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Part of Laparoscopic Cholecystectomy Training Module
Type Medical knowledge page
SDG Sustainable Development Goals SDG03 Good health and well-being
Authors Dr. Makam Ramesh
Published 2021
License CC-BY-SA-4.0
Affiliations Global Surgical Training Challenge
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Laparoscopic surgery has become the gold standard in the management of many diseases especially gall stones. Experience and maturation of technique has allowed the procedures to be performed in difficult cases. We have also come to understand that the procedures are accompanied by a number of complications. The severity and frequency of these complications can be reduced by careful attention to technique. The proper preparation of the patient and judicious use of conversions to laparotomy will reduce these complications.

Patients should be well informed of the advantages and potential disadvantages of the laparoscopic procedure. They must understand that the procedure is not a magic trick but is a major surgery performed with video guidance. Fasting for at least 8 hr. before surgery is the rule. Insertion of a urinary catheter empties and protects the bladder and is important if the Veress needle technique is used to establish pneumoperitoneum. The catheter is rarely needed, however, if the open method of peritoneal access is performed.

Achieving Pneumoperitoneum

This step in the performance of laparoscopic surgery often seems trivial, but is extremely crucial to the success and safety of the entire procedure. Carelessness or poor judgement at this point in the method can result in severe injury to the patient. Use of the Veress needle to create pneumoperitoneum is a safe and time tested technique. The operator must ensure that the "pops" of the various layers of the abdominal wall are felt, that no fluid is aspirated as the needle enters the Abdomen and that a drop of water placed into the needle's barrel falls into the needle. After attaching the gas lines to the needle, pressures should be very low, indicating no resistance to flow ( I recommend the "Golden Rule of 5" - the initial intra-abdominal pressure being less than 5 mm of Hg and the rate of gas insufflation being more than 0.5 Lit/min). If pressures are high, one should consider a second insertion at another site to localize and repair the first needle puncture injury (if any), or one should proceed to laparotomy. Severe injuries to viscera and great vessels have occurred because of thrusting the needle deep into the abdomen. Any evidence of puncture of a major vessel should prompt laparotomy to allow inspection and repair of the vessel if necessary.

An easy solution might seem to be direct cut down by the Hassan method into the abdomen at the umbilicus. It is not, however, without potential pitfalls. Bowel may be injured when the abdomen is entered, and injury may go unrecognized causing later peritonitis and sepsis. It is crucial that the bowel beneath the site be inspected on introduction of the telescope, and before removal of the telescope, the site be inspected from another port.

TYPES OF COMPLICATIONS:

Anaesthesia-related Problems

One-third of deaths associated with minor laparoscopic procedures such as sterilization are secondary to complications of anesthesia. Among the potential complications of all general anesthetics are hypoventilation, esophageal intubations, gastroesophageal reflux, bronchospasm, hypotension, narcotic overdose, cardiac arrhythmias, and cardiac arrest. Laparoscopy, when performed with CO2 or nitrous oxide (N20) insufflation induces change in several parameters of cardiopulmonary function, such as reduced pO2, O2 saturation, tidal volume and minute ventilation, and an increased respiratory rate. The use of intraperitoneal CO2 as a distension medium is associated with an increase in pCO2 and a decrease in pH. Elevation of the diaphragm may be associated with basilar atelectasis, a resultant right-to-left shunt and a ventilation perfusion mismatch.

CARBON DIOXIDE EMBOLUS

CO2 is the most widely used peritoneal distension medium. Most CO2 micro-emboli are absorbed, usually by the splanchnic vascular system, quickly and without incident. However, severe cardio respiratory compromise may result if large amount of CO2 gains access to the central venous circulation, such as with inadvertent intravascular placement of an insufflation needle.

Diagnosis: The presenting signs of CO2 embolus include sudden, otherwise unexplained hypotension, cardiac arrhythmia, cyanosis, and development of a classic "mill wheel" heart murmur. Other clinical sequelae include increased tidal CO2, findings consistent with pulmonary edema, and pulmonary hypertension, resulting in right-sided heart failure.

