Although laparoscopic and robotic surgeries are guided by the same surgical principles as open surgery, they are inherently different from conventional surgery. The major difference is that laparoscopic surgery uses a video camera to visualize a three dimensional surgical field on a two dimensional monitor. It uses long rigid instruments to manipulate, coagulate and cut the tissue. Therefore, it requires extensive training.
The robotic surgery has overcome these two obstacles by providing a three dimensional surgical view. Also by providing flexible, wristed instruments that can mimic a surgeon’s hand motions. Therefore, robotic surgery is more comparable to conventional surgery than laparoscopic surgery. It also requires a shorter learning curve.
However, unlike open surgery, both laparoscopic and robotic surgeries require a specific abdominal entry. Blindly placing a 10mm trocar into the abdominal cavity, together with a camera and ancillary instruments.
Robotic surgery uses the same surgical principles as laparoscopic surgery; prior knowledge of laparoscopic surgery helps minimize complications encountered with robotic surgery. Such complications primarily have to do with inadequate surgical expertise related to abdominal entry, use of electro surgery, knowledge of anatomy, use of proper instrumentation and adherence to the principles of minimally invasive surgery.
While some complications are unavoidable and stem from circumstances beyond a surgeon’s control, the majority of surgical complications are preventable. In order to minimize complications, the surgeons must pay attention to proper pre-operative planning, intraoperative management and finally postoperative follow-up.
Many times patients and surgeons pursue laparoscopic surgery with a misguided view that it carries a lower risk of adverse events than “open” surgery. Before obtaining the patient’s consent, a surgeon must properly counsel and inform and educate the patient about all the inherent risks of the procedure. The patient’s initial understanding and expectations of the procedure, surgical outcomes, and postoperative recovery are governed by such pre-operative discussions.
Abdominal Entry Techniques and Trocar Insertion
More than half of all complications related to laparoscopy are associated with the entry technique. Preventing complications associated with initial abdominal entry is a prime concern for laparoscopic surgeons. Complications of the abdominal entry are associated with grave patient consequences. Prompt recognition and adequate treatment are essential for patient survival. Most of these complications are defendable in litigation, if the surgeon has strictly adhered to the principles of minimally invasive surgery.
The most important factor with regard to safe entry is a surgeon’s familiarity and proficiency. Thus, a combination of patient surgical history, body habitus, gynecologic pathology, and surgeon experience affect the technique used.
There are many techniques for entering the abdomen – none of which are uniformly safe. As Table 1 indicates, there areno significant differences among complication rates based on technique used.
Table 1: Complication rates based on technique of abdominal entry (from Jacobson et al.)
|Technique||Complication Rate per 1000|
Both the anatomy of the patient and the expertise of the surgeon must be considered when determining the appropriate method of access for any procedure. For example, thin, nulliparous patients may require a different technique than the morbidly obese. Patients with previous abdominal surgeries present additional challenges.
The closed entry technique with a Veress needle consists of blindly inserting the Veress needle to insufflate the abdominal-pelvic cavity. Open laparoscopy, as described by the developer of the technique, Dr. Harrith Hasson, has been shown to minimize vascular injuries but does not reduce bowel injuries. Direct trocar entry is performed by elevating the anterior abdominal wall away from the viscera, then using a see-through trocar with endoscope attached to enter the abdomen. This technique is becoming more popular. A clear advantage of the direct trocar entry technique is in visualizing the layers of the abdominal. The trocar passes through and immediately detects vascular or bowel injuries. Alternative entry sites, such as the left upper quadrant (Palmer’s point), may be considered in cases involving a large uterus, pregnancy, challenging umbilical entry, or prior abdominal or pelvic surgeries that may have caused adhesions around the umbilical area.
Veress needle injury to retroperitoneal vessels can result in minimal hemoperitoneum with a large retroperitoneal hematoma that is difficult to visualize in laparoscopy. Catastrophic bleeding occurs when the primary trocar injures a major artery or vein deep to the umbilicus. It should be noted that the location of the aortic bifurcation varies depending on the patient’s body habitus.
