COMPLICATIONS OF LAPAROSCOPY
With the development of more sophisticated endoscopic operations,
it is important to consider the risks and benefits of laparoscopy. Whereas the benefits
of the laparoscopic approach are well documented, knowledge of the incidence of complications
is more imprecise and is frequently based on retrospective studies.
The experience of gynecologic laparoscopists extends over a relatively
long time, and as a result, large surveys are available.[281]
[282]
[283]
[284]
Mortality rates have varied from 1 per 10,000 to 1 per 100,000 cases. The number
of serious complications requiring laparotomy was 2 to 10 per 1000 cases. Intestinal
injuries accounted for 30% to 50% of these and remained undiagnosed during laparoscopy
in one half of the cases. Vascular complications also accounted for 30% to 50%.
Burns were responsible for 15% to 20% of the reported complications. Whereas the
death rate decreased, the complication rate was slightly higher in the most recent
surveys, probably because of the increased complexity of the laparoscopies performed
over the past few years.
Large surveys of complications after laparoscopic cholecystectomy
are available.[173]
[285]
[286]
[287]
[288]
The overall mortality rate is approximately 0.1 to 1 per 1000 cases. Conversion
to laparotomy was necessary in approximately 1% of patients. Bowel perforation occurred
in about 2 per 1000 cases, common bile duct injury in 2 to 6 per 1000 cases, and
significant hemorrhage in 2 to 9 per 1000 cases. Laparoscopic cholecystectomy was
accompanied by a greater frequency of minor operative complications, whereas open
cholecystectomy had a higher rate of minor general complications. A learning curve
was demonstrated for laparoscopic cholecystectomy; experience was associated with
decreased operative times and rates of minor or moderate complications. Some of
these complications may be prevented by open laparoscopy.[289]
Whereas large-vessel injury (e.g., aorta, inferior vena cava,
iliac vessels) caused emergency situations, retroperitoneal hematoma can develop
insidiously and result in significant blood loss without major intraperitoneal effusion,
leading to delayed diagnosis. During gynecologic laparoscopy, complications occur
more frequently during the creation of pneumoperitoneum and the introduction of trocars,
whereas during gastrointestinal surgery they are more closely related to the surgical
procedure itself.[173]
[290]
[291]
Injuries provoked by the Veress needle are
usually less severe than those by trocars and may even remain undiagnosed. Unrecognized
gastrointestinal tract injury and subhepatic abscess formation can lead to potentially
lethal septic complications.[292]
Although all
these events are surgery related, the anesthesiologist must be aware of the complications
and timing of their occurrence. He or she must be ready to respond promptly and
adequately to these mishaps and to help the surgeon diagnose a complication.
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