Risk Reduction: A number of steps may be taken to reduce the risk of CO2 embolus. It is important to ensure that blood is not emanating from the needle before the distending gas is introduced. Operating with the intraperitoneal pressure always less than 20mm Hg also reduces the risk of CO2 embolus. In most instances, except for the initial placement of trocars in an insufflated peritoneum, the surgeon should be able to function comfortably with the intraperitoneal pressure at 8-12 mm Hg.

The risk of CO2 embolus is further inhibited by the meticulous maintenance of hemostasis, because open venous channels are a portal of entry for gas into the systemic circulation. Another option that should virtually eliminate the incidence of CO2 or other gas emboli is the use of "gasless" or "apneumic" laparoscopy, in which extra-or intraperitoneal lifting mechanisms are used to create a working space for the surgeon. Such devices have yet to gain wide acceptance.

Management: When CO2 embolus is suspected or diagnosed, the operating room team must act quickly. The surgeon must immediately decompress the peritoneal cavity and place the patient's head below the level of the right atrium, in the Durant, or left lateral decubitus position. Immediately establishment of a large-bore central venous line may allow aspiration of gas from the heart. Because the findings are nonspecific, other causes of cardiovascular collapse should be considered.

CARDIOVASCULAR COMPLICATIONS

Hypercarbia and the resulting acidemia are the principle reasons for the relatively frequent development of cardiac arrhythmias during laparoscopic surgery. The anesthesiologist must be careful to select agents that limit the risk of cardiac arrhythmia. Operating with intraperitoneal pressures less than 12 mm Hg may reduce the incidence of hypercarbia-associated arrhythmias. Although during laparoscopy the most common cause of low blood pressure is hemorrhage, hypotension can also occur secondary to excessive intraperitoneal pressure and result in decreased venous return, which causes decreased cardiac output. This undesirable result may be potentiated if the patient is volume depleted.

GASTRIC REFLUX

Gastric regurgitation and aspiration are complications potentiated by laparoscopic surgery, especially when the patient is in Trendelenberg position. The surgeon can contribute to aspiration prophylaxis by operating at the lowest necessary intraperitoneal pressure. Patient should be taken out of the Trendelenberg position before being extubated.

HAEMORRHAGE

Great Vessel Injury: The most dangerous hemorrhagic complications of entry are from injury to the great vessels, including the aorta and vena cava and the common iliac vessels and their branches, the internal and eternal iliac arteries and veins. Trauma most often occurs secondary to insertion of an insufflation needle, but catastrophic results may result from the tip of sharp trocar inserted with closed technique.

Diagnosis: Most often the problem manifests in profound hypotension with or without the appearance of a significant volume of blood within the peritoneal cavity. Frequently, bleeding is contained in the retroperitoneal space, which usually delays diagnosis. Consequently, the patient may develop hypovolemic shock in the recovery room, secondary to the unrecognized laceration of a great vessel. To avoid this problem it is important to evaluate the course of each great vessel before completing the procedure.

Risk Reduction: The incidence of large vessel trauma can be minimized in several ways. Use of "open laparoscopy" for the initial  port has been suggested as one way to entirely avoid the issue of great vessel injury secondary to insufflation needles and trocars. Although the incidence of injury to great vessels may be reduced, injuries to the aorta and vena cava have been incurred, probably because of reduced exposure during open laparoscopy. Insufflation needles and the trocar should be kept sharp or should be disposable. The spring-loaded obturator of the insufflation needle should be checked to ensure that the sliding mechanism is functioning normally. Many disposable trocar-cannula systems are constructed with safety mechanism that covers or retracts the trocar after passage through the fascia and peritoneum. However, no current data demonstrate that these devices reduce the incidence of major vessel injury. The application of appropriate technique is based upon.

Management: Blood withdrawn from the insufflation needle should be left in place while immediate preparations are made to obtain blood products and perform laparotomy. If the diagnosis of hemoperitoneum is made at initial visualization of the peritoneal cavity, a grasping instrument may be used, if possible, to temporarily occlude the vessel. Although significant injury is unlikely to be repaired by laparoscopically directed technique, if temporary hemostasis can be obtained and the laceration visualized, some localized lesions can be repaired with suture under laparoscopic guidance. However, only experienced, technically adept surgeons should make such an attempt, and fine judgment should be used.

