Ideas for "difficult" intraoperative complications during general surgery

[europeman]

---

Members don't see this ad.

I need ideas for difficult intra-operative complications during general surgery.

For example, splenic bleeding during colectomy, pre-sacral bleeding from say an LAR, bleeding during a lap chole and how to handle it (when to open, how to avoid injuries biliary structures, liver bed hemostasis ideas, etc), etc. What to do with incidental mechels? To take or not take the normal appearing appendix during a diagnostic laparoscopy for rlq pain. No need to discuss the above mentioned ideas... i'm looking for others...

Need more ideas. anyone have any?

 

[IlDestriero]

I need ideas for difficult intra-operative complications during general surgery.

For example, splenic bleeding during colectomy, pre-sacral bleeding from say an LAR, bleeding during a lap chole and how to handle it (when to open, how to avoid injuries biliary structures, liver bed hemostasis ideas, etc), etc. What to do with incidental mechels? To take or not take the normal appearing appendix during a diagnostic laparoscopy for rlq pain. No need to discuss the above mentioned ideas... i'm looking for others...

Need more ideas. anyone have any?

Tearing the atria during VATS.😱
Seen it.

 

[SLUser11]

I need ideas for difficult intra-operative complications during general surgery.

For example, splenic bleeding during colectomy, pre-sacral bleeding from say an LAR, bleeding during a lap chole and how to handle it (when to open, how to avoid injuries biliary structures, liver bed hemostasis ideas, etc), etc. What to do with incidental mechels? To take or not take the normal appearing appendix during a diagnostic laparoscopy for rlq pain. No need to discuss the above mentioned ideas... i'm looking for others...

Need more ideas. anyone have any?

What is your goal here? Are you putting it together for a lecture or conference on complications? Before I generate a big list of common complications, I would like to know why.

 

[dynx]

I need ideas for difficult intra-operative complications during general surgery.

For example, splenic bleeding during colectomy, pre-sacral bleeding from say an LAR, bleeding during a lap chole and how to handle it (when to open, how to avoid injuries biliary structures, liver bed hemostasis ideas, etc), etc. What to do with incidental mechels? To take or not take the normal appearing appendix during a diagnostic laparoscopy for rlq pain. No need to discuss the above mentioned ideas... i'm looking for others...

Need more ideas. anyone have any?

CO2 embolus during lap surgery
Trocar injuries into major vessels or organs
Duodenal injury during a right hemi
Any "hey is that the ureter?" moment
Major mediastinal bleeding during a THE
Tear in the hepatic vein while mobilizing the liver for resection
Pacer/cardiac complications from electrocautery
There's a ton to talk about if you're trying to do a talk on complications in general.

 

[europeman]

What is your goal here? Are you putting it together for a lecture or conference on complications? Before I generate a big list of common complications, I would like to know why.

hi thanks.

yeah for a conference.

 

[SLUser11]

hi thanks.

yeah for a conference.

Peritoneal contamination during a hernia repair, either in the form of enterotomy while doing a ventral hernia repair, or dead incarcerated bowel in an inguinal/femoral hernia.

CBD or hepatic duct injury during lap chole

intra-operative cardiac arrest

dead colostomy

Ureteral transection during colectomy

I like dynx's idea about laparoscopic access injuries.

Unanticipated hypertension/hypotension or some dramatic response to pneumoperitoneum.



Of course, incidental surgery is an entirely separate topic from intraoperative complications, so I'm not sure if you should talk about incidental appys/choles/meckel's. If you are going to talk about it, I think unanticipated ovarian pathology is a good one.

 

[45408]

CO2 embolus during lap surgery
Trocar injuries into major vessels or organs
Duodenal injury during a right hemi
Any "hey is that the ureter?" moment
Major mediastinal bleeding during a THE
Tear in the hepatic vein while mobilizing the liver for resection
Pacer/cardiac complications from electrocautery
There's a ton to talk about if you're trying to do a talk on complications in general.

First one that came to mind. Not cool.

 

[SLUser11]

First one that came to mind. Not cool.

