
a JA, Gonza
l
ez-Costea R.
L
aparoscopic vs. open c
h
o
l
ecystectomy in patients age
d
65 an
d
o
ld
er.
S
urg Laparos
c
E
n
d
osc.
:
208
–
210.
6. Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B. A prospective, ran
-
d
omized comparison of laparoscopic appendectomy with open appendectomy.
L
aparoscopic Appendectom
y
Stud
y
Group.
A
m J
S
ur
g
.
995;1
6
9:208–212.
7. Picchio M, Lombardi A, Zolovkins A, Mihelsons M, La Torre G. Tension-free la
p
a-
roscopic and open hernia repair: randomized controlled trial of earl
y
results.
J Sur
g.
1999;23:1004–1007.
8. Ste
ll
ato TA. T
h
e
h
istor
y
o
f
l
aparoscopic sur
g
er
y
. In: McFa
dy
en BV, Pons
ky
JL, e
d
s.
O
p
erat
i
v
e
Laparoscop
y
an
d
T
h
oracosco
p
y
. P
h
i
l
a
d
e
l
p
h
ia: Lippincott-Raven Pu
bl
is
h-
ers
;
199
6
:3–12
.
9. Lityns
k
i GS.
H
ig
hl
ig
h
ts in t
h
e Histor
y
o
f
Laparoscop
y
: T
h
e Deve
l
opment o
f
Laparo
-
scopic Tec
h
niques—A Cumu
l
ative E
ff
ort o
f
Internists, Gyneco
l
ogists an
d
Surgeons.
Frankfurt am Main, Germany: Barbara Bernert Verlag, 1996
.
0. Bessell JR. The Development, Validation and Analysis of New Endosurgical Proce-
dures in Upper Gastrointestinal Surger
y [thesis]. Adelaide, South Australia: Depart-
m
ent of Sur
g
er
y
, Universit
y
of Adelaide; 1995
.
1. Rosen DM, Lam AM, C
h
apman M, Car
l
ton M, Cario GM. Met
h
o
d
s o
f
creatin
g
pneu-
m
operitoneum: a review o
f
tec
h
niques an
d
comp
l
ications. O
b
stet G
y
neco
l
Surv.
1998
;
53:1
6
7–174.
2. Airan MC. Basic tec
h
niques. In: McFa
d
yen BV, Pons
k
y JL, e
d
s. Operative Laparos
-
cop
y
an
d
T
h
oracosco
p
y
. P
h
i
l
a
d
e
l
p
h
ia: Lippincott-Raven Pu
bl
is
h
ers; 1996:93–123.
3. Agency for Healthcare Research and Quality.
H
CUPnet, Healthcare Cost and Utiliza
-
tion Project.
R
ockville, Maryland: Agency for Healthcare Research and Quality;
A
vailable at: http://www.ahrq.
g
ov/data/hcup/hcupnet.htm. Accessed Jul
y
8, 2001
.
4. Karam KS, Ha
jj
SN. Mesenteric hematoma-meckel’s diverticulum: a rare laparo-
s
copic complication. Fertil
S
teril.
977;28:1003–1005.
15. Lace
y
CG. Laparoscop
y
. A clinical si
g
n for intraperitoneal needle placement.
bstet
G
y
neco
l
.
976;47:625–627
.
16. Leron E, Piura B, O
h
ana E, Mazor M. De
l
a
y
e
d
reco
g
nition o
f
ma
j
or vascu
l
ar in
j
ur
y
d
uring
l
aparoscopy. Eur J O
b
stet G
y
neco
l
Repro
d
Bio
l
.
7
9
:
91
–
93
.
17. Nuzzo G, Giu
l
iante F, Te
b
a
l
a GD, Ve
ll
one M, Cavicc
h
ioni C. Routine use o
f
open
tec
h
nique in
l
aparoscopic operations. J Am Co
ll
Surg.
997
;
184:58–
6
2.
18. Riedel HH, Lehmann WE, Mecke H, Semm K. The frequency distribution of various
p
elviscopic (laparoscopic) operations, including complication rates—statistics o
f
the Federal Republic of Germany in the years 1983–1985. Zentralbl Gynakol.
1989;111:78–91.
19. Lin P, Grow DR. Complications of laparoscop
y
—strate
g
ies for prevention and cure.
bstet G
y
necol Clin North Am. 1999;26:23–38
.
https://t.me/med1917
3. Laparoscopic Entr
y
Techniques: Consensus 3
1
2
0. Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko S, Airan MC. Complications
of
l
aparoscopic c
h
o
l
ec
y
stectom
y
: a nationa
l
surve
y
o
f
4292
h
ospita
l
s an
d
an ana
ly
sis
of
77604 cases. Am J Sur
g
.
