prevenzione delle complicanze

PREVENZIONE DELLE
COMPLICANZE
Massimo Luerti
U.O. Ostetricia Ginecologia 1
A.O. della Provincia di Lodi
[email protected]
www.massimoluerti.com
INCIDENCE
IT IS DIFFICULT TO COMPARE THE VARIOUS
PUBLISHED SERIES
– HETEROGENEOUS POPULATIONS
– MIXTURE OF DIAGNOSTIC PROBLEMS
– DIFFERENT LEVELS OF OPERATIVE LPS
QUERLEU 1.08 - 5.23 ‰
NEZHAT 3.08 - 6.949 ‰
MAJOR COMPLICATIONS PER 1000
OPERATIVE LAPAROSCOSCOPIES
By Site of Injury
•Vessels/bleeding
2.6-11.0 ‰
•Bowel
0.6-2.0 ‰
•Genitourinary
0.6-1.6 ‰
•Nerve
6.1 ‰
•Uterine perforation
3.7 ‰
Complicanze gravi da accesso in laparoscopia
Mintz 1977
Loffer 1975
Berqvist 1987
Querleu 1993
Chapron 1998
Harkki-Siren 1999
Totale
N Casi
99204
32719
75035
17521
29966
102812
357257
D Intest
0.3 ‰
0.7 ‰
0.4 ‰
0.5 ‰
0.3 ‰
0.4 ‰
D Vascolari
0.5 ‰
0.07 ‰
0.2 ‰
0.2 ‰
0.1 ‰
0.2 ‰
Danni intestinali
N Casi
Laparotomia
5700
Chir Vaginale
965
Laparoscopia 3710
RCU
7575
N
48
7
11
11
%
8.4/1000
7.3/1000
3/1000
1.5/1000
Krebs Am J Ob Gyn 1986;15:509-14
MAJOR COMPLICATIONS PER 1000
OPERATIVE LAPAROSCOSCOPIES
By instrument
•Veress needle
2.7 ‰
•Large trocar
2.4-2.7 ‰
•Accessory trocar
2.5-6.0 ‰
•Electrosurgery
0.5-2.8 ‰
•Pneumoperitoneum
7.4 ‰
STRUMENTI CAUSA DI DANNI VASCOLARI IN
47 PROCEDIMENTI MEDICO-LEGALI
Ago di Veress
4
Trocar Principale
24
Riutilizzabile
10
Monouso
11
“Open Laparoscopy”
3
Trocar accessorio
4
Forbici
4
Suturatrici
2
Bisturi
3
Elettrobisturi monop.
5
R Soderstrom J of AAGL May 9
POSIZIONE DELLA PAZIENTE
RISCHI!!!
• Compressione del nervo peroneale
• Stiramento del nervo otturatorio
• Stiramento del plesso brachiale
• Lacerazione o rottura di dita e mani
POSIZIONE DELLA PAZIENTE
•Paziente supina con gambe divaricate, leggermente flesse,
mantenute da specifici supporti
•Natiche a livello del bordo del tavolo operatorio
•Braccio sinistro lungo il corpo
•Vescica vuota
•Assenza di separazione tra l’operatore e l’anestesista
•Reggispalle posizionati
PATIENT POSITIONING
•
•
•
•
Don’t flex the hips beyond a 90 degree angle
Avoid pressure over the head of the fibula
Pay attention to the abduction of the thighs
Tuck the arms by the patient’s sides, rather than allowing
them to remain outstretched on the armboards
• Tuck the arms only after the legs have been properly
positioned and the bottom part of the operating table
has been dropped down
• Replace the arms on the armboards before the bottom
of the table is brought up into the horizontal position
PERFORAZIONE DA ELEVATORE
L’inserimento dell’ago di Veress e
del trocar ombelicale sono i
momenti più critici della
laparoscopia.
Oltre il 50% delle complicanze più
gravi occorrono in questa fase.