However, certain principles may reduce the percentage of injuries, and a few tricks may provide some measure of safety in gaining access to the abdomen:
- Keep the patient flat and centered on the operating table when entering the abdomen. Avoid the Trendelenburg (when the patient’s head is lowered) position initially because the Trendelenburg position rotates the sacral promontory closer to the umbilicus.
- Use standard length instruments. If the anatomy is considered and the appropriate access site and angle are chosen, there should be no need to use longer needles or trocars.
- In patients with difficult access, either very thin or obese patients, or those who have had prior abdominal surgery, consider alternate sites for needle and trocar insertion.
- Insufflate the abdomen to a relatively high pressure (e.g. 25 mmHg) for a short period of time to permit maximal counter pressure while inserting the trocar.
- Avoid multiple passes with the Veress needle or the trocar.
- Inspect the region underneath the insertion site immediately upon placement of the laparoscope. Look for blood, debris, or bowel contents.
- Place all secondary ports under direct vision.
- Finally, at the conclusion of the procedure, remove the laparoscope under direct vision, looking at each layer of the abdominal wall as the trocar sleeve is removed and ensure that a through-and-through injury has not occurred.
After reassurance of a non-traumatic abdominal entry, the abdomen and pelvis are surveyed for pathology. Endometriosis, pelvic inflammatory disease, and prior surgeries all contribute to distortion of the normal anatomy of the pelvic organs, blood vessels, ureters, and bowel. Adhesiolysis and ureterolysis with meticulous restoration of anatomy should first be undertaken before beginning the procedure. Once normal anatomy has been restored, key anatomic landmarks should be identified and recognized. These include anterior and posterior cul-de-sac, ureters, and major blood vessels. This process, though tedious, will aid in the correct identification of pelvic structures and decrease the risk of unintended injuries.
Complications of Electrical Energy
Knowledge of electrosurgery and tissue effects is essential to properly apply monopolar, bipolar, ultrasonic, and laser energy. Unintended electrosurgical injuries can occur due to defects in insulation that cause sparking. This could be from direct coupling with another instrument, indirect (capacitive) coupling, and the use of coagulation-type current to achieve the same effect as cutting current. The knowledge of electrosurgical principles is imperative in reducing the complications of electrical energy.
Vascular or vessel injuries are the most urgent and life-threatening injuries. They present immediately and are recognized either in the recovery room or within the first 24 hours postoperatively with abnormal or unstable vital signs in the recovery room or a significant drop in blood count.
Major vascular injuries occur most commonly during laparoscopic entry while placing the Veress needle or primary trocar. In addition, major vessel injuries have been reported with a variety of instruments including scissors, electrosurgery, stapling devices, and lasers.
The risk of bowel injury during minor laparoscopic procedures is 0.08%. The risk for major operative laparoscopic procedures is 0.3%. Bowel perforations by scissors or tearing, if not recognized at the time of surgery, typically result in early and severe postoperative abdominal pain and patients do not make a normal recovery. They may not develop severe illness immediately. Fever, absent bowel sounds, and acute abdomen should provoke suspicion in the early postoperative period. Delayed perforation may occur in patients where adhesiolysis or attempts at hemostasis were accompanied by the use of electrosurgery. Devascularization and coagulative necrosis may result in perforation days after the procedure. The average time from small bowel injury to diagnosis is 2-3 days for needle and cannula injuries and 10-12 days for electrosurgery injuries. Delayed diagnosis of a bowel injury can result in major sepsis and mortality rates up to 20%.
Small or large bowel injuries, if recognized during the laparoscopic surgery, can be fixed laparoscopically. Or the injured bowel may be pulled out through an expanded 10 mm incision and fixed.
Worsening and/or persistent pain after laparoscopic surgery necessitates immediate and thorough examination and adequate imaging tests to exclude bowel trauma. The majority of litigation occurs when the physicians do not recognize those injuries on time and not act promptly by taking the patient back to the operating room.
