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7. What to Do When the O
p
eration Is Over 6
3
ostoperat
i
ve Management
I
n a
dd
ition to ma
k
in
g
an accurate recor
d
o
f
events at a time w
h
en reca
ll
is
l
i
k
e
ly
to
b
e most accurate, it is imperative t
h
at appropriate p
l
ans are ma
d
e
for the postoperative care of the patient. Document these plans clearl
y
, but
rea
l
ize t
h
at t
h
is
d
ocumentation ma
y
nee
d
to
b
e
b
ac
k
e
d
up ver
b
a
lly
. Ensure
t
h
at t
h
e
l
eve
l
o
f
care is a
d
equate, w
h
et
h
er it
b
e an overni
gh
t sta
y
or per
h
aps
trans
f
er to intensive care or a
h
i
gh
-
d
epen
d
enc
y
unit. It is
f
un
d
amenta
l
to
patient sa
f
et
y
t
h
at once an a
d
verse event
h
as occurre
d
, its consequences
b
e
limited. This should encoura
g
e a hei
g
htened awareness for the subsequent
care of the
p
atient.
at
i
ents and Relat
i
ve
s
T
he
G
eneral Medical
C
ouncil states in
ood Medical Practice
t
h
at
if
a
p
atient un
d
er one’s care
h
as su
ff
ere
d
h
arm, one must exp
l
ain
f
u
lly
an
d
p
rompt
ly
to t
h
e patient w
h
at
h
as
h
appene
d
an
d
w
h
at
l
on
g
- an
d
s
h
ort-term
s
i
d
e e
ff
ects are
l
i
k
e
ly
to occur [7].
Poor communication accounts for a signifi
cant num
b
er o
f
com
pl
aints
ag
ainst t
h
e me
d
ica
l
pro
f
ession [8]. A
d
opt an open an
d
h
onest approac
h
an
d
m
a
k
e a
ll
e
ff
ort to maintain
l
ines o
f
communication. Ex
pl
ain t
h
e circumstances
a
s
f
u
lly
as possi
bl
e, usin
g
l
an
g
ua
g
e wit
h
in t
h
e patient’s un
d
erstan
d
in
g
; use an
i
nterpreter where necessar
y
. Give the patient the opportunit
y
to ask questions,
b
ut reco
g
nize t
h
at a
f
u
ll
ana
ly
sis o
f
events is un
l
i
k
e
ly
to
b
e
h
e
l
p
f
u
l
unti
l
a
ll
t
h
e
f
acts o
f
t
h
e case are esta
bl
is
h
e
d
. Apo
l
o
g
ize t
h
at t
h
e event
h
as
h
appene
d
. T
h
is
i
s not an a
d
mission o
f
g
ui
l
t, an
d
t
h
e omission o
f
an apo
l
o
gy
is o
f
ten cite
d
in
p
atients’ comp
l
aints. It is per
f
ect
ly
reasona
bl
e
f
or patients to expect ac
k
now
l-
edg
ment t
h
at t
h
e
y
h
ave
b
een invo
l
ve
d
in an a
d
verse event to
g
et
h
er wit
h
a
v
er
b
a
l
expression o
f
empat
hy.
R
e
l
atives must
b
e
h
an
dl
e
d
sensitive
l
y. T
h
ey wi
ll
un
d
erstan
d
a
bl
y request
i
n
f
ormation a
b
out t
h
e inci
d
ent,
b
ut an
y
response s
h
ou
ld
o
b
serve patient con
-
dentiality. The duty of care of all staff is to the patient, and information
sh
ou
ld
not
b
e
d
isc
l
ose
d
i
f
one
h
as reason to
b
e
l
ieve t
h
at t
h
e
p
atient wou
ld
obj
ect [7].
The Team
T
he patient is not the only victim when an adverse incident occurs. In a
theater setting there is often a well-established team, and few members of that
team will be unaffected. This needs to be recognized and the temptation to
“
j
ust carr
y
on as normal” resisted. It ma
y
be appropriate to take a short break,
even if this means that some clinical work needs to be delayed. Acknowledge
that performance may be affected. If an intraoperative death occurs, the list
https://t.me/med1917
6
4 V
.
A
.
Beckett
a
n
d
D
.J.
T
u
ffnell
sh
ou
ld
not continue. Even in
l
ess serious events, t
h
ose
d
irect
ly
invo
l
ve
d
in t
h
e
e
vent s
h
ou
ld
consi
d
er steppin
g
d
own. I
f
an event invo
l
ves
y
ou as t
h
e primar
y
s
ur
g
eon,
h
ave t
h
e insi
gh
t to ta
k
e a
b
rea
k
f
rom or stop operatin
g
. I
f
one o
f
y
our
t
rainees is invo
l
ve
d
in an inci
d
ent, encourage t
h
e same in t
h
em.
I
t is important
f
or t
h
e team’s ps
y
c
h
o
l
o
g
ica
l
we
ll
-
b
ein
g
to
d
e
b
rie
f
a
f
ter
ad
verse events. I
f
y
ou were
d
irect
ly
invo
l
ve
d
, tr
y
to
d
iscuss t
h
e inci
d
ent wit
h
a
n appropriate co
ll
eague. T
h
is avoi
d
s
d
amaging rumination
l
ater at
h
ome an
d
h
e
l
ps you to c
l
ari
f
y your t
h
oug
h
ts on t
h
e case. Encourage t
h
is practice in
o
t
h
ers, inc
l
u
d
in
g
trainees
.
Organize a structured debriefi
ng for the team at a later date, and invite
o
t
h
er mem
b
ers o
f
t
h
e
d
epartment w
h
ere appropriate. Discuss w
h
at
h
appene
d
a
n
d
h
ow t
h
e team respon
d
e
d
. Use t
h
ese
d
iscussions to
f
ormu
l
ate
l
essons to
l
earn an
d
ways to avoi
d
simi
l
ar events in t
h
e
f
uture. Consi
d
er w
h
et
h
er t
h
is
i
nci
d
ent constitutes part o
f
a tren
d
,
f
or examp
l
e, wit
h
a particu
l
ar piece o
f
e
quipment. T
h
is approac
h
encourages a positive
l
earning cu
l
ture in t
h
e
d
epart
-
m
ent towar
d
a
d
verse inci
d
ents an
d
moves away
f
rom t
h
e “
bl
ame” approac
h.
nc
i
dent Report
i
n
g
T
he National Patient Safet
y
A
g
enc
y
(NPSA) has aimed to ensure reportin
g
o
f all adverse incidents. Such reportin
g
is essential to
g
ood risk mana
g
ement
a
nd hence patient safet
y
and clinical
g
overnance. Ensure that the correct docu-
m
ents are com
p
leted as soon as
p
ossible after an adverse event occurs. This is
t
he startin
g
point for follow-up b
y
the risk mana
g
er. Since part of the risk
m
ana
g
ement process is to track common events, this will allow the earl
y
iden-
tifi
cation of a serial incident. Where serious harm occurred, the NPSA suggests
that a report be fi
led within 3 working days and a root cause analysis under-
t
aken within 45 workin
g
da
y
s of the occurrence of the incident [5].
I
t is important that or
g
anizations encoura
g
e transparent workin
g
practices
in which the fi
ling of incident reports is routine and without fear of disciplin-
a
r
y
action. In our unit, as in others, the polic
y
on incident reportin
g
states that
“
disciplinar
y
action should not follow the reportin
g
of an incident except in
c
ases where one or more of the followin
g
applies
:
Where there is a second occurrence involvin
g
the same individual
followin
g
education and/or trainin
g
Where the incident has resulted in a police investi
g
atio
n
Where, in the view of the professional re
g
istration bod
y
, the action
is far removed from acce
p
table
p
ractice
Failure to re
p
ort an “incident”
oot Cause Anal
y
s
i
s
T
he aim of an
y
investi
g
ation into a serious adverse event or near miss
should be to identify underlying defi
ciencies within the system of working that
https://t.me/med1917
7. What to Do When the O
p
eration Is Over 6
5
ma
y
h
ave contri
b
ute
d
to t
h
e event. It
d
oes not see
k
to expose in
d
ivi
d
ua
l
error; in
d
ee
d
, i
f
ro
b
ust s
y
stems are in p
l
ace, in
d
ivi
d
ua
l
errors s
h
ou
ld
rare
ly
resu
l
t in a
d
verse events. T
h
e
p
rocess s
h
ou
ld
consi
d
er a
ll
as
p
ects o
f
an event,
inc
l
u
d
ing t
h
e organization as a w
h
o
l
e, an
d
encourage t
h
e “no
bl
ame” or “just”
et
h
os.
All
sta
ff
invo
l
ve
d
are as
k
e
d
to
p
rovi
d
e
f
actua
l
statements o
f
t
h
eir a
pp
recia-
tion o
f
t
h
e event,
f
ree o
f
conjecture. Factua
l
in
f
ormation regar
d
ing t
h
e patient’s
ai
l
ment, inc
l
u
d
ing
l
oca
l
an
d
/or nationa
l
gui
d
e
l
ines an
d
d
etai
l
s o
f
t
h
e operative
procedure, is gathered. Details of staffi
ng rosters are required in order to
c
l
ari
f
y w
h
o was avai
l
a
bl
e to provi
d
e assistance an
d
w
h
et
h
er t
h
ere were an
y
strains on staffi
ng.
Th
e ana
l
ysis s
h
ou
ld
consi
d
er w
h
et
h
er t
h
e person w
h
o ma
d
e t
h
e
d
ecision
to ta
k
e t
h
e patient to t
h
eater, w
h
et
h
er in t
h
e acute or outpatient setting,
was of appropriate seniority or level of training. Information leafl
e
t
s are
increasing
l
y use
d
to provi
d
e patients wit
h
in
f
ormation regar
d
ing p
l
anne
d
proce
d
ures, an
d
evi
d
ence t
h
at t
h
ese
d
ocuments were ma
d
e avai
l
a
bl
e
wou
ld
suggest t
h
at an attempt was ma
d
e to provi
d
e a
d
equate in
f
ormation
f
or t
h
e patient prior to o
b
taining
h
is or
h
er consent. Documentation o
f
an
y
counse
l
ing given at t
h
is time is a
l
so va
l
ua
bl
e. T
h
e use o
f
gui
d
e
l
ines an
d
w
h
et
h
er t
h
ey were a
dh
ere
d
to,
f
or examp
l
e, prea
bl
ation t
h
erapy, wou
ld
b
e
consi
d
ere
d
.
O
n a
d
mission, it is c
l
ear
l
y important t
h
at patients
b
e a
d
mitte
d
to t
h
e
appropriate war
d
, w
h
ere sta
ff
mem
b
ers are
f
ami
l
iar wit
h
t
h
e p
l
anne
d
proce
d
ure an
d
any necessary pre- an
d
postoperative care particu
l
ar to t
h
at
proce
d
ure. “Waiting
l
ist initiative”
l
ists require specia
l
mention, in t
h
at
it s
h
ou
ld
b
e ensure
d
t
h
at t
h
e team mem
b
ers assem
bl
e
d
f
or t
h
e
l
ist,
b
ot
h
on
t
h
e war
d
an
d
in t
h
e t
h
eater, are a
d
equate
l
y
f
ami
l
iar wit
h
t
h
e p
l
anne
d
proce
d
ures.
In the theater, there should be adequate staffi
ng levels and appropriately
traine
d
sta
ff
. T
h
ere s
h
ou
ld
b
e a nurse avai
l
a
bl
e as a runner. A new or un
f
ami
l
-
iar anest
h
etist may
h
ave an impact on t
h
e
d
ynamics o
f
t
h
e team, an
d
t
h
is
f
actor may
b
e exp
l
ore
d
. Evi
d
ence t
h
at t
h
e correct equipment was avai
l
a
bl
e an
d
use
d
correct
l
y wi
ll
b
e soug
h
t. Service recor
d
s
f
or some equipment may
b
e
i
mportant.
Wh
en t
h
e inci
d
ent occurre
d
, an emergency
d
ri
ll
may
h
ave
b
een a
d
opte
d
.
Any
d
ocumentation regar
d
ing t
h
is
d
ri
ll
an
d
w
h
et
h
er it was regu
l
ar
l
y practice
d
wou
ld
b
e examine
d
. T
h
e pane
l
wou
ld
l
oo
k
to ensure t
h
at any a
dd
itiona
l
equip
-
ment,
bl
oo
d
, or
d
rugs were avai
l
a
bl
e swi
f
t
l
y, an
d
t
h
at t
h
e support o
f
senior
s
ta
ff
mem
b
ers or co
ll
eagues
f
rom ot
h
er specia
l
ties was avai
l
a
bl
e. Time ta
k
en
to contact suc
h
support may
b
e re
l
evant. I
f
t
h
e patient was trans
f
erre
d
to a
h
ig
h
-
d
epen
d
ency or intensive care unit, t
h
e avai
l
a
b
i
l
ity o
f
b
e
d
s in t
h
ese
f
aci
l
i-
ties wou
ld
b
e examine
d
, as wou
ld
any time ta
k
en to trans
f
er t
h
e patient to
anot
h
er unit.
R
oot cause ana
l
ysis see
k
s not to apportion
bl
ame to in
d
ivi
d
ua
l
s
b
ut to o
ff
er
s
o
l
utions to avoi
d
f
urt
h
er a
d
verse events or near misses. It can
b
e use
d
to initi
-
ate guidelines and drills and to improve patient information leafl
ets,
f
or
example. It also serves to strengthen cases for increased staffi
ng levels, senior
s
upport in t
h
e operating t
h
eater, an
d
new equipment.
https://t.me/med1917
66
V
.
A
.
Beckett
a
n
d
D
.J.
T
u
ffnell
S
ummar
y
R
is
k
mana
g
ement is a re
l
ative
ly
new process t
h
at can sometimes evo
k
e
f
ee
l
in
g
s o
f
suspicion amon
g
c
l
inicians. However, w
h
en use
d
proactive
ly
, it
offers the opportunity to act at the root cause of an incident to expose defi
c
i
e
n
-
c
ies in t
h
e s
y
stem rat
h
er t
h
an in in
d
ivi
d
ua
l
s. T
h
is process encoura
g
es a sup
-
p
ortive a
pp
roac
h
to
p
atients, re
l
atives, an
d
sta
ff
. T
h
e overa
ll
aim s
h
ou
ld
b
e to
l
earn
l
essons rat
h
er t
h
an to attri
b
ute
bl
ame
.
e
f
erences
1. Vincent C, Neale G, Wolosh
y
now
y
ch M. Adverse events in British hospitals: a pre-
liminar
y
retrospective record review. Br Med
J
. 2001;322:517–519.
2
. Nea
l
e G, Wo
l
os
hy
now
y
c
h
M, Vincent C. Exp
l
orin
g
t
h
e causes o
f
a
d
verse events in
NHS
h
ospita
l
practice.
J
R Soc Me
d
. 2001;94:322–330
.
3
. Wa
l
s
h
e K. T
h
e
d
eve
l
opment o
f
c
l
inica
l
ris
k
mana
g
ement. In: Vincent C, e
d
.
inica
l
R
is
k
Managemen
t
. Lon
d
on: BMJ Pu
bl
is
h
ing Group; 2001, p. 45–60
.
4
. Department o
f
Hea
l
t
h
.
A
n Organization wit
h
a Memor
y
. Lon
d
on: HMSO
;
2000
.
5
. National Patient Safety Agency. Reporting incidents. Available at: http://www.npsa.
nhs.uk/health/reporting. Assessed June 25, 2007.
6. National Confi
dential Enquiry into Perioperative Deaths. Changing the way we
o
p
era
t
e.
dential Enquiry into Perioperative
Deaths.
London: National Confi
dential Enquiry into Perioperative Deaths; 2001.
Available at: http://www.ncepod.or
g
.uk. Assessed June 25, 2007.
7
.
G
eneral Medical
C
ouncil.
ood Medical Practice
.
London: General Medical Council;
2
006. Avai
l
a
bl
e at:
h
ttp://www.
g
mc-u
k
.or
g
/
g
ui
d
ance/
g
oo
d
_me
d
ica
l
_practice/in
d
ex
.
asp
.
8. Vincent C, Young M, P
h
i
ll
ips A. W
h
y
d
o peop
l
e sue
d
octors? A stu
d
y o
f
patients an
d
re
l
atives ta
k
ing
l
ega
l
action.
L
ancet.
994
;
343:1609–1613.
https://t.me/med1917
8. Laparoscopic Surger
y
J
oseph A. Ogah
Severe complications associated with laparoscop
y
are rare, but as a lar
g
e
number of laparoscopies are carried out each
y
ear, the impact and conse
-
quence of these complications are considerable. The complications ma
y
be life
threatenin
g
, and the consequences of dama
g
e to the bowel, ma
j
or blood
vessels, and urinar
y
tract are potentiall
y
catastrophic, leadin
g
to considerable
physical and emotional suffering as well as signifi
cant fi
nancial cost.
T
he overall complication rate of laparoscop
y
ran
g
es from 0.2% to 10.3 %
1–15], with prospective studies showin
g
hi
g
her complication rates [11,14].
T
he ma
j
or t
y
pes of complications that occurred in a series of 236,392
gy
neco
-
l
o
g
ical procedures from different countries are intestinal, urinar
y
tract, and
m
a
j
or vascular in
j
uries [5,8–16]. Fift
y
percent of complications arise from
e
ntr
y
technique [11,15], and in 20%–25% of cases, the in
j
ur
y
is not reco
g
nized
i
ntraoperativel
y
[10]
.
A
review of more than 350,000 la
p
arosco
p
ic
p
rocedures carried out over
m
ore than 20
y
ears usin
g
the closed Verres needle entr
y
technique
g
ives a risk
o
f ma
j
or vascular in
j
uries as 0.02% and that of bowel in
j
ur
y
as 0.04% [17–23].
T
hese rates are so low that it would be almost impossible to carr
y
out properl
y
c
onstructed randomized controlled trials to demonstrate the superiorit
y
of
o
ne entr
y
technique over the other. Garr
y
[24] estimated that to demonstrate
a
33% reduction in bowel in
j
ur
y
rate from 0.3 in 1000 to 0.2 in 1000 would
r
e
q
uire 828,204 cases
.
Vascular Injury
V
ascu
l
ar injuries can occur at t
h
e time o
f
entry into t
h
e anterior a
bd
omina
l
wa
ll
,
b
e
f
ore creation o
f
pneumoperitoneum or a
f
ter t
h
e insertion o
f
t
h
e
primary trocar, or w
h
i
l
e t
h
e
l
aparoscopic operation is
b
eing carrie
d
out. T
h
e
y
can a
l
so occur
f
rom anterior a
bd
omina
l
wa
ll
injuries, particu
l
ar
l
y invo
l
ving
t
h
e in
f
erior epigastric vesse
l
s. Secon
d
ary ports s
h
ou
ld
b
e inserte
d
un
d
er
d
irect
vision so they are less likely to lead to vascular injuries
.
R
eviews o
f
cases w
h
ere vascu
l
ar injuries
h
ave
b
een sustaine
d
s
h
ow t
h
at an
overw
h
e
l
ming majority
(
>
8
0% in some reviews) occurre
d
at t
h
e point o
f
initia
l
e
ntry into t
h
e a
bd
omina
l
wa
ll
, main
l
y
b
y t
h
e primary trocar;
f
ewer cases
o
ccurre
d
d
uring secon
d
ary port entry; an
d
even
f
ewer occurre
d
d
uring t
h
e
o
peration
[
17,25–28
].
Of
ten w
h
en major vascu
l
ar injuries occur, on
l
y minima
l
f
ree
bl
oo
d
is
e
ncountere
d
in t
h
e peritonea
l
cavity, contrary to w
h
at is expecte
d
. Most times,
https://t.me/med1917
6
8 J.A. O
g
ah
th
ou
gh
, t
h
ere is a
l
ar
g
e retroperitonea
l
h
ematoma. At ot
h
er times
h
emorr
h
a
g
e
i
s o
b
vious. W
h
en t
h
e anterior a
bd
omina
l
wa
ll
vesse
l
s are invo
l
ve
d,
anterior
abd
omina
l
wa
ll
h
ematoma can occur, w
h
ic
h
w
h
en in
f
ecte
d
can
p
resent as
ab
scess on t
h
e a
bd
omina
l
wa
ll.
I
n more t
h
an 50% o
f
cases o
f
vascu
l
ar in
j
ur
y
, repair
by
l
aparotom
y
is
n
ee
d
e
d
. For some in
j
uries,
d
epen
d
in
g
on t
h
e site, extent, an
d
a
d
equate visu-
al
ization o
f
injury,
l
aparoscopic repair may
b
e carrie
d
out [29]. Morta
l
ity rates
f
rom major vascu
l
ar injury range
f
rom 9% to 22% [17,27,30,31].
ntestinal Injur
y
I
ntestina
l
injury wi
ll
l
ea
d
to a
l
aparotomy in 60% o
f
cases [30] an
d
morta
l
-
i
ty in 2.5%–5% o
f
cases [25,30]. O
f
ten morta
l
ity occurs
b
ecause o
f
f
ai
l
ure to
r
ecognize t
h
e
b
owe
l
injury intraoperative
l
y. T
h
e
b
owe
l
is injure
d
eit
h
er in its
n
orma
l
anatomica
l
position in t
h
e a
bd
omen or w
h
en pat
h
o
l
ogica
ll
y a
dh
erent
t
o t
h
e anterior a
bd
omina
l
wa
ll
. T
h
e ris
k
o
f
b
owe
l
injury at
l
aparoscopy is sma
ll
wh
en compare
d
wit
h
ot
h
er types o
f
a
bd
omina
l
surgery (Ta
bl
e 8.1 [32]),
b
ut
b
ecause at
l
aparoscopy
b
owe
l
d
amage is more
l
i
k
e
l
y to
b
e un
d
iagnose
d
intra-
operatively, it leads to signifi
cant morbidity.
Adh
esion o
f
omentum an
d
/or
b
owe
l
to t
h
e anterior a
bd
omina
l
wa
ll
puts
th
e
b
owe
l
at increase
d
ris
k
o
f
injury
d
uring
l
aparoscopic surgery. It is impor-
t
ant to consi
d
er t
h
e ris
k
o
f
a
dh
esions prior to em
b
ar
k
ing on
l
aparoscopic
s
urgery; t
h
is ris
k
d
epen
d
s on t
h
e met
h
o
d
o
f
entry into t
h
e a
bd
omen wit
h
previ-
o
us surgery i
f
any. Au
d
e
b
ert [33] use
d
a micro
l
aparoscope inserte
d
in t
h
e
h
ypoc
h
on
d
rium to recor
d
t
h
e
d
istri
b
ution an
d
severity o
f
intraa
bd
omina
l
adh
esions an
d
corre
l
ate
d
t
h
ese wit
h
past surgica
l
h
istory (Ta
bl
e 8.2).
B
etween 25% an
d
50% o
f
b
owe
l
injury occurs
d
uring entry to t
h
e a
bd
omi-
n
a
l
wa
ll
, wit
h
50%–75% occurring
d
uring t
h
e actua
l
l
aparoscopic operative
p
roce
d
ure [25]. Symptoms o
f
b
owe
l
injury
f
o
ll
owing
l
aparoscopy are o
f
ten
a
typica
l
. Nausea, vomiting, i
l
eus, an
d
severe pain are uncommon; peritonea
l
s
igns are in
f
requent. More common
f
eatures inc
l
u
d
e pain at t
h
e trocar site
n
ear t
h
e injure
d
segment o
f
b
owe
l
, a
bd
omina
l
d
istension, an
d
d
iarr
h
ea wit
h
normal bowel sounds. This may be because laparoscopy elicits less infl
a
mm
a
-
T
a
bl
e 8.1
.
Bowel Injury A
f
ter Various Methods o
f
Gynecological Surgery
Entr
y
-Re
l
ate
d
In
j
ur
i
e
s
Ty
pe o
f
Surger
y
Total Number o
f
Cases Bowel Injuries
N
Rate
aparotomy 5700 93 48 8.3
/
100
0
V
agina
l
965 11 7 7.3/100
0
aparoscopy 3710 13 11 3.0
/
100
0
i
l
ation an
d
curettage 7575 11 11 1.5/100
0
https://t.me/med1917
8. Laparoscopic Surger
y
6
9
tory an
d
immune response t
h
an
l
aparotomy. Laparotomy rates
f
o
ll
owing
intestina
l
injury are
b
etween 52.4% an
d
90% [5]
.
Urinar
y
Tract Injur
y
U
rinar
y
tract in
j
ur
y
is observed in 0.02%–2% of laparoscopies. Bladder
injuries are more common and are recognized more commonly intraopera
-
tivel
y
than ureteric in
j
uries. The most common t
y
pe of urinar
y
tract in
j
ur
y
is
bladder
p
erforation
(
5
0%); less common are ureteric li
g
ation, ureteric trans
-
action, and fi
stula formation. Most injuries to the urinary tract occur during
operations for advanced endometriosis, h
y
sterectom
y
, oophorectom
y
, pelvic
l
y
mphadenectom
y
, and adhesiol
y
sis.
R
epair of in
j
uries to the ureters is mostl
y
accomplished b
y
laparotom
y
,
probabl
y
because most cases are dia
g
nosed postoperativel
y
. Dia
g
nosis made
intraoperativel
y
increases the chances of laparoscopic repair, dependin
g
on
the extent of dama
g
e.
revent
i
on of In
j
ur
i
es and Management Strateg
i
e
s
E
ver
y
method of enterin
g
the abdominal cavit
y
has inherent risk of in
j
ur
y
to the intraabdominal or
g
ans [32]. To reduce the rate of these in
j
uries at lapa
-
roscop
y
, several techniques have been devised, the most popular bein
g
the
“open” method devised in 1971 b
y
Harrith Hasson, a
gy
necolo
g
ist [34,35]. In
this method a small incision of 1–2 cm is made
j
ust below the umbilicus; then
dissection occurs down to the peritoneal cavit
y
. Each suture placed on either
s
ide of the rectus sheath is wrapped around pe
g
s on a cannula that has been
inserted snu
g
l
y
into the peritoneal cavit
y
. This method is thou
g
ht to be under
direct vision. Some studies confi
rm the safety of this method and claim reduced
risk of ma
j
or vascular in
j
ur
y
. In a series of 10,840 open laparoscopies, no ma
j
or
vascular in
j
uries occurred [36]. A retrospective comparison stud
y
[37] docu
-
mented a statistically signifi
cant decreased rate of major vascular injury when
the open technique of abdominal entr
y
is compared to a closed technique. A
T
ab
le
8.
2
.
Rates of Adhesions Related to Surgical Histor
y
To
t
a
l N
u
m
b
e
r
A
d
hesi
o
ns Severe A
d
hesi
o
ns
Surgical Histor
y
of Cases Rate
Rate
No previous histor
y
519 8/1000 4 4/1000
2
Previous laparoscop
y
140 14/1000 2 7/1000
1
Previous Pfannenstiel 145 214
/
1000 31 69
/
1000 1
0
Previous midline 96 531
/
1000 51 253
/
1000 3
0
https://t.me/med1917
7
0 J.A. O
g
ah
m
ore recent review o
f
t
h
e
l
iterature carrie
d
out
by
t
h
e Austra
l
ian Co
ll
e
g
e o
f
S
ur
g
eons [38]
f
oun
d
t
h
at even t
h
ou
gh
t
h
ere seeme
d
to
b
e a tren
d
towar
d
h
i
gh
er ris
k
o
f
vascu
l
ar in
j
ur
y
wit
h
t
h
e c
l
ose
d
Verres nee
dl
e met
h
o
d
, t
h
e ris
k
of
vascu
l
ar injury was so
l
ow in
b
ot
h
groups t
h
at t
h
ere was no statistica
ll
y
signifi
cant difference. It also found that the open method had a higher risk of
b
owe
l
in
j
ur
y
(re
l
ative ris
k
[RR]
2.17, 95% confi
dence interval [CI]
.57–4.63
).
Irrespective o
f
t
h
e met
h
o
d
o
f
entry c
h
osen, certain steps can
b
e ta
k
en to
r
e
d
uce t
h
e ris
k
o
f
in
j
ur
y
. Use
f
u
l
steps are out
l
ine
d
in a consensus
d
ocument
23,39
]
.
T
h
e main a
d
vantage o
f
l
ocating t
h
e primary incision in t
h
e
d
ept
h
o
f
t
h
e
u
m
b
i
l
icus rat
h
er t
h
an t
h
e perium
b
i
l
ica
l
area is t
h
at t
h
is is t
h
e t
h
innest area o
f
th
e a
bd
omina
l
wa
ll
an
d
t
h
e on
l
y area w
h
ere t
h
e peritoneum is actua
ll
y attac
h
e
d
t
o t
h
e a
bd
omina
l
wa
ll.
T
h
e Verres nee
dl
e s
h
ou
ld
b
e s
h
arp, wit
h
t
h
e sty
l
et retracting an
d
springing
o
ut
b
ris
kl
y; t
h
e nee
dl
e s
h
ou
ld
b
e c
h
ec
k
e
d
an
d
rep
l
ace
d
f
requent
l
y, or an
app
ro
p
riate
d
is
p
osa
bl
e Verres nee
dl
e s
h
ou
ld
b
e use
d
. To ac
h
ieve
f
u
ll
contro
l
of
t
h
e nee
dl
e
d
uring insertion, t
h
e
b
arre
l
s
h
ou
ld
b
e
h
e
ld
l
ow
d
own,
l
i
k
e a
d
art.
Th
e aim w
h
i
l
e inserting t
h
e Verres nee
dl
e is to insert it just
f
ar enoug
h
to
p
enetrate t
h
e
l
ayers o
f
t
h
e a
bd
omina
l
wa
ll
an
d
l
ocate t
h
e tip just into t
h
e
p
eritonea
l
cavity. Two
d
istinct c
l
ic
k
s or pops wi
ll
b
e
h
ear
d
or
f
e
l
t as it passes
th
roug
h
t
h
e s
h
eat
h
an
d
enters t
h
e peritonea
l
cavity. No
f
urt
h
er a
d
vancement
of
t
h
e nee
dl
e s
h
ou
ld
b
e ma
d
e, an
d
c
h
ec
k
ing t
h
e
l
ocation o
f
t
h
e tip o
f
t
h
e Verres
n
ee
dl
e
b
y rotatory motion runs t
h
e ris
k
o
f
creating injuries as minor as a
n
ee
dl
e-stic
k
injury o
f
t
h
e
b
owe
l
, w
h
ic
h
may not nee
d
any treatment at a
ll
, or
as major as a complex bowel tear, which will defi
nitely need surgical treatment.
T
ests t
h
at can
b
e use
d
to c
h
ec
k
t
h
e satis
f
actory
l
ocation o
f
t
h
e nee
dl
e are
the Palmer’s test, the drip test, and the pressure-fl
ow test wit
h
t
h
e CO
insuffl
ator.
W
ith the Palmer’s test, a s
y
rin
g
e is attached to the end of the Verres needle,
and a suction check is done for blood/bowel contents. If there is none
,
then
the fl
uid is instilled down the Verres needle; the fl
uid should fl
ow freely into
the peritoneal cavit
y
, and suction after this should not lead to return of the
uid back into the syringe from the cavity. With the drip test, fl
uid in a syringe
attached to the Verres needle should fl
ow passively into the abdominal cavity
after the plunger is withdrawn. With the pressure-fl
ow test with the
CO
in
su
f-
ator, when the needle is correctly situated, the fl
ow of gas when set at 1 L/min
should also re
g
ister 1 L/min combined with an intraabdominal pressure of less
than 10 mm H
g
. If the needle is inappropriatel
y
positioned within the abdomi-
nal wall, in adhesions, or in intraabdominal structures, the fl
o
w will
be
l
o
w
o
r
nothin
g
and the pressure will be hi
g
h. If bowel contents are obtained at aspira
-
tion or instillation and/or insuffl
ation pressures are high, the Verres needle
can be removed and an alternative entr
y
site selected [23]
.
T
here is some belief that using intraabdominal pressure rather than the
volume of
g
as instilled will lead to a safer distance between the anterior
abdominal wall and the abdominal viscera. Reich et al. [40] were the fi
r
st
to
describe a high-pressure technique, where, with the patient lying fl
at, instilla-
tion of gas is continued till a pressure of 25 mm Hg is reached. At this pressure,
https://t.me/med1917
8. Laparoscopic Surger
y
71
t
h
e
d
istance o
f
t
h
e viscera
f
rom t
h
e anterior a
bd
omina
l
wa
ll
is wi
d
ene
d
; as t
h
e
wa
ll
is stretc
h
e
d
, t
h
e trocar penetrates t
h
e wa
ll
more easi
ly
, an
d
t
h
e
g
reater
s
p
l
intin
g
resists t
h
e
d
ownwar
d
f
orce. T
h
is tec
h
nique
d
oes not a
d
verse
ly
a
ff
ect
t
h
e circu
l
ation or t
h
e respiratory
f
unction o
f
t
h
e patient [41]. Once a
ll
trocars
are in p
l
ace, t
h
e insti
ll
ation pressure s
h
ou
ld
b
e re
d
uce
d
to 12–15 mm H
g
. Ot
h
er
met
h
o
d
s o
f
entr
y
d
escri
b
e
d
, inc
l
u
d
in
g
d
irect trocar insertion, visua
l
access
s
ystems, ra
d
ia
ll
y expan
d
ing trocars, an
d
secon
d
-generation en
d
o-tip systems
an
d
narrow-
d
iameter
l
aparoscopes inserte
d
d
own t
h
e Verres nee
dl
e to
f
orm
an optica
l
Verres s
y
stem, ma
y
b
e
h
e
l
p
f
u
l
,
b
ut as McGur
g
an an
d
O’Donovan
report [42],
d
espite t
h
e t
h
eoretica
l
a
d
vantage, t
h
ere is as yet no evi
d
ence to
d
emonstrate t
h
e superiority o
f
t
h
is approac
h
over conventiona
l
Verres nee
dl
e.
A recent review [38] o
f
a
ll
t
h
e
l
iterature avai
l
a
bl
e s
h
owe
d
t
h
at t
h
ere was insu
f-
fi
cient evidence to indicate a preferred method.
Wh
en t
h
e um
b
i
l
icus is not use
d
as site o
f
entry, a
l
ternative sites suc
h
as
t
h
e
l
e
f
t
h
ypoc
h
on
d
rium can
b
e use
d
, as t
h
is is statistica
ll
y t
h
e area o
f
t
h
e
a
bd
omen wit
h
t
h
e
l
owest inci
d
ence o
f
a
dh
esions. W
h
en perium
b
i
l
ica
l
a
dh
e
-
s
ions are sus
p
ecte
d
, use eit
h
er t
h
e 9t
h
intercosta
l
s
p
ace, or in t
h
e mi
d
c
l
avicu
l
ar
l
ine
b
e
l
ow t
h
is point, a rationa
l
site is t
h
e Pa
l
mer’s point [43]
.
If
vascu
l
ar injury occurs an
d
a retroperitonea
l
h
ematoma resu
l
ts, it s
h
ou
ld
never simp
l
y
b
e o
b
serve
d
. W
h
en retroperitonea
l
vesse
l
injury occurs or is
s
uspecte
d
, a mi
dl
ine incision to exp
l
ore an
d
repair t
h
e injury is in
d
icate
d
.
Eva
l
uating t
h
e extent o
f
injury
l
aparoscopica
ll
y cou
ld
cause a
dd
itiona
l
d
amage
to t
h
e vesse
l
or surroun
d
ing structures an
d
l
ea
d
to
l
oss o
f
time an
d
greater
l
oss o
f
bl
oo
d
. C
l
amping or c
l
ipping major vesse
l
s s
h
ou
ld
not
b
e attempte
d
.
Frantic c
l
amping an
d
suturing resu
l
ts in
f
urt
h
er
d
amage to vesse
l
s an
d
s
urroun
d
ing structures. Ear
l
y intervention
b
y a vascu
l
ar surgeon is
recommen
d
e
d.
Wh
en
b
owe
l
injury occurs, t
h
e assistance o
f
a
b
owe
l
surgeon is o
f
utmost
importance. Prop
h
y
l
actic co
l
ostomy s
h
ou
ld
b
e restricte
d
to patients wit
h
gross
f
eca
l
contamination
.
Careful identifi
cation of the ureter at points where it is most exposed is
necessary to prevent injury. Laparoscopic ureteric injury can
b
e minimize
d
by
using a
l
aparoscopic suturing an
d
tying met
h
o
d
, w
h
ic
h
may
b
e sa
f
er t
h
an
using stap
l
es an
d
e
l
ectrocautery
.
Wh
en suspicion o
f
ureteric injury exists, cystoscopy wit
h
o
b
servation o
f
urine jetting through the ureteric orifi
ce is valuable in confi
rming injury,
especia
ll
y w
h
en intravenous in
d
igo carmine is use
d
. O
b
taining uro
l
ogy con
-
s
u
l
tation intraoperative
l
y wi
ll
h
e
l
p to
d
ecrease t
h
e
d
e
l
ay in recognition o
f
ureteric injury an
d
t
h
us increase t
h
e
l
i
k
e
l
i
h
oo
d
o
f
intraoperative repair
.
e
f
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