Nurs Clin N Am 41 (2006) 219229

NURSING CLINICS
OF NORTH AMERICA

Laparoscopy: Risks, Benets and Complications

Diana L. Wadlund, RN, CRNFA, CRNP
Surgical Specialists, 1351 Julieanna Drive, West Chester, PA 19380, USA

aparoscopic surgery is a minimally invasive alternative to traditional laparotomy. It is used as a diagnostic measure and for performing minor and major operative surgical procedures. Many procedures that traditionally were performed using open laparotomy now are being accomplished laparoscopically. There are numerous benets to laparoscopy, including smaller incisions, decreased hospital stay, and decreased recovery time. Laparoscopy also allows the surgeon better visualization and magnication of anatomy and pathology [1]. Laparoscopy does have certain risks and complications, most of which are associated with entry into the abdominal cavity. These complications can have a major impact on the patients outcome [2]. This article discusses the benets and risks of laparoscopy. Also discussed are complications of laparoscopy and methods to avoid or treat these adversities. PATIENT SELECTION Indications for laparoscopic surgery are the same as for the equivalent open procedure. The goal of laparoscopy is to perform the surgical procedure in a similar manner as the standard technique without opening the peritoneal cavity [1]. There are two absolute contraindications to laparoscopy: the patients inability to tolerate general anesthesia, and the surgeons inexperience and lack of skill with the specic procedure or technique [3]. Laparoscopy allows for decreased morbidity, decreased hospital stay, and improved cosmetic results. Conversion from laparoscopy to laparotomy is a double-edged sword. The patient has the expense of the laparoscopic procedure and a larger incision with resultant increased pain and recovery time. Although it is impossible to consistently predict the likelihood of conversion from laparoscopy to an open procedure, a few guidelines exist [3]. Patients who have had prior abdominal surgery have an increased likelihood of abdominal adhesion formation. Tissue planes may be distorted or
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impossible to identify. The experienced surgeon will have gained skill in lysis of adhesions and identifying difcult tissue planes through the laparoscope. He also will realize his surgical limitations and will open in a timely and appropriate manner when it is necessary [1]. OBESE PATIENTS Obese patients provide many challenges to the operative surgeon, and the use of laparoscopy is no exception. Obesity was once an absolute contraindication for laparoscopy. Trocar and instrument depth were often too shallow to reach the operative site. Advances in instrumentation have provided the surgeon with the means to use laparoscopic techniques on the obese patient. In reality, laparoscopy provides numerous benets for the obese patient, including:
  

Access to the surgical site is often easier, and visualization of the anatomy vastly improved with the use of the laparoscope. Large incisions required for certain open surgical procedures are often even larger in the obese patient to allow for adequate visualization. Recovery time is reduced greatly with minimally invasive surgery. decreasing the risk for potentially devastating complications [2].

Other relative contraindications include severe portal hypertension, coagulopathy, and diffuse carcinomatosis in the abdomen [2]. Patients should be evaluated medically before laparoscopy and laparotomy, with specic attention focused on cardiac and pulmonary status. If a patient is medically unt to undergo laparotomy, he or she should not undergo elective laparoscopy. PREGNANT PATIENTS Laparoscopy on the pregnant patient may be wrought with potential peril. There are certainly risks associated with anesthesia, radiologic patient evaluation, and laparoscopy, but studies have shown that most of the morbidity and mortality associated with surgical problems in the obstetric patient and in the fetus is secondary to the underlying disease process [4]. Certain things, however, should be considered, such as:
   

Length of gestation Open versus blind laparoscopic technique to avoid injury to the gravid uterus The physiologic effects of the CO2 on the fetus Alternations in technique because of the presence of the enlarged uterus [4]

The most common indications for laparoscopic surgery in the pregnant patient are appendicitis, cholelithiasis, and ectopic pregnancy. Technically, laparoscopy should occur during the second trimester, ideally before 23 weeks, to minimize risk of preterm labor and to have adequate intra-abdominal working room. This allows ease in placing the insufation needle or Hasson trocar and visualization of the appendix or gallbladder. The open laparoscopic

