Complications Complications During A During A Laparoscopic Laparoscopic Cholecystectomy Cholecystectomy Bill Cavatassi Bill Cavatassi
Jan 07, 2016
Complications Complications During A During A
Laparoscopic Laparoscopic CholecystectomyCholecystectomy
Bill CavatassiBill Cavatassi
OutlineOutlineOverviewOverview
BleedingBleeding
Pneumoperiteneum creation Pneumoperiteneum creation
Spilled stonesSpilled stones
Bile InjuryBile Injury
OverviewOverview
750,000 per year750,000 per year 90% of all CCY are lap90% of all CCY are lap 25% of surgeons with pneumo creation 25% of surgeons with pneumo creation
complicationcomplication 34-49% of surgeons will have a bile duct 34-49% of surgeons will have a bile duct
injuryinjury
Major complications 2.6%Major complications 2.6% Bleeding (0.11 – 1.97)Bleeding (0.11 – 1.97) Abscess (0.14 – 0.3)Abscess (0.14 – 0.3) Bile leak (0.3-0.9)Bile leak (0.3-0.9) Bile injury (0.26 – 0.6)Bile injury (0.26 – 0.6) Bowel injury (0.14 – 0.35)Bowel injury (0.14 – 0.35) Gas embolism (0.001%)Gas embolism (0.001%)
Variable Odds RatioVariable Odds Ratio
AC vs CC--------------AC vs CC--------------
Male vs female-------Male vs female------- Age----------------------Age---------------------- Body weight-----------Body weight-----------
Experience------------Experience------------
Time--------------------Time--------------------
1.861.86 1.181.18 1.12 per 10 years1.12 per 10 years 1.25 (>90 vs 60-89)1.25 (>90 vs 60-89) 1.34 (>90 vs <60)1.34 (>90 vs <60) 1.22 (>100 vs <10)1.22 (>100 vs <10) 1.36 (>100 vs 11-99)1.36 (>100 vs 11-99) 90% in first 30 cases90% in first 30 cases 1.68 for each 30 mins1.68 for each 30 mins
>2hrs 4x one hr case>2hrs 4x one hr case
Bleeding (0.07-1.9%)Bleeding (0.07-1.9%)
Sites: liver, arterial sources, port insertion sites)Sites: liver, arterial sources, port insertion sites)
Liver: removal GB from fossaLiver: removal GB from fossa Lap hemostasis –vs- open stitch ligature (8%)Lap hemostasis –vs- open stitch ligature (8%)
Arterial source during resection usually cystic Arterial source during resection usually cystic artery – clip if anatomial landmarks ensuredartery – clip if anatomial landmarks ensured
Pneumo CreationPneumo Creation Carbon dioxide – colorless, noncombustible, inexpensiveCarbon dioxide – colorless, noncombustible, inexpensive Rapid absorption (good: dec gas embolism, bad: Rapid absorption (good: dec gas embolism, bad:
hypercarbia)hypercarbia) Venous Return: decreaseVenous Return: decrease
Esp if hypovolemic, due to cava compressionEsp if hypovolemic, due to cava compression Heart Rate: increaseHeart Rate: increase
Hypercarbia causes tachycardia and PVCsHypercarbia causes tachycardia and PVCs Peritoneal inflammation can cause vagal response and dec HRPeritoneal inflammation can cause vagal response and dec HR
CVP: usually artificially elevated from inc thoracic CVP: usually artificially elevated from inc thoracic pressurespressures
FRC (functional reserve capacity): decreasesFRC (functional reserve capacity): decreases Diaphragm motion limited, inc peak airway pressures to maintain Diaphragm motion limited, inc peak airway pressures to maintain
same tidal volumesame tidal volume MAP and SVR: increaseMAP and SVR: increase CO: decrease (inc MAP and dec venous return)CO: decrease (inc MAP and dec venous return) GFR and urine output: decreaseGFR and urine output: decrease
Dec renal vein blood flowDec renal vein blood flow pH: decreasepH: decrease
Hypercarbia leading to respiratory acidosisHypercarbia leading to respiratory acidosis No adverse effects in healthy pts, corrected with inc minute No adverse effects in healthy pts, corrected with inc minute
ventilationventilation Problem in COPD because dec ability to get rid of CO2 Problem in COPD because dec ability to get rid of CO2
(intermittent ABGs)(intermittent ABGs)
Complications from Complications from pneumoperitoneum creationpneumoperitoneum creation
Mortality 0.2%Mortality 0.2% Incidence of injury 0.2% Incidence of injury 0.2% Veress & HassonVeress & Hasson Only 60% dx’d at time of injuryOnly 60% dx’d at time of injury