MAJOR ENTRY COMPLICATIONS
INCLUDE BOWEL AND MAJOR
VESSEL INJURY AT
FREQUENCIES OF 0.04% TO 0.5%
AND 0.01% TO 1.0%,
RESPECTIVELY
Vilos G.A., Laparoscopic bowel injuries: Forty litigated gynecological cases in Canada, J Obstet Gynecol Can, Volume: 24, (2002), pp. 224--230
Jansen F.W., Kolkman W., Bakkum E.A., de Kroon C.D., Trimbos-Kemper T.C.M., Trimbos J.B., Complications of laparoscopy: An inquiry about
closed-versus open-entry technique, Am J Obstet Gynecol, Volume: 190, (2004), pp. 634--638
Fuller J., Scott W., Ashar B., Corrado J., Laparoscopic trocar injuries: a report from a U.S. Food and Drug Administration (FDA) Center for Devices
and Radiological Health (CDRH) Systematic Technology Assessment of Medical Products (STAMP) Committee. 1-14, (2005),
CLASSIFICAZIONE DELLE LESIONI
DA ACCESSO IN LAPAROSCOPIA
• Tipo 1
Lesioni su organi in posizione normale
• Tipo 2
Lesioni su organi aderenti alla parete
addominale
A Consensus Document Concerning laparoscopic entry techniques:
Middlesbrough UK, March 19-20 1999
Risk factors for Veress needle
and trocar insertion
• Previous abdominopelvic surgery
• High or low body weight
• Very large uterus
• Large pelvic masses
RISK OF ADHESIONS IN PATIENTS WITH
PREVIOUS ABDOMINOPELVIC SURGERY
– Adhesions to Anterior Abdominal Wall
• Previous Incision
– 27% Pfannenstiel
– 55% midline below umbilicus
– 67% midline above umbilicus
• Hx – Pelvic/Abdominal Infection
– Abscess, Ruptured Appendix
Brill, Ob/Gyn, 1995
RISK OF ADHESIONS IN PATIENTS WITH
PREVIOUS ABDOMINOPELVIC SURGERY
• Patients with multiple abdominal incision have more
adhesions than patients with Pfannestiel incision
• Patients with multiple abdominal incision have not
more adhesions than patients with a single incision
• Patients with Pfannestiel incision for gynecologic
surgery have more adhesions than patients with the
same incision for obstetric surgery
• Patients with longitudinal incision have not more
adhesions than patients with Pfannestiel incision if the
surgery is obstetric
COMPLICATIONS OF THE INDUCTION
OF PNEUMOPERITONEUM
1.
2.
3.
4.
5.
6.
7.
8.
9.
Extra-peritoneal gas insufflation
Subcutaneous, pre-peritoneal and mediastinal
emphysema
Pneumothorax
Pneumo-omentum
Injury to gastro-intestinal tract
Bladder injury
Blood vessel injury
Gas embolism
Puncture of liver or spleen
I° passo: Aspirazione, che non deve produrre aria o liquido,
accertando l’assenza di perforazione vascolare, urinaria, intestinale
II° passo: Iniezione di 20 cc di aria o liquido. Non si dovrebbe
percepire resistenza e non dovrebbe essere possibile aspirare il
liquido. E’ un metodo semplice per confermare che non c’è contatto
con visceri intraaddominali o aderenze
III° passo: Tentativo di riaspirare l’aria o il liquido iniettato. Se il
Veress è nello spazio preperitoneale o nelle fibre muscolari del
muscolo retto, il tentativo può avere successo
CONTROLLI DURANTE LA CREAZIONE
DEL PNEUMOPERITONEO
• Osservare la pressione intraddominale e gli indici di
resistenza sui display dell’insufflatore elettronico
• Verificare con la percussione la scomparsa
dell’ottusità epatica (dopo circa 0,5-1 l. di CO2), la
diffusione dell’onda sulla parete addominale e il
corretto sviluppo del pneumoperitoneo
• Mappare la profondita della falda di gas aspirando
gas attraverso un ago da spinale 18 G, connesso ad