ABDOMINAL WALL VESSEL INJURY

By far the most commonly injured abdominal wall vessels are the superficial inferior epigastric vessels as they branch from the femoral artery and course cephalad in each lower quadrant. These vessels are invariably damaged by initially passage of an ancillary trocar or by a wider device introduced later in the procedure. The problem may be recognized immediately by observation of blood dripping along the cannula or out through the incision. However, it is not uncommon for the cannula to obstruct bleeding until withdrawal at the end of the procedure.

Diagnosis: Injury can be diagnosed by visualization of blood dripping down the cannula, by the post operative appearance of shock, abdominal wall discoloration, or a hematoma located near to the incision. In some instances blood may track to a more distant site and present as pararectal or vulvar mass. Delayed diagnosis may be prevented at the end of the operation by laparoscopic evaluation of each peritoneal incision after removal of the cannula.

Risk Reduction: Transillumination of the abdominal wall from within the peritoneal cavity usually provides identification of the superficial inferior epigastric vessels. However, the deep inferior epigastric vessels cannot be identified this way because of their location deep to the rectus sheath. At the pubic crest, the deep inferior epigastric vessels begin their course cephalad between the medially located medial umbilical ligament and the more laterally positioned exit point of the round ligament. The trocar should be inserted medial or lateral to the vessels, if they are visualized. If the vessels cannot be seen, and it is necessary to position the trocar laterally, the trocar should be inserted 3-4 cm lateral to the median umbilical ligament. Too lateral an insertion endangers the deep circumflex epigastric artery.

A common mistake is to fashion the skin incision appropriately, but then direct the trocar medially through the abdominal wall, which injures the vessels. Another factor that my contribute to the risk of injury is use of large-diameter trocars and cannula. Consequently, it behooves the surgeon to use the smallest cannula necessary for performance of the procedure.

Management: Superficial inferior epigastric artery lacerations usually respond to expectant management. Rotation of the cannula to a position in which compression is possible is also helpful. Rarely is a suture necessary. For the ligation of lacerated deep inferior epigastric vessels, it is found that the use of a modified, straight ligature carrier is most useful. After removal of the trocar and cannula, the ligature carrier is used to advance a suture laterally and inferiorly under laparoscopic guidance, the suture is held in place by grasping forceps. The ligature carrier is removed and subsequently passed through the incision again, this time without a suture, medial and inferior to the lacerated vessels. The suture is threaded into the carrier from within the peritoneal cavity then externalized and tied. For small incisions (narrower than the diameter of the surgeon's finger), the knot may be tightened with a laparoscopic knot manipulator. The most obvious method is placement of large, through-and-through mattress sutures, usually removed after about 48 hr.

INTRAPERITONEAL VESSEL INJURY

As with any intraperitoneal surgical procedure, hemorrhage may occur from injury to vessels encountered in the course of the surgical dissection.

Risk Reduction: During dissection, vessels should be identified and occluded before division, a task made simpler by the magnification afforded by the laparoscope. Electrosurgical coagulation, if used, should be applied in the appropriate waveform and power density long enough to allow sufficient tissue desiccation. Clips should be of a size appropriate for the vessel, and they must be applied in a secure fashion with an adequate pedicle of tissue.

Management: Transected vessels should be secured immediately. Arteries larger than 3mm in diameter are less reliably occluded with desiccation than are arteries less than 3mm. If bipolar electrosurgical desiccation is used to maintain or achieve hemostasis, a serial ammeter is useful to demonstrate the end point of energy application. Blind clamping followed by electrosurgical desiccation must be avoided, even with bipolar instruments, especially when the location is less than 1 cm from ureter or bowel. When a vessel is in this location, securing it with clip is usually preferable.

