Major Laparoscopic Complications: A Review in Two Parts

Background: Gynecologic laparoscopy began in the United States at Cornell Medical Center in New York and at the Johns Hopkins Hospital in Baltimore in 1968. Laparoscopy has continued to evolve over the years from a purely diagnostic tool to a major operative technique. Many advantages have been recognized by the application of laparoscopic techniques including small incisions, instrument-only manipulations, decreased postoperative pain, and rapid recovery. As more and less expert surgeons have used gynecologic laparoscopy, the number and severity of complications has increased in frequency. This review focuses on major laparoscopic complications, which include major vessel injury, gastrointestinal injuries, and urologic injuries, as well as a group of unique and rare injuries. Serious injuries can create significant morbidity. Additionally, both major vessel and intestinal injuries can result in death. Although urinary tract injuries are rarely fatal, they can, if not managed appropriately lead to permanent kidney damage and require nephrectomy. Data: The risk of great vessel injury at laparoscopy is 0.5/1000. The risk for intestinal injury ranges from 1 to 5 per 1000 cases. Ureteral injuries range from 0.1 to 1.0% and bladder injuries range from 0.8 to 2%. The factors most involved in major vessel injury are lack of knowledge of pelvic anatomy, trocar or needle deviation from the midline during entry, and insertion of trocars and needles at angles approaching 90 degrees. The factors most often associated with intestinal injury are adhesion formation secondary to prior surgical procedures, and subumbilical insertion of needles and trocars regardless of entry technique. Risk factors for urologic injuries include adhesions from prior laparotomies, lack of ureteral identification, prior cesarean delivery, and the use of energy devices. For all of the major injury categories the risk for injury is increased for obese women, that is those with body mass index (BMI) > 30. Conclusions: Although the laparoscopic approach is increasing used as the procedure of choice for a large variety of gynecologic operations, serious complications can and will occur, especially when less experienced and less skillful surgeons are performing these operations. Additionally, the risk of these incidents occurring to any extent is inherent in the laparoscopic technique itself, that is, the necessity of gaining entry through the anterior abdominal wall by needle and trocar devices. Even open laparoscopy and optical viewing trocars do not provide significant protection from misadventures. Delay in diagnosis compounds the effects of the injury itself. Every surgeon who uses the laparoscopic approach must always bear in mind that the clinical pathway following laparoscopic operations should be one of continuous improvement. When there is deviation from that pathway, the top of the differential diagnostic list should always be operative injury.