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Overcoming Technical Challenges: Prevention and Managing Complications

  • Bradley R. DavisEmail author
Chapter

Abstract

Laparoscopy for colorectal disease is complex and poses many new challenges for the minimally invasive surgeon. Knowledge of pitfalls and strategies to avoid and mitigate complications will improve outcomes for patients. Techniques for trocar insertion and vascular ligation and maneuvers to lengthen the conduit for an intestinal anastomosis are varied and not applicable to every situation or case. Establishment of pneumoperitoneum and adequate exposure are critical for the safe performance of laparoscopy and can be more difficult in obese patients.

Keywords

Small Bowel Splenic Flexure Inferior Mesenteric Artery Veress Needle Ileorectal Anastomosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

Video 21.1

A bladeless trocar is used to bluntly dissect the layers of the abdominal wall. A zero-degree 5 mm laparoscope is inserted into the core of the trocar and focused just past the tip. Recognition of the peritoneal cavity is easy if a Veress needle has been used first to establish pneumoperitoneum. However, this is not necessary as seen in the latter part of the video (MOV 25112 kb)

Video 21.2

In this patient a previous laparotomy has resulted in the omentum adhering to the abdominal wall. Despite an optical view entry, the trocar is initially placed below the omentum, which can cause confusion upon camera insertion. Recognition of the malpositioned trocar and subsequent repositioning should be achieved quickly. An alternate trocar placed off midline under direct visualization can be used to reposition the camera and the adhesions to the abdominal wall can then be dissected free (MOV 171566 kb)

Video 21.3

When performing a laparoscopic adhesiolysis, judicious use of sharp dissection is encouraged to avoid thermal injury to the bowel. Thermal injury can be harder to recognize and occur remote to the site of dissection. Serosal injuries should be inspected to assess if repair is warranted (MOV 209264 kb)

Video 21.4

An enterotomy is inadvertently created during this re-operative right colon resection for Crohn’s disease. While the enterotomy would ultimately be part of the specimen, it is immediately closed to prevent contaminating the abdomen with enteric content (MOV 112286 kb)

Video 21.5

The mesentery of the left colon is being transected with a harmonic scalpel when too much traction is applied resulting in arterial bleeding. Initial attempts to control the bleeding with a 5 mm clip applier are not successful as proximal control and identification of the bleeding vessel are suboptimal. By transecting the tissue completely, the end vessel is identified and then ligated with an ENDOLOOP ® (MOV 223752 kb)

Video 21.6

Vaginal packing cut into short strips can be inserted through a 10 mm or larger trocar and used to absorb fluids and blood as well as provide pressure on a bleeding structure. It can also serve as a guard for the suction irrigator so that it will not be occluded with tissue. Once identified, the bleeding structure can then be ligated (MOV 99379 kb)

Video 21.7

Sacral bleeding is encountered following the placement of a stitch in the promontory during a laparoscopic rectopexy. This is particularly frustrating as the procedure is near completion. The bleeding is controlled with a clip applier (MOV 176648 kb)

Video 21.8

Following a stapled colorectal anastomosis, the serosa separates and is not incorporated into the staple line. This may result in an increased risk of leak and the staple line is oversewn with Vicryl™ sutures (MOV 144267 kb)

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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Cincinnati Medical CenterCincinnatiUSA

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