una siringa contenente 5-10 cc di soluzione fisiologica
GAS EMBOLISM
CARBON DIOXIDE INTRODUCED INTO LARGE VEIN
WITH VERESS (rare) -> RIGHT VENTRICLE ->
PULMONARY ARTERY -> COLLAPSE ->CYANOSIS
• RECOGNITION :
– BLOOD ON THE VERESS
– CARBON DIOXIDE CONCENTRATIONS
• MANAGEMENT
– STOP INSUFFLATION
– DON’T REMOVE VERESS
– RESUSCITATION
INSERZIONE TROCAR
Evitare la posizione di Trendelemburg
COMPLICANZE DA INTRODUZIONE DEL
TROCAR PRINCIPALE
• Sanguinamento della parete
addominale
• Perforazione di un viscere
• Lacerazione di un vaso
• Danni epatici o splenici
No randomised studies confirm that
disposable trocars are safer than the
reusable ones
Easy insertion of the former may cause
vascular or intestinal injuries, if
excessive strength is used
LESIONI INTESTINALE DA ACCESSO
• Tecnica classica
0.3‰
• Open Laparoscopy 0.4‰
• La open laparoscopy elimina solo
le lesioni di tipo 1
OPEN vs CLOSED
• The Swiss Association for Laparoscopic and
Thoracic Surgeons : In contrast to general surgery
publications the OPEN access method used in the
current series failed to show any superiority over
the Closed method
• The european Ass for endoscopic surg: there are
similar bowel injuries but no major vascular injuries
with the open technique
• AJOG 2004 : the number of entry-related
complications in the OPEN technique was
significantly higher than the CLOSED
COMPLICANZE VASCOLARI
•Incidenza 0,05%
•Mortalità 8-17%
PREVENTION OF VASCULAR INJURIES
• Adequate skin incision
• Feel with fingers the position of aortic bifurcation remembering that
in 80% of cases it is situated  1,25 cm from the level of iliac crest
• Position of umbilicus variable
• Manually elevate abdominal wall,
mainly in thin women: avoid Bachaus
• The trocar must have a sharp tip
MIDLINE
• Stay in midline
– Thin: 45 degrees
– Obese: 90 degrees
• No Trendelenburg
• Pressure at insertion
– Higher (15-18 mm) is better ?
VASCULAR INJURY
Large retroperitoneal vessels
• PRESENTATION:
– PERITONEAL OR RETROPERITONEAL BLEEDING OR
HAEMATOMA
– DROP OF BLOOD PRESSURE
• MANAGEMENT:
– DON’T REMOVE VERESS/TROCAR
– DO NOT OPEN PERITONEUM
– MIDLINE LPT
– APPLY A PRESSURE OVER THE SITE OF DEFECT
– VASCULAR SURGEONS/ANAESTHETIC STAFF
INSERZIONE DEI TROCAR ACCESSORI
• Transilluminazione della parete addominale
• Premere col dito nella sede di inserzione
• Inserzione sotto controllo della vista nel “triangolo di
sicurezza”
• Identificazione con la pressione digitale della zona
avascolare lateralmente ai vasi epigastrici
• Inserzione dei trocars sotto controllo visivo,
perpendicolarmente alla parete, fino al peritoneo, e
quindi in direzione del Douglas
• Usare trocars a punta conica?
Anatomia laparoscopica
COMPLICANZE LEGATE
ALL’ALTO FLUSSO DI CO 2
In un trocar di 10 mm di diametro, senza strumenti all’interno, il flusso
massimo di gas sarà di circa 6.5 (+/- 0.5) litri/min.
E’ inutile usare flussi superiori ai 10 l/min.
Se il flusso supera 3 litri / min., la pressione istantanea della macchina
diventa significativamente più alta della pressione media del
pneumoperitoneo.
Queste alte pressioni di insufflazione sono implicate in:
• enfisema
sottocutaneo
• ipercapnia
• rischio di embolia gassosa.
L’alto flusso non dovrebbe essere utilizzato che in particolari
condizioni (laser, cambio di trocar etc.)