Even though the literature says the injury rates are the same regardless of access techniques, I can't help but feel that the "optiview" approach is the most likely to cause major injury. At least with the veress, your iatrogenic injury is small.....

I am actually struggling with this as I near attending status....I did the majority of my access as a resident with the veress needle, but still did enough other approaches to be comfortable with the different techniques. In CRS, most people, including the leaders in the field, use an open technique. I'd be interested to hear what technique other SDNers prefer to obtain access.

 

[45408]

Even though the literature says the injury rates are the same regardless of access techniques, I can't help but feel that the "optiview" approach is the most likely to cause major injury. At least with the veress, your iatrogenic injury is small.....

I am actually struggling with this as I near attending status....I did the majority of my access as a resident with the veress needle, but still did enough other approaches to be comfortable with the different techniques. In CRS, most people, including the leaders in the field, use an open technique. I'd be interested to hear what technique other SDNers prefer to obtain access.

We do virtually all of our access with open technique and blunt trocars. I've never even seen a Veress needle used since med school rotations. I've only seen the Optiview used a few times (and only in very obese patients).

Only two injuries I've seen with access (one unrecognized bowel injury and one IVC puncture) were with bladed trocars.

 

[SocialistMD]

Even though the literature says the injury rates are the same regardless of access techniques, I can't help but feel that the "optiview" approach is the most likely to cause major injury. At least with the veress, your iatrogenic injury is small.....

Who does optiview without first insufflating with the Veress?

 

[Steelermd]

At my institution we do about a 70/30 mix of Hassan and optiview approaches, only in a few select patients have I used the veress. I've seen injuries with all three techniques though. I would agree with the above comment about bladed trocars being more worriesome for injury. Our pediatric surgeons love them and almost always use them. Just my 2c

 

[SLUser11]

Who does optiview without first insufflating with the Veress?

I thought that was the whole point of the optiview?

SocialistMD is right....the recommended use of the optiview port is for gaining access after pneumoperitoneum has already been obtained with a veress needle. However, that's not how it's used in real life, and many surgeons/institutions use it for primary access without pneumoperitoneum.

Everyone has bias on this subject. The literature suggests that there is no statistically significant difference in injury rates among different access techniques. They can all be safely, and they can all be done poorly. The safest thing for the patient is probably whichever technique the surgeon is most comfortable performing.

I tend to individualize it a little bit....but if I'm starting with a 5 port, which I do for lap choles/appys/ventral hernias, I tend to use the veress if it's a virgin abdomen. For lap colectomies, most of my bosses want a 10mm camera, and I've been doing an open approach.

It's my personal bias that bladed trocars cause more incisional hernias, so I don't use them unless forced.

The hardest access is when you need to go off the midline. When I'm going in at the umbilicus, I can elevate the fascia by pulling the umbo anteriorly...but when I can't do that, I like to get access in the left upper quadrant. The ribcage provides counter-traction on the peritoneum, and if I screw up, it's just the stomach or spleen, as opposed to the liver/biliary tree/major liver vessels. In this location, I go in with a veress first, then optiview.

 

[Dr.LeoSpaceman]

Back to adding to the "most feared complication" list: avulsing the right adrenal vein during a laparoscopic adrenalectomy. Even worse if you're doing it via a retroperitoneal approach. Nothing like a near retrohepatic caval injury to make your stomach drop out of your *****.

 

[GregsAnatomy]

I like Optiview with the Applied Fios trocar. It has a small hole at the tip which give you a "pop" of pneumo once you enter the abdomen, in theory preventing you from injuring any organs. That said, I've seen this trocar go into the liver and cause a CO2 embolus.

 

[cpants]

Back to adding to the "most feared complication" list: avulsing the right adrenal vein during a laparoscopic adrenalectomy. Even worse if you're doing it via a retroperitoneal approach. Nothing like a near retrohepatic caval injury to make your stomach drop out of your *****.

That's why you should leave adrenal surgery to the urologists...

All kidding aside, any serious vascular injury while operating with a scope can be pretty effing scary.