| Complication
| Method of prevention
|
| Vascular injury by trocar
|
|
| Bleeding from arteria epigastrica
| Transillumination prior to trocar insertion
|
| Bleeding from aorta/vena cava
| Appropriate skin incision, use of trocars with safety device, use of small calibre ports (2 or 5 mm) with telescopes (e.g. children), use of Hasson trocar (open access) preferably though retroperitoneoscopy
|
| Vascular injury during dissection
|
|
| Bleeding from branches of major vessels
| Right-angle clamp for dissection, use of bipolar coagulation forceps, use of curved endoclips, use of harmonic scalpel (Ultracision?)
|
| Bleeding from renal hilum
| Put traction on hilum by elevating the kidney, use suction device also for blunt dissection. Use sponge introduced into the abdomen to tamponade the bleeding site
|
| Visceral injury by trocar (intestinal lesions)
| Use ultrasound prior to laparoscopy, use of small calibre ports (2 or 5 mm) with telescopes (e.g. in case of adhesions), use Hasson trocar, preferably through retroperitoneoscopy
|
| Visceral injury during dissection
|
|
| Intestinal lesions
| Careful use of monopolar coagulation. Check the course of your instruments. Prefer bipolar coagulation close to the intestines. Do not hesitate to convert to open surgery
|
| Ureteric lesions
| Be aware of the anatomical course of the ureters; try to identify them early during dissection. Pre-stent the ureter in difficult cases. Do not hesitate to convert to open surgery
|
| Pancreatic lesions
| Be aware of the anatomical situation (e.g. during left adrenalectomy or nephrectomy). Reduce the application of monopolar electrocautery near the pancreas. Long-lasting secretion (for more than 7 days) on the left side may indicate a pancreatic fistula
|
| Perforated urinary bladder
| Check the hole in the bladder and try to suture it laparoscopically if possible. If this is not possible, move to open surgery
|
| Nerve lesions
| Be aware of the anatomical course of relevant nerves (e.g. obturator nerve, femoral nerve). Do not hesitate to convert to open surgery in case of transection
|
| Associated trauma
|
|
| Local emphysema
| Reduce the carbon dioxide pressure after placement of trocars (e.g. to 10-12 mm Hg)
|
| Healing
|
|
| Hernia related to trocar
| Close the fascia of all ports > 5 mm, preferably by retroperitoneoscopy
|
Published evidence exists to support the concept that 50 laparoscopic procedures are required before a plateau in the incidence of complications occurs. It is therefore suggested that until this time an individual surgeon should not regard himself to be an expert in laparoscopy. Patients should also be informed about the number of specific procedures already undertaken by the proposed surgeon, in addition to the small but calculated risk of conversion to open procedure (less than 5%), and the rare but life-threatening complications of serious vascular damage (0.2%), bowel injury (0.2%) and carbon dioxide embolus (0.1 %), which may require emergency surgery.
Training is required for those at all levels of expertise and it is recommended that all urologists should follow a progressive series of dedicated courses. It is hoped that all endourologists will consider attendance at Course A (Table 2.6). More complex procedures, especially those involving reconstruction are difficult and require attendance of theoretical and practical courses and some degree of innate perception.
