Guest Author - Dr. Denise Howard
Laparoscopy is a method by which abdominal surgery is performed through small openings using a camera and slender long instruments. It has become the standard of care for many gynecologic procedures and the more recent graduates of gynecology training programs are well versed in it. More complex procedures can also be performed via this route but this takes a much higher skill level. All procedures carry risks and this article will review the more common complications and aftereffects of laparoscopy.
The procedure is performed under general anesthesia with the legs placed in the dorsal lithotomy position. After cleaning, the bladder is drained or a catheter is left in place. Once draped, an incision is made in the umbilicus and the trocar through which the camera is placed is inserted at this site. The abdomen is then distended with carbon dioxide. In one technique the gas is inserted after placing a veress needle followed by the blind insertion of a sharp trocar. The other technique is the open or Hasson technique whereby a larger incision is made in the umbilicus and the trocar is inserted under visualization. Once the abdomen is adequately distended additional trocars can be placed under direct visualization. This is usually done in the right and left lower quadrant or in a lower midline (suprapubic) location. In many cases the bed is placed in a head down position (reverse trendelenberg) to tilt the pelvis forward and shift the intestines up and away from the gynecologic organs.
The risks and potential complications can be associated with the anesthesia, the position during the surgery and the procedure itself. In addition individual risks of complications are altered by health status, age, weight and medical co-morbidities. Those of younger age and good health have a much lower risks than those who have chronic medical problems and are older. Those who are overweight or obese are also at much greater risk.
General anesthesia has always carried risk but it is safer now than ever and the actual risk is quite low. The death rate has decreased or the past decades from 2/10,000 to 1/200,000-300,000 procedures. The more serious risk includes inciting a heart attack, which occurs approximately 0.6% of the time wherein, nausea and vomiting is the most common complication occurring 23% of the time. Other complications include airway problems, hypertension, hypotension, arrhythmias and altered mental status.
Lying still during a procedure especially for long periods of time can compromise blood supply to the nerves. Nerve damage can occur to the shoulders and limbs when they are left in one position for long periods or when they are improperly positioned during surgery. In addition the position maybe altered when the table is moved which can occur during the procedure to facilitate the surgery. The nerve damage may present with numbness, tingling, pain, weakness in the limbs, or inability to use the extremity. In the vast majority of cases, the symptoms resolve over time.
The surgical related risks include injury to bowel, bladder and blood vessels during the placement of the veress needle and trocars. The consequences are death from a massive quick bleed if the aorta or other major blood vessels are struck. The vascular injury rate is approximately 3.1/10,000 procedures. Bladder and bowel injury are easily repaired if identified immediately but if discovered later will require a more complex repair and longer recovery. The risk of intestinal injury is approximately 4.4/10,000 procedures and it is usually delay in recognition that leads to death from overwhelming infection. Fortunately these major complications occur with low enough frequency that most of these cases are done as an outpatient.
Most women do quite well after the procedure but the most common complaints relate to shoulder pain form the instilled gas or nausea from the medications used. Some complications occur several days to weeks after the procedure and can include herniation of intestine through the trocar site and infection or breakdown of the incision sites. Other infections can occur such as pneumonia and a urinary tract infection. A blood clot in the legs (deep venous thrombosis) and/or a clot in the lungs (pulmonary embolus) can occur and these can be life threatening if left untreated.
The most common procedures performed using laparoscopy are tubal ligation, ovarian cystectomy (removal of cyst from ovary), ectopic pregnancy surgery and removal of an ovary or tube. Laparoscopy is the procedure of choice for these procedures. The alternative surgeries carry greater risks. The decision to undergo surgery should not be taken lightly but if you need it, be assured that the procedure can be accomplished easily with a high chance of success without complications.
I hope this article has provided you with information that will help you make wise choices, so you may:
Live healthy, live well and live long!