GASTROINTESTINAL COMPLICATIONS

Insufflation Needle Injuries

Needle entry into the stomach occurs in the presence of gastric distension or when adhesions bind the stomach to the abdominal wall. Mechanical entry into large or small bowel may occur in any instance, but is up to 10times more common when laparoscopy is performed on patients with previous intraperitoneal inflammation or abdominal surgery.

Diagnosis: Recognizing gastric entry by the insufflation needle may follow identification of signs of extra peritoneal entry, such as increased filling pressure, asymmetric distension of the peritoneal cavity, or the aspiration of gastric particulate matter through the lumen of the needle. However, the hollow capacious nature of the stomach may allow the initial insufflation pressure to remain normal. Recognition of bowel entry usually follows observation of the signs described for gastric injury, with, in the case of colonic entry, the addition of feculent odor.

Management: the management of any trauma to the gastrointestinal tract partially depends on the nature of the injury and on the organ(s) involved. In general, insufflation needle punctures that have not caused a defect significantly larger than their diameter may be handled expectantly. Large defects should be repaired or resected by laparoscopic or laparotomy-based technique according to the skill of the surgeon and the extent of the lesion.

TROCAR INJURIES

Damage caused by sharp trocar penetration is usually more serious than injury from a needle. Most often, injury is created by the primary trocar because of its blind insertion.

Diagnosis: When a primary trocar inserted with closed technique penetrates bowel, the diagnosis is usually made when the surgeon visualizes a mucosal lining after the laparoscope is inserted. If large bowel has been entered, a feculent odor maybe noted. However, in some instances, the injury may not be recognized immediately because the cannula may not remain in place or may pass through the lumen and out on the other side of the viscus. Such injuries usually occur when a loop of bowel is adherent to the anterior abdominal wall near the entry point. Consequently, at the end of the procedure one should directly view the removal of the primary cannula, either through the device itself or via an ancillary port. Unfortunately, the lesion may go unrecognized until it presents post operatively with peritonitis, abscess enterocutaneous fistula, or death.

Risk Reduction: Trocar injury to the stomach is generally eliminated with liberal use of oral or nasogastric decompression. Bowel injuries usually occur when the intestine is adherent to the abdominal wall under the site of trocar insertion. Consequently, preoperative mechanical bowel preparation should be used for high-risk patients to facilitate repair of colonic injury without the need to perform a laparotomy/colostomy.

Despite the widespread use of disposable cannula insertion systems with retractable trocars or safety sheaths, injury to bowel or other structures may occur. Many surgeons routinely use open laparoscopy, but bowel entry may still occur. An alternative approach, especially when one enters an abdomen with previous laparotomy scars, is left upper quadrant insertion, preferably with an insufflation needle especially designed to allow passage of a narrow laparoscope. This approach allows direct visualization of the abdominal wall under the umbilicus or other planned site of insertion and may facilitate dissection of underlying adhesions.

Management: Trocar injuries to the gastrointestinal tract almost always require repair. If one can ascertain that the injury is isolated and if the surgeon is experienced, the lesion may be repaired with appropriate suture by laparoscopic guidance. Extensive lesions may require resection and reanastomosis, which can be performed with laparoscopic direction but usually requires laparotomy. If the injury is to sigmoid colon, primary repair may be attempted if the bowel has been mechanically prepared preoperatively. If uncertainty exists regarding the extent of injury, laparotomy is always indicated.

DISSECTION AND THERMAL INJURY

Diagnosis: Any amount of dissected bowel should be carefully examined during the dissection because comprehensive "running" of the bowel near the end of the procedure is far more difficult under laparoscopic guidance. Thermal injury to bowel may be more difficult to diagnose intraoperatively, particularly if the injury was created with electrical or laser energy, a feature that makes careful adherence to safety protocols imperative. Even if thermal injury is recognized, estimating the extent of the damage visually is difficult because the zone of desiccation may exceed the area of visual damage. An understanding of the differing impacts of various types of electrical current is essential to estimate the extent of injury. In some instances, diagnosis is delayed until the patient develops peritonitis and fever, which usually occurs a few days after the procedure but occasionally does not happen for several weeks.