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technique to establish pneumoperitoneum is the safest method to avoid injury to intra-abdominal organs. After the second trimester, an open laparotomy would be a safer technique [4]. During the surgical procedure certain guidelines should be followed. The mothers acid base balance and end-tidal CO2 should be monitored. The patient should be rolled 30 to the left side to avoid compression of the inferior vena cava (IVC). Intra-abdominal pressure should be limited to between 8 and 12 mm Hg. The fetal heart rate should be monitored during anesthesia induction and periodically throughout the procedure [1,4]. SURGICAL PROCEDURE The rst step in the laparoscopy is establishment of pneumoperitoneum. There are two techniques used to establish pneumoperitoneum: the closed technique and the open technique. Closed Technique The closed technique involves use of an insufation needle. Janos Veres invented an insufation needle, which is an automatic, spring-loaded, dual needle. The blunt inner portion of the Veress needle is pushed back by the resistance of the skin, allowing the sharp outer portion to easily puncture the skin. Once through the skin, resistance from skin and soft tissue is lost, and the blunt inner portion springs forward to prevent injury to internal organs [5,6]. The technique for inserting the Veress needle involves placing the patient in Trendelenburg (head down) position to displace the small bowel from the pelvis, elevating the anterior abdominal wall, and inserting the needle at a 45 angle pointed inferiorly [6]. After the abdomen is insufated with CO2 to an intra-abdominal pressure of 12 to 18 mm/Hg, the Veress needle is removed, the incision enlarged, and a 10 mm Trocar inserted into the abdomen. Although precautions are taken to avoid injury to the intra-abdominal organs, the insufation needle approach to establishing pneumoperitoneum is still a blind technique. Complications can occur because of lack of visualization of intra-abdominal organs [7,8]. Also, if the patient has any intra-abdominal adhesions to the anterior abdominal wall, a fact that cannot predicted with even the slightest degree of certainty, there is a greater risk for complications. Open Technique The open laparoscopic technique involves placement of a Hasson trocar. The Hasson trocar is a blunt tip trocar designed to be inserted using the open laparoscopic technique. This technique involves making a small incision near the patients umbilicus and placing two stitches into the patients external oblique fascia. The two stitches then are lifted and an incision made between them through the fascia and into the peritoneum under direct visualization. The Hasson Trocar then is inserted into the opening in the abdominal wall and adhered securely to the abdominal wall using the two fascial stitches. Although the open technique

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for establishing pneumoperitoneum is technically safer than the closed technique, inadvertent injury to the abdominal contents can still occur. Insufation of the peritoneal cavity follows placement of the Veress needle or the Hasson trocar. Insufation is necessary, because the abdomen is lled with organs that take up all the available space. Without insufation, there is no room to visualize anatomy or perform a surgical intervention. After pneumoperitoneum has been established, other trocars are placed into the abdomen under direct visualization. Direct visualization involves using a laparoscope to watch a trocar being inserted through the abdominal wall. This decreases the risk of visceral injury. PNEUMOPERITONEUM Pneumoperitoneum is achieved by infusing CO2 into the peritoneal cavity. CO2 is the agent of choice for establishing pneumoperitoneum for gynecologic and general surgical procedures. CO2 is more soluble in blood than air, oxygen, or N2O. CO2 is also accessible and inexpensive; it suppresses combustion and is eliminated rapidly, increasing its margin of safety [9]. A few disadvantages of CO2 include increased peritoneal irritation with increased postoperative discomfort and an increased risk for cardiac arrhythmia. CO2 is tolerated poorly by patients with impaired pulmonary function [9]. In its infancy 20 to 30 years ago, laparoscopy was performed on young healthy individuals. The intra-abdominal pressure (IAP) could be as high as 40 mm Hg with no adverse effects on the patient. Currently, the intraabdominal pressure is kept at 12 to 18 mm/Hg, which is a much safer level for the older, more medically and physiologically debilitated patients treated today [3]. Pneumoperitoneum causes certain physiologic changes. These changes are based on such things as IAP, amount of CO2 absorbed, circulatory volume of the patient, ventilatory technique used, underlying pathology, and type of anesthesia [3]. Table 1 discusses the effects of pneumoperitoneum on several body systems [1]. PULMONARY EFFECTS Increased intra-abdominal volume and pressure impede diaphragmatic excursion. Patient positioning does not alter the effects of insufation on pulmonary function. Table 1 outlines the physiologic effects of pneumoperitoneum on the pulmonary system. Because the minimally invasive nature of laparoscopic surgery, the patient has less pain and subsequently fewer pulmonary issues postoperatively when compared with open procedures [1]. CIRCULATORY EFFECTS Healthy individuals are under no threat from the cardiovascular effects of peritoneal insufation. Patients with impaired compensatory mechanisms, however, do not tolerate the effects of laparoscopy [1].