Bladder injury most commonly occurs in the setting of suprapubic trocar placement or dissection of the bladder from the lower uterine segment in women with prior pelvic surgery or cesarean sections, which can cause the bladder to scar or be pulled superiorly. The bladder is a forgiving organ; if the injury is detected intraoperatively it can be repaired laparoscopically in two layers using absorbable sutures. Bladder injury also presents in the immediate postoperative period with decreased urine output, abdominal distension, and constant leakage through the vaginal cuff after hysterectomy.
Ureteral injury occurs in 0.5-1.5% of open gynecological surgeries, and is slightly higher for laparoscopic surgeries. The best way to prevent ureteral injury is to identify the ureters at the beginning of the procedure and be certain of their location at all times during the procedure. Aside from knowing the location of the ureters, there are several techniques to prevent ureteral injury. In difficult cases where there is fibrosis and scarring, routine dissection of the pelvic ureters can be performed so that their location is clear throughout the entire surgical procedure.
Where there is doubt about a ureteral injury, an intraoperative cystoscopy is recommended. Indigo carmine is administered intravenously. After 5-10 minutes blue colored urine should be visualized jetting out of the ureteral orifices. Thermal injury to the ureter may be difficult to diagnose intraoperatively. Signs and symptoms of thermal injury usually do not appear until 10-14 days after surgery. Injuries recognized and repaired intraoperatively have the best prognosis. Still, a delay in diagnosis can lead to progressive deterioration of renal function. As many as 25% of unrecognized ureteral injuries result in eventual loss of the affected kidney. Depending on the location and the extent of the injury, the ureter can be laparoscopically repaired after passing a stent.
Ureteral injury usually occurs within the first 48-72 hours postoperatively, but may present later. Fever, flank pain, peritonitis, and abdominal distention should be recognized as concerning signs. These injuries may also present with leukocytosis and hematuria. If these injuries were not recognized intraoperatively, intravenous pyelogram (IVP) can assist with diagnosis.
Checking of Unrecognized Injuries
While an unintended injury is an unfortunate occurrence, an unrecognized injury carries more serious, as well as long-term, problems. If extensive dissection of the pelvic sidewall was performed or electosurgery was used close to the ureter, cystoscopy with direct visualization of ureteral patency can assist in diagnosing ureteral injury. Directly visualizing ancillary trocar removal would reduce the possibility of unrecognized abdominal wall vessel injury. Dissection of endometriosis or adhesions from the posterior cul-de-sac may expose the bowel to injury. Sigmoidoscopy is a helpful test to detect defects in the rectum and sigmoid colon through visually inspecting the interior at the site of dissection. Another check is performed by filling the pelvis with saline irrigation while simultaneously occluding the distal portion of the sigmoid and placing air in the rectum through the sigmoidoscope. If there is a hole in the bowel air bubbles will escape from the hole.
While laparoscopic surgery has been a tremendous advance in the field of gynecology, it is not without its risks and complications. With careful attention to detail, a systematic approach to each procedure starting with the preoperative patient evaluation and counseling, complications may be anticipated and steps taken to minimize them.
Expert Witness Bio
This article was authored by the professor of OB/GYN, Director of Minimally Invasive Gynecologic Surgery and Director of the Fellowship in Minimally Invasive Gynecologic Surgery. He has clinical practice experience in Minimally Invasive Gynecology spanning more than two decades and has extensive experience working as an expert witness.
M.D., University of Sarajevo
M.S., University of Sarajevo
Ph.D., University of Sarajevo
Internship, Rotating, University Medical Center of Sarajevo
Residency, Obstetrics and Gynecology, Women’s Hospital, Sarajevo
Fellowship, Endoscopy, University of Louisville Hospital
Fellowship, Endoscopy, University of Louisville School of Medicine
Board Certification, Yugoslavia Board of Obstetrics and Gynecology
Member, American Association of Gynecologic Laparoscopists
Past President, American Association of Gynecologic Laparoscopists
Member, Society of Laparoscopic Surgeons
Member, International Society of Gynecologic Endoscopy
Member, Kentucky Medical Association
Current, Professor, Department of Obstetrics, Gynecology and Women’s Health, Major university
Current, Section Chief, Minimally Invasive Gynecologic Surgery, major university
Current, Co-Director, Fellowship in Advanced Gynecologic Endoscopy, Major University