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New Complications of Laparoscopic Surgery 

I would like to frame this by talking not just about complications, but how we can reduce complications; hopefully, that will be the theme. If you do enough surgery, you have complications. There are a number of windows of opportunity for the laparoscopic surgeon to help minimize disasters. We will touch on these a bit. Preoperative and intraoperative preparation and methods for peritoneal access will be discussed. There is - and should be - a big focus on peritoneal access. We will touch on electrosurgery and some nuances and some important technological issues and how we can become aware of disasters early.

I am a firm believer that everyone in laparoscopic surgery should have a bowel prep. As you know, things happen and if they haven't yet, they will. GoLytely is benign, well tolerated and takes some time, but surely works. We know it is both mechanical and chemoprophylactic in its effects on the bowel and it is an appropriate preparation for basic bowel injury and/or repair. It can be given as a liquid on the night before surgery.

Most surgeons say that complications are problems, but they are problems for people who are inexperienced, because they are experts at doing surgery. The reality is that complications in laparoscopic surgery virtually boil down to peritoneal access.

How might we reduce some risk? There is nothing more fundamentally evil in laparoscopic surgery than force. One way we can become less forceful is to disengage what is big and use what is small; we can become humans instead of being dinosaurs in the way we operate by making large muscles and large nerves become smaller muscles and smaller nerves. One of the easiest ways to do this is to reduce the height of the table. The height of the table should be at

A Veress needle, as you know, has a grip on it. This grip is quite a distance from the tip. If I told you to sound a uterus this way, you would look at me twice. You know that your training never told you to hold the end of the sound and jab it into the fundus, through the fundus and into the bowel.

There is no angle - no particular angle of insertion - that is going to keep you safe. What makes you think that the bifurcation of the aorta doesn't vary? What makes you think that the level of the umbilicus doesn't vary? What makes you think that the anatomy over the sacral promontory doesn't vary, which is below the bifurcation?

The only way that you can control this disaster, fundamentally, is to reduce your force. Reducing your force reduces your depth of insertion - you know when you have entered and you can stop. Fundamentally, there is nothing safer than knowing that you just got in and you stopped. It doesn't matter what angle you use, as long as you get in and stop. If your incision is too tight, you have to push harder and your control is out the door. You have to get rid of abdominal wall dystocia. We talked about propriocepting the tip so that when there is a release of pressure you know it and you can stop. If you use something that is dull, you have to push harder. When it

What about if you can't feel it very well? One of the things we gave away in using nice disposable instruments is that they are so sharp, we don't get proprioception. The worst thing about a disposable Veress needle is that it is so sharp, you don't feel the pop-pop, you just kind of drop in. You don't feel the resistance of the layers. So you must learn how to tell everybody in the operating room to be quiet, which is sometimes difficult.

What about different kinds of incisions? What is the safest - Pfannenstiel, multiple incisions, single incisions? This is something that I participated in a few years ago and published, looking at a large number of patients and looking at what percent had adhesions between the bowel and the anterior abdominal wall - the kind of adhesions that make us crazy and that could lead to a

23 or 25-gauge spinal needle and aspirate to make sure that you have a gaseous pocket where you are going to put your trocar. If you get gas, you proceed. If you get nothing, you might have adhesions, but if you get stool, be thankful, because you got stool from a needle, which saved

What about open laparoscopy? I'm not here to tell anybody who does open laparoscopy in their practice to change, but I do want to examine with you what the fundamental tenets are about this procedure. Harry Hassan developed open laparoscopy and reported it to prevent injury to retroperitoneal vessels. His technique was predicated on two issues - one is, I can identify the layers that I am going through and the other is that I can find the peritoneum and enter it. Now

How does left upper quadrant entry differ from the umbilical site? Remember that you are left lateral, so you are now muscle splitting. You now have peritoneum that stretches, because it's not the umbilical ring. Your access has to be different - if you go straight, you might go into the iliacs; if you go medial, you might go into the retroperitoneal vessels, if you settle on an angle that is somewhat in between those two acute angles and you have to avoid the vessels just like you

No area is devoid of vessels. There is a piece of work coming out in the next couple of months in the literature of five umbilical bleeds that required transfusion. The one thing we can't predict is the superficial epigastric vessel, which comes from the femoral vessels, because it is subcutaneous and is different in everybody. Unfortunately, in patients who have had prior

What about the inferior epigastric vessel? This is a different story. The inferior epigastric vessel comes from the external iliac vessels, wraps around the inguinal ring and travels on the transversalis fascia, below the rectus muscles, in the rectus sheath. You can't see this if you transilluminate it. Any book that says you can, you close it and go to another book. You don't identify the inferior epigastric vessel by transillumination, you identify it by direct visualization. The way you identify it is that you know where it is, because you know your anatomy; everything is anatomy in surgery and it is more so in laparoscopy. The medial umbilical fold, the vesical plane and the round ligament form a triangle; within this triangle you always have the

If you can see nothing, can't find the inferior epigastric, you use normative anatomy. Normative anatomy says that if you are outside the rectus sheath, you are not going to hit inferior epigastric vessel, because it is inside the rectus sheath. McBurney's point on either side is outside the rectus sheath. Give yourself an approximate McBurney point on the left, the real one on the right, take that and you will not hit inferior epigastric vessel.

What about Richter's hernias? Unfortunately, no incision is immune. The smaller ones probably aren't more than the larger ones, because you have pieces of fat that can get pulled up. There are lots of predisposing factors and large ports and taking things out to make ports larger and longer operations that have repeated insertions and removals and insertions, fascial screws that destroy fascial openings and abdominal closure, where you don't see the fascia is important. The problem with these defects, of course, is that they tend to not be diagnosed, because it is a partial small bowel obstructions and symptoms are very nonspecific. They have slow postoperative recovery, they sound like something is not quite right, but you can't see anything. Rarely will they come in with a big protrusion and you will not likely be lucky enough to feel soft bowel that has not already turned black at that point. If you have a suspicion, a CT scan will show you the loop of bowel in the defect in the anterior abdominal wall. There is a preperitoneal space that exists that can give you a Richter's hernia. If you want to fundamentally reduce these to near zero, you have to close both defects; that means you have to close in the direct