Retro of 12,919 cases in RomeRetro of 12,919 cases in Rome
Overall 0.18% Veress vs 0.09 HassonOverall 0.18% Veress vs 0.09 Hasson Major Vascular 0.07 – 0.4Major Vascular 0.07 – 0.4
[.02-.24 vs 0][.02-.24 vs 0] Aorta, CI, cava, IMAAorta, CI, cava, IMA 8-17% mortality8-17% mortality
Minor Vascular 0.1 – 1.2Minor Vascular 0.1 – 1.2 Epigastrics, omental, SB mesEpigastrics, omental, SB mes
Visceral 0.05 – 0.26Visceral 0.05 – 0.26 [.03-.15 vs 0-.19][.03-.15 vs 0-.19] 80% GI, 20% urinary80% GI, 20% urinary
Hasson with dec vascular but inc visceral (may be pt Hasson with dec vascular but inc visceral (may be pt selection), not definitive evidence superior or inferiorselection), not definitive evidence superior or inferior
VeressVeress Easier, less gas leakageEasier, less gas leakage 1 in 11,805 insertions cause injury1 in 11,805 insertions cause injury 0 in 117 with LUQ insertion (Palmer’s point)0 in 117 with LUQ insertion (Palmer’s point)
• Must have NG, insert perpendicularMust have NG, insert perpendicular Vessels can be 1-cm beneath umbilicus in Vessels can be 1-cm beneath umbilicus in
thin people, umbilicus shifted over bifuraction thin people, umbilicus shifted over bifuraction in obesein obese• At umbilcus insert 45 deg if thin, 90 if obeseAt umbilcus insert 45 deg if thin, 90 if obese
Lifting abd wall not generally helpfulLifting abd wall not generally helpful• (5% omentum with it, towel clips best)(5% omentum with it, towel clips best)
Veress cont’dVeress cont’d
Safety tests not very helpfulSafety tests not very helpful best indicator is pressure less than 10best indicator is pressure less than 10 Don’t waggle needle (inc 1.6mm puncture Don’t waggle needle (inc 1.6mm puncture
wound to 1cm in size)wound to 1cm in size) Complications inc with triesComplications inc with tries
Gasless entry and optiview are safe Gasless entry and optiview are safe alternativesalternatives
Spilled GallstonesSpilled Gallstones
Gallbladder perf 8-40% with Gallbladder perf 8-40% with complications of 2.3%complications of 2.3%
unretrieved stones occur about unretrieved stones occur about 60% of the time with up to 60% of the time with up to 7% complication rate7% complication rate
Abscess 60%Abscess 60% Subhepatic or subphrenicSubhepatic or subphrenic Duodenal obstruction, diaphragm irritationDuodenal obstruction, diaphragm irritation
Wound sinus/fistula 30% and port site infectionsWound sinus/fistula 30% and port site infections Others: empyema, SBO (adhesions), fistulas Others: empyema, SBO (adhesions), fistulas
(SB, colon, biliary system, bladder)(SB, colon, biliary system, bladder)
Local inflam response with omentum and Local inflam response with omentum and local fibrosislocal fibrosis
Inc with bile infection, multi stones, Inc with bile infection, multi stones, >1.5cm, stone fragmentation and >1.5cm, stone fragmentation and pigmented stones (80-90% w/ bacteria)pigmented stones (80-90% w/ bacteria)
Micro bile/stonesMicro bile/stones Abscesses also need drainage AND stone Abscesses also need drainage AND stone
removalremoval BottomlineBottomline
Bile InjuriesBile Injuries
0.2% - 0.8% lap vs up to 0.25% open0.2% - 0.8% lap vs up to 0.25% open Only up to 66% discovered at time, remainder post Only up to 66% discovered at time, remainder post
(usually 2-10 days, if stricture only then mean of 57 (usually 2-10 days, if stricture only then mean of 57 days)days)
Sx: fever, abd pain,, inc WBC and LFTs esp Alk PhosSx: fever, abd pain,, inc WBC and LFTs esp Alk Phos
Risk factorsRisk factors
Inflammation (inc approximation of cystic Inflammation (inc approximation of cystic and CBD)and CBD)
Excessive cephalad or insufficient lateral Excessive cephalad or insufficient lateral retraction (aligns ducts)retraction (aligns ducts)
Excessive lateral retraction (tear) Excessive lateral retraction (tear) 0 degree scope0 degree scope Excessive cauteryExcessive cautery Aberant anatomyAberant anatomy
IOC ?IOC ?
