Insufflation of carbon dioxide

The insufflation of carbon dioxide (CO2) required for the maintenance of the pneumoperitoneum results in partial absorption of the applied gas by the patient during surgery. This leads to an increase in the arterial partial pressure and end-expiratory partial pressure of carbon dioxide. There is also a decrease in blood pH. The anaesthetist can influence the situation by increasing the ventilation, while the surgeon can use the carbon dioxide sparingly. A lower intra-abdominal pressure (e.g. 10-12 mm Hg) will result in a lower carbon dioxide absorption rate. The duration of surgery is also important, since the rate of carbon dioxide absorption increases with the operating time.

Especially in obese patients, considerable emphysema of the skin due to the insufflated carbon dioxide can occur, depending on the duration of surgery. This emphysema is quickly resorbed within a few hours following surgery. However, carbon dioxide absorption can cause further impairment of cardiac and pulmonary function in patients suffering from severe cardiac insufficiency or disorders of pulmonary function. In these patients, the laparoscopic approach should be evaluated in relation to the benefit and risks for the patient.

Vascular injuries

Vascular injuries are the most common injuries occurring during urological laparoscopic surgery. Unforeseen haemorrhage can occur at any point in time during laparoscopic surgery, as in open surgery. But, in laparoscopy, it is much more difficult to control the bleeding source. Thus, the prevention of bleeding through careful preparation is the number one priority in laparoscopic surgery.

Bleeding from blood vessels in the abdominal wall, resulting either from insertion of the Veress needle or the optic trocar, can usually be controlled by coagulating the port through a second trocar, or by using a circular suture to enclose the bleeding vessel and the port with the trocar.

During the process of inserting the working trocars, both indispensable transillumination and the laparoscopically controlled technique should prevent injury to larger blood vessels. Damage of the epigastric vessels in the lower abdomen can be prevented by avoiding the area in which they are found.

It is always better to control an injured blood vessel using clips or sutures than by using extensive endocoagulation.

Injuries of the large abdominal vessels lead to extensive haemorrhage. Thus, in most cases, an immediate laparotomy should be performed.

Injuries to organs

Injury to organs during laparoscopic surgeries can generally affect all intra-abdominal and retroperitoneal organs. Besides the complications due to haemorrhage, injuries to organs comprise the most severe potential for complications in laparoscopic procedures. The frequency of organ perforation ranges from 0.3% to 1.5%. Visceral lesions are more often observed when a transperitoneal access has been used compared to retroperitoneoscopy.

There are several different ways of causing organ damage, with the main causes being direct injury through instruments and the effects of endocoagulation used for haemostasis. All instruments used during surgery have to be checked for an intact insulation prior to their use. It is recommended that bipolar coagulation is used when feasible, either ultrasonic or radio-frequency coagulation, in preference to monopolar coagulation.

If a lesion to an organ, that has occurred during surgery, is detected, the surgeon must decide whether laparoscopic or open surgery is the better choice for suture-repair of the lesion. The incurred damage can usually be limited with immediate proper treatment. Lesions that have not been detected during surgery are usually more severe and show their effects following a latent period of 2 to 3 days.

Date: 2016-06-13; view: 11