Complications Abstracts

Complications Abstracts

Incisional Hernias After Operative Laparoscopy, Ceana Nezhat, MD, Farr Nezhat, MD, Daniel S. Seidman, MD, and Camran Nezhat, MD; Journal of Laparoendoscopic & Advanced Surgical Techniques Volume 7, Number 2, April 1997

The objective of the study was to determine the possible risk factors of incisional hernias after operative laparoscopy. A retrospective case review was performed in a single referral obstetrics/gynecology clinic and center for special pelvic surgery considering the last 5300 surgeries. Of the approximately 5300 patients who underwent laparoscopy from January 1988 through June 1996, 10 women were evaluated for incisional hernias. A total of 11 hernias occurred, which is an incidence of approximately 0.2%. Omentum herniated in seven cases and bowel herniated in four cases. In one case, the sigmoid epiploica irreducibly herniated through the peritoneum and not the fascia. The hernia occurred through a 5mm trocar incision site in five cases. The median duration of the laparoscopic surgeries was 192 minutes (range, 25-375 minutes). Six women required laparoscopic surgery in order to retract the entrapped omentum or bowel. In one case, laparoscopically assisted bowel resection was necessary. The underlying fascia and peritoneum should be closed not only when using trocars of 10mm and larger as previously suggested but also when extensive manipulation is performed through a 5mm trocar port, causing extension of the incision.

Vaginal Vault Evisceration After Total Laparoscopic Hysterectomy, Ceana H. Nezhat, MD, Farr Nezhat, MD, Daniel S. Seidman, MD, & Camran Nezhat, MD; Obstetrics & Gynecology, 0029-7844/96, SSDI 0029-7844(95)00482-3

Vaginal vault rupture with intestinal herniation, although rare, has been reported after vaginal and abdominal hysterectomies. We report three such cases, two postcoital and one spontaneous, after total laparoscopic hysterectomy.

Traumatic Hypogastric Artery Bleeding Controlled With Bipolar Desiccation During Operative Laparoscopy, Farr Nezhat, MD, Andrew Brill, MD, Ceana Nezhat, MD; Camran Nezhat, M.D., Stanford U Med School, 300 Pasteur Dr., Stanford CA 94305

During multipuncture operative laparoscopy to excise peritoneal endometriosis involving the pelvic sidewall near the origin of the uterine artery, the lower portion of the hypogastric artery was perforated. The acute hemorrhage was controlled by immediately grasping the lacerated blood vessel with a 5-mm atraumatic grasping forceps. A Kleppinger bipolar forceps set at 25 W desiccated and sealed the artery successfully. As no further bleeding was noted, the procedure was terminated. The patient remained overnight for observation, and was discharged from the hospital the next day. She is doing well 18 months after the injury and repair.

Major Retroperitoneal Vascular Injury During Laparoscopic Surgery, Camran Nezhat, Joel Childers, Farr Nezhat, Ceana H. Nezhat, & Daniel S. Seidman; Human Reproduction, vol.12, no.3, pp 480-83, 1997

We sought to assess the outcome of large retroperitoneal vascular injury that occurred during operative laparoscopy but was not related to trocar or Veress needle injury. We conducted a retrospective review of cases operated and reviewed by our centres. Eight cases were identified. Four women were undergoing lymphadenectomy, where vascular injury is a recognized risk. Distorted anatomy was a compounding factor in three of the remaining four patients who were undergoing intraperitoneal procedures. The injuries involved the inferior vena cava (n=2), the right external iliac artery (n=2), the left external iliac artery (n=1), the hypogastric artery (n=1), and the inferior mesenteric artery (n=1). Injuries were caused by unipolar electrode (n=1), electrosurgical scissors (n=3), sharp scissors (n=2), and CO2 laser (n=2). The vessel injury was repaired at laparotomy in four women. The other four cases were managed laparoscopically. Transfusion attributable to the vascular injury occurred in two cases. The outcome in all cases was good, except for the one in which the patient died. These cases demonstrate that all energy sources used without proper understanding and caution can cause significant vascular injury. The adequacy and safety of laparoscopic control of major vessel bleeding should be investigated further and consultation with a vascular surgeon should be considered in all cases.

Life-Threatening Hypotension After Vasopressin Injection During Operative Laparoscopy, Followed by Uneventful Repeat Laparoscopy, Farr Nezhat, MD, Dahlia Admon, MD, Ceana H. Nezhat, MD, Joseph E. Dicorpo, MMS, PA, & Camran Nezhat, MD; J of American Association of Gynecologic Laparoscopists, November 1994, Vol2, No. 1

Vasopressin may be associated with systemic hemodynamic changes, including severe myocardial ischemia, even in healthy patients. A 36-year-old woman underwent laparoscopy for the treatment of a uterine leiomyoma. After intravascular injection of vasopressin, she experienced life-threatening hypotension, and the procedure was subsequently aborted. After she recovered, she underwent successful laparoscopy without the use of vasopressin, and no complications occurred. As endogenous vasopressin levels sometimes rise during laparoscopy, patients may become susceptible to the drug’s effects, and appropriate precautions must be taken.

Laparoscopic Repair of Ureter Resected During Operative Laparoscopy, Camran Nezhat, MD, Farr Nezhat, MD; Obstet Gynecol, 1992;80:543-4

Ureteral injury is a recognized complication of gynecologic surgery. During operative laparoscopy performed to treat extensive endometriosis of the pelvic sidewall, a 1.5 cm portion of the right ureter was resected and was repaired successfully. repair of resected ureter may be effectively accomplished endoscopically by experienced operative laparoscopists.