50 to 70% less injuries50 to 70% less injuries dec from .43 to .21%dec from .43 to .21% Time: +16minsTime: +16mins Cost: NNT 500, not cost effective for the avg pt, Cost: NNT 500, not cost effective for the avg pt,
but if consider cost of bile duct injury (direct and but if consider cost of bile duct injury (direct and indirect) likely cost effectiveindirect) likely cost effective
Interpretation: 79% of injuries with IOC had Interpretation: 79% of injuries with IOC had abnormal study that was overlookedabnormal study that was overlooked
?minimization: injury can be fixed with T-tube vs. ?minimization: injury can be fixed with T-tube vs. progression to transection requiring a Rouxprogression to transection requiring a Roux
W/UW/U US or CT to look for fluid collectionsUS or CT to look for fluid collections HIDA: can confirm presence of bile leak (esp if HIDA: can confirm presence of bile leak (esp if
no fluid collection)no fluid collection) ERCP: diagnostic as well as therapeuticERCP: diagnostic as well as therapeutic MRCP: determines anatomy and defines injury MRCP: determines anatomy and defines injury
(esp good for hilar injuries that are less well (esp good for hilar injuries that are less well defined on ERCP)defined on ERCP)
PTC: to eval and decompress if complete PTC: to eval and decompress if complete disruption or occlusion of proximal ductdisruption or occlusion of proximal duct
Doppler u/s: 12-32% also have vascular injuryDoppler u/s: 12-32% also have vascular injury
Types – Strasberg ClassificationTypes – Strasberg Classification
A: into GB bed from minor hepatic ducts, cystic A: into GB bed from minor hepatic ducts, cystic duct (75%) or ducts of Luschka (6-17%)duct (75%) or ducts of Luschka (6-17%)
B: occlusion of B: occlusion of aberrant right aberrant right hepatic ducthepatic duct
C: transection of C: transection of aberrant right aberrant right hepatic ducthepatic duct
D: lateral D: lateral damage to CBDdamage to CBD
E: injury to main duct (Bismuth)E: injury to main duct (Bismuth) E1: Transection >2cm from confluenceE1: Transection >2cm from confluence E2: Transection <2cm from confluenceE2: Transection <2cm from confluence E3: Transection in hilumE3: Transection in hilum E4: Seperation of major ducts in hilumE4: Seperation of major ducts in hilum E5: Type C plus injury in hilumE5: Type C plus injury in hilum
Management – A and DManagement – A and D
Fluid collection – Fluid collection – perc drainperc drain
A and D – endoscopy stent – preferential A and D – endoscopy stent – preferential bile flow (+sphincterotomy if retained bile flow (+sphincterotomy if retained stone)stone)
Management – B & CManagement – B & C B (usually occult resulting in segmental cholestasis in B (usually occult resulting in segmental cholestasis in
liver and yrs later causing right lobe atrophy – can get liver and yrs later causing right lobe atrophy – can get cholangitis)cholangitis) <3mm – ligate<3mm – ligate >5mm: hepatico-J +/- segemental liver resection >5mm: hepatico-J +/- segemental liver resection
pending degree of atrophypending degree of atrophy
Management – Type D and EManagement – Type D and E Small lateral CBD injury (<50%, Small lateral CBD injury (<50%,
cystic avulsion) - repair over T-tube cystic avulsion) - repair over T-tube (<0.05% leak or stricture)(<0.05% leak or stricture)
>50% - Roux (primary high incidence >50% - Roux (primary high incidence of breakdown/stricture)of breakdown/stricture) Mortality 2- %Mortality 2- % Re-stenosis 5-28%Re-stenosis 5-28%
*some strictures and occlusions *some strictures and occlusions amendable to endo dilation and amendable to endo dilation and stenting (50-70% success)stenting (50-70% success)
ALTERNATIVE: drain and transfer – ALTERNATIVE: drain and transfer – don’t open to confirm obvious injury if don’t open to confirm obvious injury if no intent to repairno intent to repair