993;165:9–14.
2
1. Baa
d
sgaar
d
SE, Bi
ll
e S, Ege
bl
a
d
K. Major vascu
l
ar injury
d
uring gyneco
l
ogic
l
apa
-
roscopy. Report o
f
a case an
d
review o
f
pu
bl
is
h
e
d
cases. Acta O
b
stet G
y
neco
l
Scan
d
.
1989
;6
8:283–285.
2
2. Dingfelder JR. Direct laparoscope trocar insertion without prior pneumoperito
-
n
eu
m
. J Reprod Med.
7
8;21
:45–47.
2
3. Woolcott R. The safet
y
of laparoscop
y
performed b
y
direct trocar insertion and
carbon dioxide insuffl
ation under vision.
Aust N Z J Obstet Gynaecol. 1997;37:
2
16–21
9
.
24. Hasson HM. Modifi
ed instrument and method for laparoscopy.
Am J Obstet G
y
necol.
1971;110:886
.
2
5. Peit
g
en K, Nimtz K, He
ll
in
g
er A, Wa
l
z MK. Open access or Veress nee
dl
e tec
h
nique
f
or
l
aparoscopic surgery? C
h
irurgie 1997
;6
8:910–913.
26. Bemelman WA, Dunker MS, Busch OR, Den Boer KT, de Wit LT, Gouma DJ. Effi
cacy
of
esta
bl
is
h
ment o
f
p
neumo
p
eritoneum wit
h
t
h
e Veress nee
dl
e, Hasson trocar, an
d
modifi
ed blunt trocar (TrocDoc): a randomized study.
J Laparoendosc Adv Sur
g
2
000;10(
p
art A):325–330
.
2
7. Co
g
liandolo A, Man
g
anaro T, Saitta FP, Micali B. Blind versus open approach to
laparoscopic cholec
y
stectom
y
: a randomized stud
y
.
S
ur
g
La
p
arosc Endosc Percutan
ec
h
.
;
8
:
3
5
3
–
3
55
.
2
8. Berni
k
TR, Troccio
l
a SM, Ma
y
er DA, Patane J, Czura CJ, Wa
ll
ac
k
MK. Ba
ll
oon
bl
unt
-
tip trocar
f
or
l
aparoscopic c
h
o
l
ecystectomy: improvement over t
h
e tra
d
itiona
l
Hasson an
d
Veress nee
dl
e met
h
o
d
s. J Laparoen
d
osc A
d
v Surg Tec
h
A.
2001;11
:
7
3
–7
8
.
2
9. Sigman HH, Fried GM, Garzon J, et al. Risks of blind versus open approach to celi-
o
tomy for laparoscopic surgery.
S
urg Laparosc Endosc.
993
;
3:29
6
–299
.
30. Holtz G. Laparoscop
y
in the massivel
y
obese female.
bstet Gynecol. 1987;
6
9:
42
3
–424
.
31. Hurd WW, Randolph JFJ, Holmber
g
RA, Pearl ML, Hubbell GP. Open laparoscop
y
w
ithout special instruments or sutures. Comparison with a closed technique.
J
Re
p
ro
d
Me
d
.
4;
39
:
393
–
39
7.
32. Ma
y
o
l
J, Garcia A
g
ui
l
ar J, Ortiz Os
h
iro E, Carmona JAD, Fernan
d
ez Represa
J
A. Ris
k
s o
f
t
h
e minima
l
access approac
h
f
or
l
aparoscopic surgery: mu
l
tivariate
a
na
l
ysis o
f
mor
b
i
d
ity re
l
ate
d
to um
b
i
l
ica
l
trocar insertion.
or
ld
J Surg.
7
;21:
5
29
–5
33.
33. Bonjer HJ, Hazebroek EJ, Kazemier G, Giuffrida MC, Meijer WS, Lange JF. Open
v
ersus closed establishment of pneumoperitoneum in laparoscopic surgery.
B
r
J
S
urg.
997
;
84:599–
6
02
.
34. Wherry DC, Rob CG, Marohn MR, Rich NM. An external audit of laparoscopic
c
holec
y
stectom
y
performed in medical treatment facilities of the Department of
D
e
f
e
n
se.
A
nn Sur
g
.
994;220:626–634.
https://t.me/med1917
3
2 S. Lalchandani and K. Philli
p
s
3
5. Bateman BG, Kolp LA, Hoe
g
er K. Complications of laparoscop
y
—operative and
d
ia
g
nostic.