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Most patients can have a safe laparoscopic experience with careful monitoring, proper uid balance, and prompt attention to problems that arise. Patients with severely impaired cardiac function are served better with an open procedure [1]. Physiologic effects of pneumoperitoneum on the circulatory system are outlined in Table 1. Physiologic change is affected by patient positioning. For example, the Trendelenburg position increases intra-thoracic pressure, central venous pressure, capillary wedge pressure, and mean arterial pressure, thus increasing cardiac work load. Reverse Trendelenburg leads to decreased cardiac output by decreasing preload, possibly causing hypotension [1].

Table 1 Physiologic effects of pneumoperitoneum and potential clinical outcomes Organ system Pulmonary Physiologic effects " Peak airway pressures # Pulmonary compliance and vital capacity Superior displacement of the diaphragm " End-tidal CO2 Direct effectsincreased CVP, CWP, SVR, MAP Indirect effects of CO2arteriolar dilation and myocardial depression Indirect effects on the sympathetic system, renin-angiotensin system, and vasopressin Renal Coagulation Immunity and inammation # Renal blood ow Lower extremity venous stasis Preserved systemic immunity Impaired local immunity " ICP Attenuated sympathetic response Potential outcomes Barotrauma/pneumothorax " Pco2 and/or # Po2 " Pco2 and/or # Po2 Acidosis " Cardiac work; effects on cardiac output dependent on volume status # Blood pressure

Circulatory

" Blood pressure and cardiac output

# Urine output # Urine output DVT and PE Greater resistance to infection and tumor seeding # Resistance to infection or tumor seeding # Central perfusion pressure Less ileus

Central nervous system Intestinal

Abbreviations: CVP, central venous pressure; CWP, capillary wedge pressure; DVT, deep venous pressure; ICP, intracranial pressure; MAP, mean arterial pressure; PE, pulmonary embolus; SVR, systemic vascular resistance. From Philips PA, Amaral JF. Abdominal access complications in laparoscopic surgery. J Am Coll Surg 2001;192(4):52536; with permission.

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RENAL EFFECTS Urine output is lower with pneumoperitoneum than with open laparotomy. Oliguria is common during long laparoscopic procedures. Increased intraabdominal pressure leads to decreased renal blood ow [1]. COMPLICATIONS OF PNEUMOPERITONEUM Cardiovascular Hypercarbia and acidosis result from CO2 absorption and can lead to myocardial irritability. Cardiac dysrhythmia, specically ventricular ectopy, can occur [9]. Extraperitoneal Insufation Extraperitoneal insufciency can occur because of an improperly placed Veress needle, resulting in subcutaneous emphysema. CO2 emphysema resolves promptly after insufation ceases [9]. Inadvertent insufation of intra-abdominal structures such as omentum or mesentery can obscure the visibility of intraabdominal structures, increasing the risk of injury to them [3]. Pneumothorax/Pneumomediastinum/Pneumopericardium During the creation of pneumoperitoneum, the movement of gas can produce pneumomediastinum, unilateral pneumothorax, bilateral pneumothorax, and pneumopericardium. These maladies occur for several reasons. Embryonic remnants that allow potential channels of communication between the abdomen and the chest open because of increased intra-abdominal pressure. Defects in the diaphragm and weak points in the aorta and esophageal hiatus may allow passage of gas into the thorax. Pleural tears that can occur because of laparoscopic surgical technique at the level of the GE (gastroesophageal) junction can result in pneumothorax. Opening of peritoneopleural ducts can result mainly in right-sided pneumothorax. Pneumothorax during fundoplication is noted more frequently on the left side [9]. Potentially serious complications associated with pneumoperitoneum may lead to respiratory and hemodynamic disturbances. Capnothorax (CO2 pneumothorax) decreases thoracopulmonary compliance, increases airway pressures, and increases PaO2 and PETCO2 [9]. CO2 absorption is greater from the pleural cavity than from the peritoneal cavity. Tension pneumothorax with cardiorespiratory compromise can occur [9]. When CO2 pneumothorax occurs during laparoscopy, several guidelines are followed:
     

Stop N2O administration. Correct hypoxemia, adjust ventilator. Apply PEEP (positive end-expiratory pressure). Decrease intra-abdominal pressure. Pneumothorax usually resolves promptly after exsufation; thoracocentesis should be avoided. In the case of a preexisting bullae rupturing, PEEP and thoracocentesis should be applied [9].

