Columbus: complications of laparoscopy and hysteroscopy Flashcards
(42 cards)
What is the rate of uterine perforation at hysteroscopy?
When does this typically occur?
1%
During sounding, dilation or initial insertion of the scope
What is the single greatest factor leading to injury and liability?
Ignoring contraindications
When does uterine perforation require surgical exploration?
Lateral perforation or perforation with an active electrode
What factors increase the risk of CO2 embolism at laparoscopy?
Length of surgery Obesity Cardiopulmonary disease Patient position Amount of dissection
When does air embolism usually occur during laparoscopy?
At insufflation
What steps should be taken when trocar injury to the large bowel is recognized?
- Leave the laparoscope in place to prevent spread of bacteria
- Begin broad-spectrum antibiotics
- Anesthesiologist to place an NG/OG tube
- consuly general surgery.
What complications can occur during laparoscopy during insufflation?
Failed pneumoperitoneum Pneumoperitonium-Induced Pneumothorax Subcutaneous emphysema Extra peritoneal insufflation Pneumo-Mediastinum CO2 embolism
What are some strategies for failed pneumoperitoneum?
Left upper quadrant insertion
Open laparoscopic port placement
Ninth intercostal space insertion
Laparotomy
How does CO2 embolism present?
Decreased oxygen saturation and expired CO2 Bradycardia, arrhythmia, and widened QRS Bilateral mydriasis Pulmonary interstitial edema Cyanosis Hypotension Acidosis Cardiovascular collapse and death
How is CO2 embolism treated?
Immediate release of pneumoperitoneum
Left side down in Trendelenburg forces gas into base of right ventricle
100% oxygen and anticholinergics
Place central line
Consult cardiologist to aspirate air bubble from right heart
How is CO2 embolism prevented?
Continuous end-tidal CO2 monitoring
Maintenance of intra-abdominal pressure within predetermined limits
Rarely invasive cardiac monitoring
What steps are done prior to surgery to reduce stomach perforation?
Bladder perforation?
Minimal bagging and NG/OG tube.
Indwelling Foley catheter or preoperative emptying.
What patients require consideration of alternative entry site for laparoscopy?
Large pelvic mass, pregnancy, or previous surgery.
How is ureteral injury best diagnosed?
What is the most common clinical finding in patients with ureteral transaction?
Intravenous pyelogram
Elevated WBC
How is left upper quadrant insertion performed? What needs to be considered?
Palmers point
Entry at midclavicular line or lateral
Empty the stomach with NG or OG tube
Evaluate for hepatosplenomegaly
When do patients usually present with ureteral injury?
What are the most common signs of ureteral injury?
48 to 72 hours
Elevated WBC, fever, peritonitis. Hematuria and flank pain are present infrequently.
How is major vascular injury managed laparoscopy?
Leave the Veress or trocar in place to help mark the site of injury
Perform immediate laparotomy with midline incision
Stabilize hemodynamic parameters
Consult vascular surgery
How is ureteral injury repaired?
Reimplantation into the bladder
Anastomosis of the damage ureter
Transureteral ureterostomy
How is inferior epigastric vessel perforation managed?
Pressure, vasopressin, Foley balloon, or suture
How should brisk intraoperative bleeding be managed?
Hydrolavage Mechanically coapt the bleeder Revisit anatomy Mobilize vasculature if necessary Desiccate Hydro lavage and reassess
What are risk factors for adhesion formation?
Ischemia Infection Necrosis Hemorrhage Foreign body Abrasion Surgery
What steps can be performed to improve the safety of hysteroscopy?
Void prior to surgery or Foley catheter
Examination under anesthesia or preoperative imaging
Careful dilation and uterine sounding
How can adhesions be prevented?
Incise rather than excise
Avoid crushing and desiccation
What are contraindications to hysteroscopy?
PID or acute vaginitis
Profuse uterine bleeding
Pregnancy
