Delayed Complications

Hernias

There is a growing amount of literature on the risk of postoperative laparoscopic hernia formation following trocar removal (95-99). The standard custom has been to close the fascia in all trocar sites 10 mm in diameter or above. The literature would suggest that although the risk of port site herniation is uncommon below the 10 mm cutoff it is by no means certain. In fact, children and obese patients are significantly at risk of herniation from the 5 mm trocars and smaller (100).

The estimated risk of developing a trocar site hernia is about 0.77% to 3.0%. This compares to the open operative counterpart risk of 10% of all cases following conventional laparotomy. The smallest trocar site currently reported with postoperative complication is a 3 mm umbilical port site. The umbilicus has been investigated as the site most likely to develop this complication. In fact, this has not held up to scrutiny (101). Any laparoscopic trocar site appears to be likely to develop herniation. Organs that can be herniated and cause symptoms include the bowel, omentum, preperitoneal fat, and rarely the large bowel (or mesentery) (102). It is important to realize that an outward pressure is produced as the laparoscopic cannulas are removed, which fosters entrapment of loose tissues such as the small bowel or omentum. This is even more likely to occur if the flapper valve of the trocar is held open during its removal. This creates a suction-like effect drawing any underlying structures into the trocars transabdominal path (103). Much work remains to be done regarding the optimal method of access site management. The evolution of the science behind this fundamental part of laparoscopic surgery is burgeoning and the potential for needless injury from this source is beginning to be questioned (104).

Wound Infections

Laparoscopic wounds, trocar sites, are different from open surgical wounds. A foreign body is introduced through the anterior abdominal wall or flank, it is locked into position with sutures or fascial screws, and it is manipulated throughout the operation by instruments that are passing and extracting to perform the work of surgery remotely (105). Infection at the trocar site has long been a clinical concern but there is no evidence that the incidence of wound infection is higher than in open surgery. In fact, there is some evidence that the risk of wound infection is less with laparoscopic procedures particularly in some high-risk populations (106-110).

The need for routine laparoscopic cases to receive prophylactic antibiotics remains controversial (111,112). In large series of laparoscopic cholecystectomy this probably is not necessary, but these cases tend to be much quicker than the usual urologic

Pouiin et al. stated that the laparoscopic procedures have the same rate of infectious complications compared to the open counterpart. As such, the complexity of the surgery and the actual laparoscopic procedure may affect the rate of postoperative trocar site infection.

C02 gas is typica lly at 21.10 C at insufflation, whereas the peritoneal cavity is 35.52°C to 36.2°C.

laparoscopic case (49). In one recent prospective, randomized study on the use of prophylactic antibiotics, there was no effect on incidence and severity of infections between both groups (113). Multivariate analysis showed that diabetes mellitus and colic episodes within 30 days before surgery were independent factors significantly associated with the onset of infectious complications. Laparoscopic surgery performed for known infectious diseases such as appendicitis do show significant benefits for the routine use of prophylactic antibiotics. In a large prospective multicenter evaluation of patients operated on for appendicitis, Koch et al. demonstrated that in this high-risk group wound infections occurred in 2.5% of 4968 patients. Laparoscopic wound infections were again statistically significantly lower than with open appendectomy (p < 0.001) and that routine use of prophylaxis resulted in lowering the rate in both the open and laparoscopic groups. Other high-risk surgeries for wound infection have been operations upon the bowel. Laparoscopic surgical resection of the small bowel is necessary for radical cystectomy and ileal conduit formation. In a recent publication of 500 consecutive laparoscopic colorectal resections, Pouiin et al. reported an incidence of postoperative wound infections of 7.2% (includes infections of both the anterior abdominal wall and perineum) (114).

Pouiin et al. stated that the laparoscopic procedures have the same rate of infectious complications compared to the open counterpart. As such, the complexity of the surgery and the actual laparoscopic procedure may affect the rate of postoperative trocar site infection.

In the urologic literature, several large series estimates that the postoperative trocar site infection rate is very low, 0.06 (49,88-90).

Port Site Metastases

Incisional metastases following open resection for cancer is an infrequent but known risk of cancer surgery (115). The first reported case of cancer recurrence was in 1978 in a patient with ovarian cancer (116). Reports for certain kinds of cancer such as colon cancer have notoriously high rates, ranging from 0.6% to 0.8%. The laparoscopic port site risk has been noted to be as high as 1.1% raising some concern about laparoscopic caner surgery. Though rare, incisional metastatic disease is a morbid complication to patients nearing the end of life and decreases the potential for cure in patients to near zero. The port site has been portrayed to be a breeding site for tumor implantation because of the trauma that occurs in the port site (117). If viable tumor were to be seeded into such a tract, some have speculated that port site recurrence might occur. Little science and few clinical trials are available to evaluate this phenomenon but recent work has been progressing. In urologic practice, one large extensive, retrospective review identified etiologic factors such as natural malignant disease behavior (transitional cell carcinoma), host immune status, local wound factors, laparoscopy-related factors such as aerosolization of tumor cells (harmonic scalpel vs. electrocautery plumes), type of insuf-flant gas (C02, nitrous oxide, helium, and room air), and surgical skill. Suffice it to say, that the risk of port site metastasis in urologic laparoscopic surgery seems not to be rising with associated increase in the numbers of cases (118). Methods to reduce risk should be actively employed. Attempts at reducing manipulation of the specimen should be employed during all laparoscopic procedures. Wu et al. (119) clearly demonstrated that by decreasing the inoculum of intraperitnoeal cells lead to a decreased wound implant rate. Others have shown that the use of potentially cytotoxic agents such as providone-iodine solution and chemotherapeutic agents will decrease tumor implantation rates (120).