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GAS EMBOLISM Gas embolism is a rare but very dangerous complication of laparoscopy. Gas embolism can be caused by needle or trocar placement into a vessel or insufation into an abdominal organ [9]. Physiologically, rapid insufation of gas under high pressure causes a gas obstruction of the vena cava or atrium. Decreased cardiac output, circulatory collapse, and obstruction to venous return can occur. In patients who have patent foramen ovale, 20% to 30% of the population, right ventricular hypertension can open the foramen, allowing gas embolism of the cerebral and coronary beds [9]. Diagnosis is obtained by detecting gas embolism on the right side of the heart or in recognizing physiologic changes. In events occurring with 0.5 mL/kg or air or less, changes will be noted in Doppler sounds and increased mean pulmonary arterial pressure. When embolism increases in size to 2 mL/kg of air, signs and symptoms include:
       

Tachycardia Hypotension Increased central venous pressure Mill wheel cardiac murmur, Cyanosis Flash pulmonary edema Cardiac arrhythmia and EKG changes consistent with right heart strain [9]

Treatment includes:
  

 

Immediate cessation of insufation and release of pneumothorax Place patient in steep Trendelenburg on left side to prevent gas from entering the pulmonary outow tract. Discontinue N2O and ventilate with 100% oxygen. The high solubility of CO2 in blood results in rapid absorption of CO2 from the blood, allowing for rapid reversal of signs and symptoms. Aspiration of gas with a central venous catheter External cardiac massage to fragment large bubbles [9]

TECHNICAL COMPLICATIONS Laparoscopic complications occur at a rate of approximately 4 to 6 complications per 1000 patients, with a mortality rate of approximately 3 deaths per 100,000 patients. The more complex laparoscopic procedures result in a higher risk for complications. Box 1 lists some complications of laparoscopy [1]. Vascular Injuries Although vascular complications are rare, with an incidence of 0.02% to 0.03%, there is a signicant mortality rate of 15% [1]. Injuries to intra-abdominal vascular structures with the insufation needle or trocar placement are the

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Box 1: General complications of laparoscopy Injury to adjacent organs Bleeding from solid organs (liver and spleen) Vascular injuries Puncture/perforation/cauterization of the bowel Transection/perforation of bile ducts Perforation of the bladder Puncture/perforation of the uterus Complications of abdominal access
  

Port site hernia Wound infection Also see Injury to adjacent organs

Complications of specimen removal Port site recurrence of cancer Splenosis Endometriosis Complications of pneumoperitoneum
   

Pneumothorax Pneumomediastinum Gas embolus Subcutaneous emphysema

From Philips PA, Amaral JF. Abdominal access complications in laparoscopic surgery. J Am Coll Surg 2001;192(4):52536; with permission.

most threatening laparoscopic complication [2,7]. Vascular injuries can be prevented by:
   

Evaluation of anterior abdominal wall Proper patient positioningTrendelenburgwhen placing the insufation needle or a trocar Insertion of insufation needle or a trocar at the correct angle, 45 angle directed caudally Using the open laparoscopic technique with use of the Hasson trocar [1]

Large vessel injuries occur during laparoscopic access. The right common iliac artery is the most commonly injured blood vessel because of its location directly below the umbilicus. Box 2 discusses factors responsible for large vessel injury during laparoscopic access [1]. Lateral to the abdominal wall midline are blood vessels: superior epigastrics, inferior epigastrics, and superior circumex iliac vessels. These vascular structures can be injured when placing lateral trocars. In most patients,