Risk Reduction: When one is dissecting, adequate exposure of the operative field must be accomplished, frequently with the retraction and counter traction provided by a competent assistant. Dissection close to bowel should be performed mechanically with sharp scissors, not with electrical or laser energy sources. Occlusion of blood vessels near to bowel is accomplished with clips, or bipolar current, provided that an adequate margin of tissue exists. Regardless, if the difficulty of the dissection makes the surgeon uncomfortable, alternative methods of hemostasis should be used. If other methods are not feasible, one should seek the aid of a more experienced colleague, abandon the procedure or convert to an open procedure.

Management: Thermal injury may be handled expectantly, if, in the estimation of the surgeon, the lesion is superficial and confirmed. Estimating the degree of tissue injury is possible if one knows the nature of the current and other parameters, such as the wattage, current density, and duration of contact with tissue.

UROLOGIC INJURY

Laparoscopy-associated damage to the bladder or ureter may occur secondary to mechanical or thermal trauma.

Diagnosis: As with all visceral trauma, intraoperative identification of the injury is the most important aspect of management. The diagnosis is relatively easy if the surgeon recognizes entry into a hollow viscus or urine in the opeative field. Hematuria suggests urinary tract injury and pneumaturia (CO2 in the indwelling drainage system) is diagnostic of vesical entry. The existence of a bladder laceration may be confirmed with the injection a dilute methylene blue solution via an indwelling catheter. Thermal injury to the bladder may not be initially apparent; it frequently presents later in the patient's postoperative course when the traumatized area sloughs off and allows egress of urine into the peritoneal cavity.

Ureteric lacerations may be proven intraoperatively with the systemic injection of indigo carmine dye. Intraoperative recognition of mechanical obstruction secondary to staples or suture can be made by direct visualization of the occlusion or realized when cystoscopic imaging fails to demonstrate injected indigo carmine dye entering the bladder from the affected side.

Unfortunately, diagnosis is frequently delayed until after the procedure. Thermal injury presents 24 hours to 14 days after surgery with fever, abdominal or flank pain, clinical findings of peritonitis, or a combination of these signs. Leukocytosis may be present. An intravenous pyelogram can demonstrate extravasation of urine or a urinoma. Not surprisingly, cases of laparoscopy-associated ureteric obstruction seem to present at a time similar to that for cases after laparotomy based procedures-a few days to 1 wk after the operation, usually with flank pain and fever. The diagnosis may be suggested by abdominal ultrasound, but intravenous pyelogram can be more precise at identifying the site and degree of the obstruction.

Uretero-or vesicovaginal fistula presents in a delayed fashion with urinary incontinence or vaginal discharge. Bladder fistula can be confirmed by direct visualization or the leakage of instilled methylene blue onto a tampon. A ureterovaginal fistula does not pass methylene blue from the bladder; it can be identified by intravenous injection of indigo carmine.

Risk Reduction: Trocar related bladder injuries are generally preventable with routine preoperative bladder drainage. Additional caution must be exercised in the patient previously exposed to abdominal or pelvic surgery because there may be scarring and retraction that pulls the bladder above the level of the symphysis pubis. The urachus, although rarely patent, should be avoided if possible. For prolonged or difficult cases, placement of an indwelling catheter may reduce the incidence of injury resulting from dissection. However, sharp mechanical dissection is preferred, particularly when relatively dense adhesions are present.

A requisite to risk reduction is knowledge of the ureter's anatomy as it courses through the pelvis. It is essential to understand the proximity of the ureter to the uterine artery, the cervix, and the uterosacral ligaments and to realize that any of these relationships may be distorted by previous surgical dissection or by disease such as endometriosis or leiomyomas.

If the surgeon cannot, with assurance, steer a wide path from the ureter's course, the ureter must be directly visualized, especially when laser, electrosurgical, or stapling techniques are used. Frequently, the ureter can be seen through the peritoneum of the pelvic sidewall between the pelvic brim and the attachment of the broad ligament.

However, even in this location, the location of the ureter can be obscured because of anatomic variation or the presence of pathology, situations that mandate dissection of the retroperitoneal space.