Others

A whole host of other injuries have been reported in the expanding literature of laparoscopic surgery. Hypothermia during surgery is a well-recognized result of having patients exposed for surgery in relatively cold ambient operating room environments (121). In addition, the insufflation of the abdomen with room temperature C02 gas might increase the potential incidence of this condition.

C02 gas is typically at 21.1°C at insufflation, whereas the peritoneal cavity is 35.52°C to 36.2°C. Fortunately, the peritoneum and its contents expose the insufflated gas to a large surface area, and the gas usually reaches equilibrium temperatures rather quickly. The mesenteric circulation receives 10% of the cardiac output and the estimated surface area of the peritoneal cavity is equal to that of the cutaneous surface (1-2 m2). One study by Ott (121) showed that 5 L of C02 gas took only 7.5 minutes to reach equilibrium to the previous intra-abdominal temperature (121).

Core temperatures decreased at a rate of 0.3°C for each 50 L of CO2 used during continuous infusion during a laparoscopic case. It is advisable, especially during prolonged laparoscopic procedures to warm the patient with an external warmer throughout the procedure to minimize the risk of hypothermia.

It is always preferable to have no complications. This is rarely ever entirely possible, but there are many factors that can be controlled and deserve mentioning here.

Core temperatures decreased at a rate of 0.3°C for each 50 L of CO2 used during continuous infusion during a laparoscopic case. It is advisable, especially during prolonged laparoscopic procedures to warm the patient with an external warmer throughout the procedure to minimize the risk of hypothermia.

Adhesion formation following laparoscopic procedures is often thought to be reduced secondary to a lessened inflammatory response; however, they can and do occur (122,123). Intraperitoneal adhesion formation with the formation of long-term complications of bowel obstruction can be due to inflammation caused by fibrin clot accumulation or direct manipulative injury and subsequent repair processes to the bowel. In numerous studies, laparoscopic procedures routinely demonstrate less risk of subsequent adhesion formation than the open counterpart (123). Controversy continues as to whether instilling a solution of lactated Ringer's or normal saline with or without an antibiotic leads to even fewer adhesions. In addition, additives such as heparin, hyaluronic acid, and tolmentin have also been postulated to decrease the risk of this unusual complication (124).

Other rare risks of laparoscopic surgery include injury to nerves (125). The most commonly injured nerve would be the motor obturator nerve during a laparoscopic pelvic lymph node dissection. Injuries can be direct, that is cutting, lacerating, or crushing the nerve. More likely however, is an indirect nerve injury that can occur by conduction of electrical current (72). These types of nerve injuries manifest insidiously during the postoperative recovery period. Since the nerve is not transected, it gradually becomes less viable and incomplete nerve conduction gradually gives way to a more complete injury. This injury has been also reported to occur with the long thoracic nerve that can be injured with a conductive injury to the inner aspect of the anterior abdominal wall. These patients demonstrate loss of motor function such as inability to adduct the leg with injury to the obturator nerve and winging of the scapula with injury to the long thoracic nerve. Most of the time, a thermal conductive injury to the nerve will resolve over time. This is probably secondary to axonal regeneration. Severed nerves however will not recover unless repaired. An observed injury to a major motor nerve should prompt repair of the injury.

Another category of rare laparoscopic injuries are those associated with retained foreign bodies (126). It is hard to imagine that with the abdomen closed and only trocars traversing the abdominal wall that foreign bodies could be left behind, but in fact this has occurred. As complex intraperitoneal laparoscopic surgeries arise, the inherent complexities and the use of more portals for assistance and retraction will carry an increased risk for foreign body retention. Retroperitoneal dilation balloons can rupture and pieces of the balloon are capable of being left behind (127,128). In one of the largest reported series of retroperineoscopy, Gaur noted that in 351 procedures the retroperitoneal balloon ruptured in several cases, but Gaur et al. (127) state that balloon rupture causes no tissue damage. Adams et al. (128) did report that balloon rupture could lead to excessive times for hunting for fragments. Since the balloon material is typically not radiopaque, only visual exploration can discover their presence. Moore et al. (129) noted that a balloon inflated with liquid created less energy release than a similarly inflated balloon with gas. Laparoscopic clips likewise are foreign and if left behind can cause future consequences (130). Migration of these metallic foreign bodies can happen (131). Finally, the urinary bladder has been identified as the final repository of some of these foreign bodies, such as microtacks that are becoming popular for the performance of laparoscopic hernia repairs (132).

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