F
erti
l
S
teri
l
.
996;66:30–35.
36. Pasic R, Levine RL, Wo
lf
e WM. Laparoscop
y
in mor
b
i
dly
o
b
ese patients.
J
Am Assoc
G
y
neco
l
Laparosc.
999
;6
:307–312.
37. Ba
ll
em RV, Ru
d
omans
k
i J. Tec
h
niques o
f
pneumoperitoneum. Surg Laparosc En
d
osc
P
ercutan Tec
h
.
:4
2
–4
3
.
38. Gulla N
,
Patriti A
,
Lazzarini F
,
Tristaino B. Our choice of the method to induce
p
neumoperitoneum in videolaparoscopic surgery [in Italian]. Minerva Chir.
2
000;55:371–375.
39. Ma
y
ol J, Blasla
y
na JL, Mallen Valiela A, et al. Dehiscence of the umbilical wound
c
losure after laparoscopic cholec
y
stectom
y
.
S
ur
g
Endosc. 1994;8:1012
.
4
0. Rumstadt B, Sturm
J
,
J
entschura D, Schwab M, Schuster K. Trocar incision and
cl
osure:
d
ai
ly
pro
bl
ems in
l
aparoscopic proce
d
ures—a new tec
h
nica
l
aspect.
S
ur
g
La
p
arosc En
d
osc.
7;7:
3
45–
3
4
8.
4
1. Zaraca F, Catarci M, Gossetti F, Mu
l
ieri G, Car
b
oni M. Routine use o
f
open
l
aparos-
c
opy: 1,006 consecutive cases. J Laparoen
d
osc A
d
v Surg Tec
h
A.
:75–
80.
42. Du
b
uisson JB, C
h
apron C, Decuypere F, De Spir
l
et M. “C
l
assic”
l
aparoscopic entry
i
n a university hospital: a series of 8324 cases. Gynaecol Endosc. 1999
;
8:349–352
.
4
3. Jansen FW, Kapiteyn K, Trimboskemper T, Hermans J, Trimbos JB. Complications
o
f laparoscop
y
: a prospective multicentre observational stud
y
. Br J Obstet Gynaecol.
1997;104:595–600
.
4
4. Târcoveanu E, P
l
esa C, Geor
g
escu S, et a
l
. Laparoscopic c
h
o
l
ec
y
stectom
y
: experience
w
it
h
2025 cases. G
l
o
b
a
l
Hea
l
t
h
J.
2
001;104
(
4
)
:91–93.
4
5. Ka
d
ar N, Reic
h
H, Liu CY, Man
k
o GF, Gimpe
l
son R. Incisiona
l
h
ernias a
f
ter
major
l
aparoscopic gyneco
l
ogic proce
d
ures. Am J O
b
stet G
y
neco
l
. 1993
;
1
6
8
:
4
93
–
1
4
9
5
.
4
6. Ahn YW, Leach JA. A comparison of subcutaneous and preperitoneal emphy-
sema arising from gynecologic laparoscopic procedures.
J
Reprod Med. 197
6;
17:
335
–
337.
4
7. Ba
gg
ish MS, Lee WK, Miro SJ, Dacko L, Cohen G. Complications of laparoscopic
sterilization. Comparison of 2 methods. Obstet G
y
necol. 1979;54:54–59
.
4
8. Chapron C, Querleu D, Bruhat MA, et al. Sur
g
ical complications of dia
g
nostic and
o
perative
gy
naeco
l
o
g
ica
l
l
aparoscop
y
: a series o
f
29,966 cases.
H
um Re
p
ro
d
.
1998;13:867–872.
4
9. Nez
h
at C, C
h
i
ld
ers J, Nez
h
at F, et a
l
. Major retroperitonea
l
vascu
l
ar injury
d
uring
l
aparoscopic surgery. Hum Repro
d.
199
7
;12
:4
80
–4
83.
5
0. Hasson HM, Par
k
er WH. Prevention an
d
management o
f
urinary tract injury in
laparoscopic surgery.
J
Am Assoc Gynaecol Laparosc.
1998;
5:
99
–
11
4
.
5
1. Saidi MH, Sadler RK, Vancaillie TG, et al. Diagnosis and management of serious
urinary complications after major operative laparoscopy. Obstet Gynaecol
.
199
6
;87:272–27
6
.
5
2. Cottin V, Delafosse B, Viale JP. Gas embolism durin
g
laparoscop
y
: a report of seven
cases in patients with previous abdominal sur
g
ical histor
y
.
S
ur
g
Endosc. 1996;10:
166–16
9
.
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана