Complications of Laparoscopic cholecysectomy By Brief history n

Complications of Laparoscopic cholecysectomy By 醫六 黃昌逢、 張凱閔

Brief history n n This is a 45 y/o woman suffered from acute cholecystitis and laparoscopic cholecystectomy was planned. The known preop data included: ASA class II BW: 45 kg Hb: 12. 5

Brief history n n n Drops both in Sp. O 2 and ETCO 2 were noted when creation of pneumoperitoneum was attempted. The management include: resumption of trandelenburg position and pumping air out of abdomen Operation was resumed and the course was smooth hereafter.

Treatment of acute cholecystitis n n Medical: NPO, NG suction, IV fluid, analgesia, and antibiotics. Surgical: open (OC), laparoscopic (LC) and minimal invasive (MC) cholecystectomy

Comparison between LC, and OC n n n 1. No evidence of symptomatic outcome between LC, and OC. 2. Weak evidence that mortality and complication rates were lower after LC than OC. 3. Weak evidence that biliary tract complication were more common in LC. 635 1 March 1997 The Lancet 349(9052) p 631 -

Comparison between LC, and OC n n 4. Strong evidence that LC causes less deterioration in pulmonary function than OC. 5. Strong evidence that postoperative pain after LC is less than after OC. 635 1 March 1997 The Lancet 349(9052) p 631 -

Results of Laparoscopic Cholecystectomy NEJM 330(6): 409 -19, 1994 Feb 10.

Indication for open cholecystectomy n n n 1. Poor cardiopulmonary function 2. Previous abdominal surgery 3. Severe adhesion 4. Massive hemorrhage or structure unclear 5. Malignancy

Methods of creating pneumoperitoneum n n n 1. USE OF THE VERESS NEEDLE AND PRIMARY TROCAR 2. DIRECT TROCAR INSERTION 3. OPEN LAPAROSCOPY 4. TRANSFUNDAL/TRANSFORNICEAL 5. GASLESS LAPAROSCOPY 1998 Mar. Obstetrical & Gynecological Survey. 53(3): 167 -74,

1. USE OF THE VERESS NEEDLE AND TROCAR n n Procedure: Veress needle insertion, gas insufflation and trocar insertion Test for correct placement of the needle. Presence of flatus, abdominal wall crepitus, or blood returning via Veress needle indicate the incorrect placement. Blind insertion: source of complications

2. DIRECT TROCAR INSERTION n n n Is pneumoperitoneum before trocar insertion absolutely necessary ? Distended abdomen may contribute to bowel and major vascular injury. Procedure: infraumbilical skin incision and trocar insertion and creation of pneumoperitoneum after correct placement checked by laparoscope

3. OPEN LAPAROSCOPY n n Procedure: skin incision and dissection to expose peritoneum, trocar placement and wound closure The technique was supposed to guarantee pneumoperitoneum and to avoid the dangers of blind insertion esp. in high risk patients.

4. TRANSFUNDAL/ TRANSFORNICEAL n n n Procedure: transfundal or transforniceal approach of abdominal insufflation and blind insertion of trocar It is a useful esp. in patients who are obese or not suitable for abdominal approach. Potential complication: persistent bleeding from uterus, perforation of the bladder or the broad ligament

5. GASLESS LAPAROSCOPY n n Procedure: cutdown and insertion of the lifting device either within the peritoneal cavity or in the preperitoneal space and creating the space Benefits: 1. preperitoneal insertion to avoid interference with adhesions 2. the more planar shape of abdominal wall bringing the operative field more close to surgeon 3. no pneumoperitoneum

Complication of laparoscopic cholecysectomy 1、trocar insertion 2、trendelenburg position and reverse trendelenburg position 3、pneumoperitoneum creation

1. Trocar insertion n A. Bleeding abdominal wall vessel intra-abdominal vessel Aorta iliac arteries inferior venal cava

n n n B. hepatic 、splenic tears C. gastrointestinal trauma perforation avulsion of adhesion omental disruption D. herniation

2、Trendelenburg position during pneumoperitoneum: 10 to 20 degree head down position to increase cardiac output n Reverse Trendelenburg position during dissection of gallbladder: prevent bowel injury and provide optimal exposure n

Physiological effect of Trendelenburg position Cardiovascular change: n 1、Healthy pt: ↑cardiac index；CVP、 、PCWP、HR、SVR remain unchanged n 2、normotensive but CAD pt: ↑ CVP、 PCWP；↓ cardiac index；possibility of cerebral congestion

Physiological effect of Trendelenburg position Respiratory change n 1. Associated with pt age, preop lung function, head-down degree…. n 2. Reduce lung vital capacity due to abdominal visera on diaphragm n 3. Increase work of breathing n 4. associated disease: COPD, asthma n 5. compensatory increase in respiratory rate in health pt

Physiological effect of Trendelenburg position Endotracheal tube site change n The endotracheal tube, firmly secured at its proximal end, dose not always move cephalad with the trachea as diaphragm presses upwards and displaces the lung and carina.

3. Pneumoperitoneum creation n 1. technical difficulties n 2. cardiovascular effects n 3. respiratory function

Technical difficulties n n 1. method of creating pneumoperitoneum 2. subcutaneous insufflation of CO 2 -extensive surgical emphysema

Cardiovascular effects of pneumoperitoneum n n n 1. low intra-abdominal pressure(less than 25 mm. Hg): increase cardiac output due to hypercarbia- induced sympathetic activity 2. high intra-abdominal pressure(greater than 40 mm. Hg): decrease cardiac output due to reduce venous return or IVC compression 3. hemorrhage-due to trocar injury 4. dysrhythmia-CO 2 related 5. myocadial depression-due to acidosis

Respiratory effects of pneumoperitoneum Intraoperative hypoxemia n 1. Preexisting conditions: A. cardiopulmonary disease: asthma or COPD acute exacerbation acute myocardiac infarction B. morbid obesity

2. Hypovetilation n n A. patient posture B. pneumoperitoneum C. ET tube obstruction D. inadequate ventilation

3. intrapulmonary shunting n n A. pneumothroax B. bowel distension-N 2 O related C. pulmonary aspiration of gastric content D. CO 2 venous embolism

4. reduce cardiac output n n A. massive hemorrhage B. IVC compression C. dysrhythmia D. myocadial depression

CO 2 venous embolism 1. Incidence Carbon dioxide embolism is a potentially lethal complication of laparoscopic procedures, although its incidence is low (15 of 113, 253 gynecologic laparoscopies). From ANESTHESIOLOGY 1999: Probable Carbon Dioxide Embolism during Endoscopically Assisted Varicose Vein Stripping by Mladen I. Vidovich, M. D. ; Edwin W. Lojeski, D. O.

CO 2 venous embolism 2. Pathophysiology: A. Rapid entry or large volumes of CO 2 put a strain on the right ventricle because of the migration of the emboli to the pulmonary circulation. B. The pulmonary arterial pressure increases, and the increased resistance to right ventricular outflow causes diminished pulmonary venous return. C. Because of the diminished pulmonary venous return, there is decreased left ventricular preload, resulting in diminished cardiac output and, ultimately, systemic cardiovascular collapse.

CO 2 venous embolism 2. Pathophysiology: D. Tachyarrhythmias often develop, but bradycardias are possible as well. When large quantities of gas (over 50 ml) are injected abruptly, acute cor pulmonale, asystole, or both are likely to occur. E. The alteration in the resistance of the lung vessels and the mismatch between ventilation and perfusion cause intrapulmonary right-to-left shunting and increased alveolar dead space, leading to arterial hypoxia and hypercapnia. From NEJM Volume 17 Feb 2000 Primary Care: Gas Embolism by Muth, Claus M. ; Shank, Erik S

CO 2 venous embolism 3. clinic findings n n n A. decrease in end-tidal carbon dioxide and O 2 saturation B. Cardiovascular collapse, hypotension, , dysrhythmias , pulmonary edema and right heart failure C. mill-wheel heart murmur : a splashing auscultatory sound due to the presence of gas in the cardiac chambers

CO 2 venous embolism 4. Diagnosis n Transesophageal echocardiography is the most sensitive method of detection of carbon dioxide embolism, whereas changes in end-tidal carbon dioxide, pulmonary artery pressure, and precordial Doppler are less sensitive

CO 2 venous embolism 5. Treatment n n A. change to horizontal position B. desufflation and hyperventilation C. insertion of a CVP to attempt aspiration D. cardiopulmonary resuscitation

CO 2 venous embolism 1. The median lethal dose of carbon dioxide embolism in dogs is 25 ml/kg. 2. In pigs, the volume of carbon dioxide required to change end-tidal carbon dioxide is approximately 0. 66 ml/kg. 3. Because carbon dioxide is highly soluble in blood, it is rapidly absorbed from the bloodstream, and if embolization does occur, it is less likely to be fatal than if air or oxygen is used for insufflation. From ANESTHESIOLOGY 1999: Probable Carbon Dioxide Embolism during Endoscopically Assisted Varicose Vein Stripping by Mladen I. Vidovich, M. D. ; Edwin W. Lojeski, D. O.

Thank you for your attention! By醫六 張凱閔, 黃昌逢