Acute Complications

Peritoneal Access

Complication from Veress needle or trocar placement can occur as with any laparoscopic procedure. Injuries to the abdominal wall vasculature or visceral organ injury can occur. If perforation occurs, the needle should be immediately removed and discarded. Because of the small size of Veress needle, the majority of the injuries do not require operative intervention (70). The Veress needle may injure the omental or mesen-teric blood vessels or may cause major abdominal or pelvic vessel vascular injury. Their management depends on the amount of bleeding.

The incidence of serious hemorrhage from trocar injury requiring transfusion is approximately 0.4% (71). The introduction of a trocar into the abdominal cavity is likely responsible for bowel injury when a peritoneal dialysis catheter is inserted using the peritoneoscopic technique (16) or laparoscopic techniques. Bowel injuries due to the introduction of insufflation needles, trocars, and rigid catheters and colonoscopic examinations have been reported (73-76). A majority of these perforations are usually small and seal spontaneously (77,78). These "miniperforations" close spontaneously within 24 to 48 hours, most likely secondary to omental adherence (77,78). Simkin and Wright (79) provided direct evidence of the self-sealing nature of bowel perforations sustained during peritoneal dialysis catheter insertion.

During surgical exploration, they observed sealed bowel perforations that were sustained during peritoneal dialysis catheter insertion 12 to 16 hours earlier. A majority of small perforations are self-sealing and do not require surgical intervention (76-78,80-82).

Pneumoperitoneum

Pneumoperitoneal pressure greater than 10 to 15 mmHg, especially in children, for prolonged time can result in barotrauma. High gas pressure can cause decreased venous return due to caval compression and can result in decreased cardiac output, leading to hypotension (70). Hydrothorax occurs in less than 1% of patients and is manifested by very poor drainage of dialysate, dyspnea, and abnormal chest radiographic findings (pleural effusion) (72).

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