Laparoscopic Repair of a Vesicovaginal Fistula: A Case Report, Ceana H. Nezhat, MD, Farr Nezhat, MD, Camran Nezhat, MD, & Howard Rottenberg, MD; Obstet Gynecol, 1994;83:899-901

Operative laparoscopy was performed for the management of ovarian remnant syndrome involving the bladder, bowel, vagina, and ureters, and requiring extensive dissection. A vesicovaginal fistula developed postoperatively. Because of the complexity and location of the fistula, a vaginal approach was not appropriate. Using techniques of videolaparoscopy, videocystoscopy, and operative laparoscopy, the fistula was repaired. In experienced hands, endoscopic management of complex vesicovaginal fistulas may be an alternative to the traditional abdominal approach.

Laparoscopic Management of Intentional and Unintentional Cystotomy, Ceana H. Nezhat, Daniel S. Seidman, Farr Nezhat, Howard Rottenberg & Camran Nezhat; J Urology, 0022-5347/96/1564-1400

With advanced laparoscopic procedures, such as treatment of extensive pelvic adhesions and severe endometriosis, hysterectomy or retropubic urethropexy, there is a risk of bladder injury. The conventional approach to intraperitoneal bladder injury is celiotomy and repair of the perforation in multiple layers. This complication can be treated successfully at laparoscopy regardless of whether partial cystectomy was done intentionally to treat endometriosis or remove ovarian remnants, or the bladder injury was incidental. We summarize the outcome of 19 cases of bladder injury treated laparoscopically.

Injuries Associated with the Use of a Linear Stapler During Operative Laparoscopy: Review of Diagnosis, Management, and Prevention, Camran Nezhat, MD, Farr Nezhat, MD, Oleg Bess, MD, Ceana H. Nezhat, MD; J Gynecol Surg 9:145, 1993

We report 7 recent examples of intraoperative and postoperative complications and injuries resulting from the use of an automatic stapling device during operative laparoscopy. The cases were collected throughout the United States and represent a cross-section of common complications. This report should alert surgeons to the possibilities of ureteral, bladder, and bowel injuries, postoperative bleeding, and instrument malfunctions. In addition, precautions and techniques to prevent and resolve complications are discussed.

Complications and Results of 361 Hysterectomies Performed at Laparoscopy, Farr Nezhat, MD, Ceana H. Nezhat, MD, Dahlia Admon, MD, Stephen Gordon, MD, & Camran Nezhat, MD; J. Am. Coll. Surg., 1995, 180:307-16

Before the appropriate use of laparoscopy in hysterectomy can be determined, it is necessary to evaluate the results, including complications. There must also be an accepted classification system to facilitate accurate comparison to total abdominal hysterectomy. We retrospectively evaluated the charts of 361 women who underwent hysterectomy for various benign pathologic condition. Intraoperative and postoperative complication rates for hysterectomy performed at operative laparoscopy were examined. The hysterectomies were classified as one of four types according to the number of steps performed laparoscopically. All women were candidates for total abdominal hysterectomy, but not vaginal hysterectomy. The overall complication rate for hysterectomy performed at operative laparoscopy was 11.1%. Most complications were minor, including cystitis (1.66 %), transient high fever (1.39%), abdominal wall ecchymosis (1.12 %), and pneumonia and bronchitis (1.12 %). There was no correlation between the type of laparoscopic hysterectomy performed and the complication rate. Our rate of intraoperative and postoperative complications associated with laparoscopic hysterectomy compares favorably with published complication rates for vaginal and abdominal hysterectomy.

Initial Report of the Carbon Dioxide Laser Laparoscopy Study Group: Complications, Nezhat et al, J Gynecologic Surgery, 5:269, 1989

Operative laparoscopy using the CO₂ laser is becoming increasingly common in reproductive pelvic surgery. However, to date, characterization of the safety of this technique has been limited. However, to date, characterization of the safety of this technique has been limited. To assess this issue, the reports of the 821 women in the database of the Carbon Dioxide Laser laparoscopy Study Group were reviewed. Procedures performed at laparoscopy included vaporization of endometriosis, adhesiolysis, transection of the uterosacral ligaments, fimbrioplasty, salpingostomy for ectopic pregnancy, ovarian cystectomy, and neosalpingostomy. Ninety (11%) were hospitalized overnight, and 22 (2.6%) were hospitalized two or more nights. Operative complication were limited and consisted of 9 cases of intraabdominal bleeding, 3 women with uterine perforation, 1 with trocar injury to the uterus, and 1 with an omental hemotoma. None of these women required laparotomy. One patient underwent laparotomy to rule out small bowel injury, but none was noted. Postoperative complications reported consisted of 2 women with urinary retention and 1 each with postconization bleeding, periumbilical hematoma, acute infectious colitis, and allergic reaction to i.m. Depo Provera. Thus, operative or postoperative complications attributable to performance of operative CO2 laser laparoscopy per se were rare and without clinically significant morbidity or mortality. It is concluded that in experienced hands, CO2 laser laparoscopy can be safely used in the performance of reproductive pelvic surgery.

Vaginal Vault Evisceration After Total Laparoscopic Hysterectomy; Ceana H. Nezhat, MD, Farr Nezhat, MD, Daniel S. Seidman, MD, Camran Nezhat, MD; Obstet & Gynecol , 1996/87:868-70