วันอังคารที่ 2 ธันวาคม พ.ศ. 2568

Complications of Minimally Invasive Surgery (Laparoscopic / Robotic)

Complications of Minimally Invasive Surgery (Laparoscopic / Robotic)

⭐ INTRODUCTION

  • Minimally invasive surgery (MIS) มีอัตราภาวะแทรกซ้อนต่ำ แต่ major vascular injury และ bowel perforation เป็นสาเหตุหลักของ morbidity/mortality
  • ภาวะแทรกซ้อนกว่า 50% เกิดตอน abdominal access
  • อาจต้อง convert to open หากควบคุมภาวะแทรกซ้อนไม่ได้ หรือมี delayed presentation postoperative

🚨 EPIDEMIOLOGY & RISK FACTORS

Complication

อัตราโดยประมาณ

Any complication in gynecologic laparoscopy

0.2 – 18%

Major complication

0.6 – 14.6%

Mortality

0.01 – 0.03%

Risk factors เพิ่มภาวะแทรกซ้อน

  • Previous abdominal/pelvic surgery → adhesions
  • High complexity: massive distension, large mass, diaphragmatic hernia
  • Poor cardiopulmonary reserve → intolerance to pneumoperitoneum
  • Surgeon learning curve

🔥 Major Intraoperative Complications

1. VASCULAR INJURY (0.1–6.4/1000 cases)

  • สาเหตุเสียชีวิตอันดับ 1 ของ laparoscopy (74–82%)
  • 50–83% เกิดระหว่าง initial entry

Major vessels injured:

  • Right iliac artery/vein > aorta > IVC > mesenteric vessels
  • Mortality up to 6–31%

Management principles

  • Immediate recognition → announce major bleeding
  • Trendelenburg if needed, rapid midline laparotomy if uncontrolled
  • Direct pressure + packing + vascular consult
  • Consider transfer if no expertise → damage control

Inferior epigastric injury

  • Common minor vascular injury (≈48% of port-site bleeds)
  • Management: direct pressure / electrocautery / clip / transfixed suture
  • Remove trocar under direct vision to inspect bleeding

2.  GASTROINTESTINAL INJURY (0.03–0.65%)

  • 3rd leading cause of death after MIS
  • 30–50% missed intraoperatively

Mechanism

  • 41–50% during trocar entry → mostly small bowel
  • 23–57% during dissection → ~⅓ due to electrosurgery
    (thermal spread often > visible injury!)

Clinical clues (delayed)

  • Persistent abdominal pain, tachycardia, fever 12–72 hr post-op
  • Increasing free air after POD1–7 → suspect perforation

Management

  • Immediate repair if recognized: primary closure vs resection with margin
  • Delayed diagnosis → urgent reoperation
    (mortality ↑ to 3–3.6%)

3.  URINARY TRACT INJURY (0.03–1.7%)

  • Most commonly bladder, then ureter

Bladder (36% during access below umbilicus)

  • Prevention: Foley catheter before port placement
  • Signs: gas in urine bag, hematuria
  • Very small puncture → Foley drainage only
  • Larger injury → 2-layer absorbable suture + catheter 7–14 days

Ureter

  • Risk: pelvic dissection, thermal injury
  • Prevention: anatomic identification ± prophylactic stent
  • Only 3–12% diagnosed intra-op
  • Confirm ureter integrity before closure

⭐ Surgical Site Complications

Complication

Key points

Infection

Umbilicus > other ports (specimen extraction site)

Trocar site hernia

↑ risk with port >10–12 mm, single-site surgery, obesity

Extraction site hernia

Midline > Pfannenstiel (lowest risk)

Port-site metastasis

0.4–2.3% if intraperitoneal malignancy

Nerve injury

From positioning (brachial plexus, peroneal, femoral)

Management

  • Treat wound infection: drainage + antibiotics
  • Repair trocar/extraction site hernia to prevent obstruction

🌬 Pneumoperitoneum-related

Complication

Mechanism/Notes

Subcutaneous emphysema

Malpositioned Veress / leak

Pneumothorax, mediastinal emphysema

Gas dissection

Hypercarbia → arrhythmia

↑ CO₂ absorption

Post-op shoulder pain (50–80%)

Retained CO₂/diaphragmatic irritation

VTE

Prolonged operative time

Gas embolism (rare, but fatal)

Most in laparoscopic liver surgery

Gas embolism management

  • 100% O₂, ↓ insufflation pressure
  • Flood field with saline
  • Trendelenburg or Durant position (left lateral + head down)
  • Attempt aspiration via PA catheter if available

💡 When to CONVERT to OPEN

  • Ongoing bleeding / unclear source / poor visualization
  • Hemodynamic instability
  • Significant organ injury
  • Surgeon discomfort or inadequate expertise

“Failure to convert in time” = major cause of catastrophic outcomes

📌 Practical Prevention Checklist (Quick Use)

  • Foley before subumbilical port
  • Decompress stomach for upper abdominal access
  • Direct visualization for secondary ports
  • Avoid energy close to bowel/ureter
  • Identify ureters in pelvic surgery
  • Maintain protective positioning and limit lithotomy time
  • Active CO₂ evacuation at end of case
  • DVT prophylaxis for moderate–high-risk patients

 

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