PREVENTION OF GASTRIC LESIONS
• Insert an oral gastric tube after anesthesia
induction, mainly in case of difficult
intubation or masked hyperventilation
• Elevate the abdomen and correctly insert
the needle
• Induce an adequate pneumoperitoneum
before insertion of trocar
TROCAR REMOVAL
•
•
•
•
Also under direct vision
Release pneumo-peritoneum
Re-inspect trocar sites
Inspect umbilical port
– On way out
INCISIONAL HERNIA
• RECOGNITION:
– PAIN, TENDER SWELLING
– X-RAY, CT, US
– DD: HAEMATOMA
• MANAGEMENT
– REDUCE AND REPAIR
• PREVENTION:
– CLOSURE OF THE FASCIA >10mm
– TROCAR VALVE CLOSE
– SECONDARY REMOVED FIRST AT LOW INTRAABDOMINAL PRESSURE AND
UNDER DIRECT VIEW
– INSERT A SOUND INTO THE SLEEVE BEFORE REMOVING IT
– SLOWLY MOVE ABDOMINAL WALL AFTER THE EXTRACTION OF THE
INSTRUMENTS
RECOMMENDATIONS TO AVOID
ELECTROSURGICAL COMPLICATIONS
• Inspect insulation carefully
• Use lowest possible power setting
• Use a low voltage waveform (cut)
• Use brief intermittent activation vs. prolonged activation
• Do not activate in close proximity or direct contact with another instrument
• Use bipolar electrosurgery when appropriate
• Select an all metal cannula system as the safest choice
• Do not use hybrid cannula systems that mix metal with plastic
• Utilize available technology, such as a tissue response generator
to reduce capacitive coupling or an active electrode monitoring system,
to eliminate concerns about insulation failure and capacitive coupling
Type of Current
CUT
BLEND
COAG
PREVENTION OF BLADDER INJURIES
• Insert indwelling or “in-out” catheter
• Alternatively ask the patient to void just
before the operation
• If the limits of the bladder are not clear-cut,
fill it with 300 ml saline
• Identify high risk patients (previous surgery,
mainly CS)
• Warning to the bladder dissection in LAVH
INJURY TO THE URINARY TRACT
• RECOGNITION:
– IMMEDIATE (rarely):INDIGO -CARMINE
I.V.
– DELAYED: NON-SPECIFIC SYPTOMS
• MANAGEMENT:
– STENT
– UROLOGICAL SURGEON
PREVENTION OF URETERAL INJURIES
• Identification
• Isolation the ureter in case of endometriosis, LUNA or other
risky procedures
• Injection of fluid in the retroperitoneal space
• Bipolar coagulation with continuos visualisation of the
coagulated tract and of the structures nearby and for a short time
• Catheterise the ureter ( ev. with transilluminated catheter)
INCIDENCE 1.8/1000
BOWEL INJURY
NOT RECOGNIZED
• CAUSATION:
– LACERATION (VERESS/TROCAR)
– THERMAL INJURY
• RECOGNITION:
– FOUL SMELLING GAS
– GREENISH FLUID
– BOWEL MUCOSA
PREVENTION OF SURGICAL
INJURIES OF SMALL BOWEL
• Direct mechanical injury is less frequent than thermal
one
• If unipolar forceps are used, pay attention to insulation
and leave the bowel outside the energy field
• If bipolar forceps are used, don’t touch the bowel
neither during nor immediately after the activation
• In adhesions between bowel-adnexa or bowel-pelvic
sidewall remain nearer to genital structures or to
vaginal or abdominal wall
• Prevent bleeding or washing operating field to look for
avascular planes avoiding uncontrolled gesture
PREVENTION OF INTRAOPERATIVE
LARGE INTESTINE INJURIES
• Avoid non controlled trocar insertion
• Avoid non controlled insertion of sharp instruments
PAY ATTENTION!!!!!
• to the distortion of anatomy for endometriosis or
previous surgery
• to the dissection of Douglas in case of endometriosis
LAPAROSCOPIA
RACCOMANDAZIONI POSTOPERATORIE
•Stendere una descrizione dettagliata dell’intervento
(comprendente il nome degli strumenti, le sorgenti di
energia, le potenze utilizzate).
•E’ utile aggiungere documentazione fotografica.
•Ricordare che il dolore dopo una laparoscopia
dovrebbe diminuire costantemente nel tempo.
L’aumento o il mantenimento del dolore è un segno di
pericolo.
GRAZIE PER
L’ATTENZIONE
www.massimoluerti.com