Treatment: Small caliber (1-2mm) injuries to the bladder heal spontaneously with prolonged catheterization. However, the duration of catheterization can be reduced or eliminated if repair is undertaken intraoperatively. A fairly significant injury to the bladder can usually be repaired under laparoscopic direction, provided the surgeon has adequate surgical skill and the location is amenable to laparoscopic technique. Further evaluation of the location and extent of the laceration may be provided by direct laparoscopic technique. Further evaluation of the location and extent of the laceration may be provided by direct laparoscopic examination of the bladder lumen with use of a small caliber  endoscopes (1.5-2.0 mm in diameter). If the laceration is near to or involves the trigone, open repair may be preferable.

For relatively small lesions, a single layer, simple or purse string closure may be fashioned using synthetic absorbable sutures of 2-0 or 3-0 caliber and tying the knot either intra or exracoporeally. For linear lacerations, the defect is preferably closed in two layers.

If significant thermal injury exists, excising the damaged area before repair may be advisable. Postoperative catheterization with a large- caliber urethral or suprapubic catheter should be maintained for 5-7 days for simple fundal lacerations and for 2 week for injuries closer to the trigone or the vaginal vault.

Intraoperative diagnosis of ureteral injury provides the opportunity for intraoperative management. Very limited damage may respond adequately to the passage of a ureteric stent for 10-20 days. In most instances, however, repair is indicated according to the surgical principles for open procedures.

When the diagnosis of obstructive ureteral injury is delayed until after surgery, the first imperative is to establish drainage. Some incomplete or small obstructions and lacerations may be successfully treated with retrograde or antegrade passage of a ureteral stent. Urinoma may be drained percutaneously. If a stent cannot be successfually manipulated across the lesion, a percutaneous nephrostomy should be created and plans should be made for operative repair.

SOFT TISSUE EMPHYSEMA

Subcutaneous emphysema most commonly results from periperitoneal placement of an insufflation needle or leakage of CO2 around the cannula sites, the latter frequently because of excessive intraperitoneal pressure. Although the condition is usually mild and limited to the abdominal wall, it can become extensive, involving the extremities, the neck, and the mediastinum. Another relatively common location for emphysema is the omentum or mesentery. Subcutaneous emphysema may be readily identified by the palpation of crepitus in the abdominal wall; if it extends along contiguous fascial planes to the neck, it can be visualized directly. This finding can be reflection of the development of mediastinal emphysema, which, if severe, may lead to pneumothorax and cardiovascular collapse.

Risk Reduction: Proper positioning of an insufflation needle reduces the risk of subcutaneous emphysema. No one test absolutely predicts intraperitoneal placement. A variety of tests such as aspiration, creation of preinstillation negative pressure, and maintenance of low insufflation pressure with symmetrical distension of the abdominal wall, should be used. Pre-inflation negative pressure can be demonstrated by aspirating a drop of water placed on the open end of the insufflation needle, followed by elevation of the anterior abdominal wall. A more quantitative demonstration is to elevate the abdominal wall after the tubing is connected to the needle, the result should be a low or negative intraperitoneal pressure (-1 to –4mm Hg).

Insufflation should be initiated at a low flow rate (1 L/min) until the surgeon has confidence that proper placement has been achieved. Loss of liver dullness should occur when about 1500 mL of gas has entered the peritoneal cavity. The distension should be symmetrical and the measured intraperitoneal pressure should be below 10mmHg, sometimes slightly higher in patients. If, at any time, the surgeon feels that the needle is not located intraperitoneally, it should be withdrawn and reinserted. After the peritoneal cavity has been insufflated with an adequate volume of gas, the primary trocar is introduced. Then the laparoscope is introduced, and if the cannula is satisfactorily located, the tubing is attached to the appropriate port.

Subcutaneous emphysema may evolve despite intraperitoneal placement of the trocars, an even that can be avoided by maintaining low intraperitoneal pressure below 15mm Hg (preferably near 10 mmHg) after placement of the desired cannula. Other approaches that may reduce the chance of developing subcutaneous emphysema are use of open laparoscopy and the abdominal wall lifting systems that render gas unnecessary.

