1.1 Complications Due to Positioning
To improve organ exposure, patients are often placed in extreme positions during laparoscopic procedures, which can compromise superficially running, long nerves during positioning. Particularly at risk are:
- Peroneal nerve
- Femoral nerve
- Ulnar nerve
- Brachial plexus
Prevention
- Padded shoulder supports in anticipation of a head-down position.
- In the lithotomy position, the leg supports should be additionally padded with gel cushions at the fibular heads.
- Arms positioned alongside the body should be additionally padded at the elbow area and loosely fixed in a pronated position.
- Arms positioned away from the body should be placed on a padded arm board and not abducted more than 90°.
1.2 Complications Due to Trocar Insertion
Inserting the trocars, especially the first trocar, can lead to injuries of hollow organs and vessels, which in many cases necessitates a prompt conversion to laparotomy for safe assessment and management of the injury. Even if an accidental bowel injury can be managed laparoscopically, the possibility of further intra-abdominal injuries that are not immediately apparent must also be considered.
1.3 Complications Due to Pneumoperitoneum
Pneumoperitoneum can trigger numerous pathological changes at haemodynamic, pulmonary, renal, and endocrine levels. Depending on the intra-abdominal pressure, the type of anaesthesia, the ventilation technique used, and underlying conditions, the following complications may occur.
Cardiovascular Complications
- Arrhythmias
- Cardiac arrest
- Pneumopericardium
- Hypo/Hypertension
Pulmonary Complications
- Pulmonary oedema
- Atelectasis
- Gas embolism
- Barotrauma
- Hypoxaemia
- Pneumothorax/-mediastinum
Immediate Measures
- Release of the pneumoperitoneum
- If the complication cannot be managed by anaesthesiological means: possibly convert to an open procedure or abort the operation.
Extreme Subcutaneous Emphysema
In up to 3% of all laparoscopies, a cervical subcutaneous emphysema occurs, which in extreme cases can lead to impending airway compression and secondarily to pneumothorax and pneumomediastinum, then requiring a cervical incision to release the CO2. If there are no ventilation problems with a CO2 pneumothorax, a wait-and-see approach can initially be adopted, as the CO2 in the thorax is rapidly resorbed; in the case of ventilation problems or an extensive capnothorax, a chest drain is indicated. Older patients are particularly affected owing to lax tissue.
1.4 Organ-Specific Complications
Anastomotic Leak
Positive leak test: in the case of a small and easily accessible leak, oversewing should be performed. In this situation, the creation of a protective ileostomy should be considered. In case of doubt, the anastomosis should be re-created.
Organ Injury
- Injury to the spleen: Coagulation with bipolar current, possibly applying a hemostatic agent or fibrin glue. A laparotomy is only necessary in exceptional cases.
- Injury to the pancreas: In case of bleeding, proceed similarly to spleen injuries. Here, the placement of a drain may be advisable to drain secretions in case of a potential pancreatic fistula.
- Injuries to the intestine/duodenum: With appropriate expertise, laparoscopic oversewing is possible.
- Thermal damage using bipolar scissors or ultrasonic dissector
- Vascular injury: Bleeding from smaller vessels can usually be controlled using bipolar current or ultrasonic scissors and, if necessary, by clipping.
Injuries to large vessels (e.g., aorta, vena cava) require immediate laparotomy. - Injury to the ureter: In case of partial transection, laparoscopic oversewing can be performed; otherwise, laparotomy and open ureteral suture. In any case, the insertion of a ureteral stent is indicated.
- Injury to the vagina: Accidental entrapment of the vagina when using the stapling device can lead to the formation of rectovaginal fistulas.