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Box 2: Factors responsible for large-vessel injury during laparoscopic access Inexperienced or unskilled surgeon Failure to sharpen the trocar Failure to place the patient in Trendelenburg position Failure to elevate or stabilize the abdominal wall Perpendicular insertion of the needle or trocar Lateral deviation of the needle or trocar Inadequate pneumoperitoneum Forceful thrust Failure to note anatomic landmarks Inadequate incision size
From Philips PA, Amaral JF. Abdominal access complications in laparoscopic surgery. J Am Coll Surg 2001;192(4):52536; with permission.

transillumination of the anterior abdominal wall will allow for visualization of these structures. Sometimes abdominal wall thickness disallows visibility of theses structures. In that case, it is advised to place the lateral trocars approximately 8 cm from the midline and at least 5 cm from the symphysis pubis to avoid injury to the abdominal wall blood vessels [2]. Bowel Injuries Potentially catastrophic injury can occur to the gastrointestinal tract during trocar placement. One contributing factor to potential bowel injury is prior abdominal surgery. It is estimated that approximately 25% of patients with midline abdominal incisions from prior surgery have periumbilical adhesions [1]. One study reveals that the incidence of bowel injury during gynecologic laparoscopy ranged from 0.08% to 0.33%. As many as 15% of these injuries were not discovered until several days postoperatively, with one out of ve resulting in death [8]. In yet another study by Chandler and colleagues, reviewing general and gynecologic procedures, 76% of all injuries incurred during the establishment of the primary port were bowel and retroperitoneal vascular in nature. Nearly 50% of the injuries to the small and large intestine went unrecognized for at least 24 hours [7]. In the patient who has midline abdominal scars, an alternate site for entry into the abdomen should be considered. The left upper quadrant rarely has adhesions and would provide an excellent view of the periumbilical region to evaluate for bowel adhesions [1]. Although it seems logical that the use of the open laparoscopic technique would be safer, statistically there is no difference between use of the insufation needle and the Hasson trocar [10].

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Bowel burns can occur during laparoscopy, resulting in the need for open laparotomy and possible colostomy. The use of the new harmonic scalpel, bipolar cauterization techniques, and methods that use surgical clips or staples helps to minimize this risk [11]. Delayed diagnosis of these injuries is an independent predictor of mortality [8]. When major abdominal procedures are being performed, patients should be instructed to do a preoperative antibiotic bowel preparation to reduce the incidence of peritonitis caused by inadvertent bowel injury [12,13]. Urologic Injuries Injuries to the ureter have occurred as a consequence of thermal injury, ligation, or laceration caused by inadequate exposure or poor dissection. Bladder injury can occur with trocar placement. Placement of a Foley catheter can help decrease the size of the bladder, thus decreasing the risk of perforation [14]. Studies have demonstrated that the risk of injury correlates positively with the degree of complexity of the surgical procedure. Proper identication of anatomic structures and surgical planes is mandatory to avoid injury [2]. Small injuries to the bladder such as a Veress needle stick can be managed with bladder decompression. Larger injuries induced by a trocar stick or dissection require open laparotomy with repair of the injury [8,11]. WOUND COMPLICATIONS Hernia Hernias occur in 0.1% to 0.3% of patients. Larger trocars pose a greater the risk for herniation. When using a 10 mm or larger trocar, the patients fascia should be sutured closed to avoid possible herniation [3]. Wound Infection It is uncommon for a wound infection to occur, and risk depends largely on the type of surgical procedure performed. Diagnostic laparoscopy has an extremely low wound infection rate approximately 0.1%. Wound infections following laparoscopic cholecystectomy, for example, can be as high as 1%, however [3]. Use of the bag or other device to remove the specimen may decrease the incidence of infection [3]. SUMMARY When laparoscopic surgery was in its infancy, many said that it was a temporary phenomenon, a passing phase on the surgical timeline. Tincture of time has proven the efcacy of laparoscopic surgery, and advances in laparoscopic surgery have altered the way surgery is viewed and performed. Attention to the detail of proper patient selection, use of appropriate surgical technique, and prompt management of surgical complications can ensure that the minimally invasive nature of laparoscopic surgery remains the outcome for most if not all laparoscopic patients. Perioperative nursing care plans must be in place to address possible complications such uncontrollable intraoperative bleeding or adverse occurrences such as pneumothorax [15].

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References
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