Management: If the surgeon finds that the initial insufflation has occurred extraperitoneally, several options exist. Removing the laparoscope and repeating the insufflation is possible, but using this method is more difficult because of the new configuration of the anterior peritoneum. Options include open laparoscopy or the use of an alternate site such as the left upper quadrant. One attractive approach is to direct insertion of the insufflation needle visually after leaving the laparoscope in the expanded preperitoneal space.

For mild cases of subcutaneous emphysema, no specific intra-or postoperative therapy is required because the findings quickly resolve after evacuation of the pneumoperitoneum. When the extravasation extends to involve the neck, terminating the procedure is usually preferable because pneumomediastinum, pneumothorax, hypercarbia, and cardiovascular collapse may result.

NEUROLOGIC INJURY

Peripheral neurological injury is usually related either to inappropriate positioning of the patient or to pressure exerted by the surgeon or assistants. Nerves may also be injured as a result of the surgical dissection.

Diagnosis: In most instances, the patient has sensory deficits, motor deficits, or both on emerging from anaesthesia. The diagnosis can usually be suspected by clinical examination. Injuries to the peritoneal nerve are reflected by loss of sensation in the lateral aspect of the leg and foot and foot-drop. Brachial plexus injuries usually involve damage to the C-5 or C-6 roots and manifest in loss of flexion of the elbow and adduction of the shoulder.

Risk Reduction: The incidence of brachial plexus injury can be reduced by placing the patient's arms in an adducted position, which facilitates the performance of pelvic surgery and prevents the surgeon from leaning on the patient's arm. If leaving the patient's arm in an abducted position is necessary, adequate padding and support of both arms and shoulders should be provided. Also helpful is the use of shoulder supports to prevent slippage when the patient is placed in the Trendelenberg position.

Sciatic and peritoneal nerve injury is best prevented with the use of appropriate stirrups and careful positioning protocols. Stirrups that combine both measures include simultaneous raising and lowering of the patient's legs, flexion of the knees before flexion of the hips, and limitation of external rotation of the hip.

Management: Most injuries to peripheral nerves recover spontaneously. The time to recovery depends on the site and severity of the lesion. For most peripheral injuries, the patient recovers full sensorineural function in 3-6 months. Recovery may be facilitated with physical therapy, appropriate braces, and electrical stimulation of the affected muscles.

INCISIONAL HERNIA AND WOUND DEHISCENCE

The reports seem to indicate that defects that are 10mm or larger in diameter are particularly vulnerable, albeit no incision is immune to the risk of herniation. Another important factor contributing to risk may be the use of cannula anchoring devices that increase the diameter of the incision, sometimes as much as 3mm. Dehiscence of a laparoscopic wound may be irrelevant unless bowel or other intraperitoneal tissue herniates into and through the defect. One of the more sinister complications, involving only a portion of the bowel wall, is Richter's hernia, which is somewhat more difficult to diagnose and may result in perforation, peritonitis, and death. The most common defect appears immediately postoperatively when bowel or omentum passes through the unopposed or inadequately repaired incision. Many defects probably remain asymptomatic, but late presentation may occur if bowel or omentum has become trapped.

Risk Reduction: Whenever possible, the smallest diameter cannula should be used; hernia has been reported in conjunction with the use of 5mm trocars. The Z-track insertion method offsets skin and fascial incisions, which potentially reduces the incidence of hernia. Another approach is to remove all ancillary cannula under direct vision to ensure that bowel is not drawn into the incision. Insertion of an obturator (or a laparoscope) into the cannula may also prevent suction from drawing bowel or omentum into the incision. Incisions 10mm or larger in diameter should undergo facial closure under laparoscopic direction to prevent incorporation of bowel, which may be accomplished by using a 5mm or smaller diameter laparoscope through one of the smaller cannula. A narrow diameter, three-quarter round needle facilitates closure, as does use of a laparoscopic ligature carrier.

Management of laparoscopic incisional defects depends on the timing of the presentation, the presence or absence of entrapped bowel, and the condition of the bowel.

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