Year : 2009 | Volume
: 1 | Issue : 1 | Page : 40--46
Comparison of complications rates in endoscopic surgery performed by a clinical assistant vs. An experienced endoscopic surgeon
Consultant, Apollo Clinic, Mumbai, Associate Consultant, National Institute of Laser & Endoscopic Surgery, Ghatkopar (East), Mumbai - 400077, India
National Institute of Laser and Endoscopic Surgery, 1,2,3, Gautam Building, Opposite Balaji Temple, Tilak Road, Ghatkopar (East), Mumbai - 400 077
Study Objectives: (a) To find out the actual incidence of complications during endoscopic surgeries. (b) Comparison of complication rate between an experienced laparoscopic surgeon (> 10 years of experience in endoscopic surgery) and a clinical assistant (> 3 years of experience in endoscopic surgery). (c) How to manage complications in endoscopic surgery. (d) Concrete suggestions to reduce the complication rate. Design: Retrospective study (Canadian Task Force classification ii-2). Setting: Tertiary gynecologic endoscopic unit. Patients: A total of 3204 cases of gynecologic endoscopic surgery out of which 2001 were laparoscopic and 1203 were hysteroscopic surgeries. Interventions: Laparoscopic and hysteroscopic gynecologic surgeries in indicated cases. Measurements and Main Results: The study was carried out between April 2003 and October 2007 at a referral center for endoscopic surgery. A total of 3204 cases of gynecologic endoscopic surgery were studied. There were five significant complications in laparoscopic surgeries and four significant complications in hysteroscopic surgeries seen in four years and six months. All the complications could be managed with no mortality. Conversion to laparotomy was needed in eight cases of laparoscopic surgeries and none in hysteroscopic surgeries. Conclusion: The risk of complication reduces with the experience in endoscopic surgery. However, the proper grooming of a novice in experienced hands, for a sufficient period of time, can minimize the complication rate in the initial learning phase. The complication may be utilized as a stepping-stone to overcome any given situation without panic, but with adequate safety.
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Singhi A. Comparison of complications rates in endoscopic surgery performed by a clinical assistant vs. An experienced endoscopic surgeon.J Gynec Endosc Surg 2009;1:40-46
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Singhi A. Comparison of complications rates in endoscopic surgery performed by a clinical assistant vs. An experienced endoscopic surgeon. J Gynec Endosc Surg [serial online] 2009 [cited 2019 Dec 9 ];1:40-46
Available from: http://www.gynecendoscopy.org/text.asp?2009/1/1/40/51909
Gynecologic surgeries particularly vaginal and to a lesser extent abdominal have a low complication rate.
Similar to any other surgical modality, complications during endoscopic surgeries are directly related to the skill and experience of the surgeon. Apart from the proven benefits, these methods have also brought a host of complications related to the pneumoperitoneum, extensive electocautery, lasers, ureteric dissection, and so on. However, the complications should be minimal for patients safety [Figure 1],[Figure 2].
Materials and Methods
This study was carried out from April 2003 to October 2007, at a referral center for endoscopic surgeries, having all the facilities of the five parameters of monitoring (Non-Invasive Blood Pressure (NIBP), Saturation percentage of oxygen (SpO 2 ), End tidal carbondioxide (ET CO 2 ), electrocardiogram (ECG), and temperature) and proper state-of-the-art endoscopic surgical instruments and equipments, namely, Endomat for uterine distension, electronic CO 2 insufflators, the most recent vessel sealing device with dedicated electrosurgical unit and electronic morcellators, high definition three chip camera, and facilities to document all endoscopic surgeries.
A total of 3204 cases of gynecologic endoscopic surgeries were studied, out of which 2001 were laparoscopic [Table 1] and 1203 were hysteroscopic surgeries [Table 4]. After routine pre-operative investigations, including complete blood count (CBC), erythrocyte sedimentation rate (ESR), blood sugar fasting, serum creatinine, thyroid function tests, chest X-ray, ECG, and occasionally physician's fitness, the pre-anesthetic check up was performed. An informed written consent was taken. A day prior to all operative laparoscopic surgeries bowel preparation was done with polyethylene glycol solution, with electrolytes (PEGLAC). Pre-operative antibiotics were given on the day of surgery. The patient was put in a modified lithotomy position, in Allen stirrups, with a padded shoulder rest. Under all aseptic precautions, after painting and draping, a Veress needle was introduced through the umbilical incision (after 1 - 2 ml of 0.25% local sensorcaine infiltration, for postoperative pain relief).
In cases of previous abdominal surgeries, the Veress needle was put two inches above the umbilicus, after emptying the stomach with a nasogastric tube. Occasionally, the palmer's point (at the left mid clavicular line, below the twelfth rib or rib cage) was used for insertion of the Veress needle. Confirmation of entry into the peritoneal cavity was done by pushing 2 - 3 ml of normal saline through it and a drop was kept visible on the needle, which was sucked mechanically on elevation of the abdominal wall. The pneumoperitoneum was created. Insufflation pressure was kept at 15 mm Hg and the flow rate at 4 - 6 liters / min. When three liters of CO 2 distended the abdomen, the primary trocar was inserted. The woman was in the supine position without headlow, avoiding closeness of the illiac vessels.
The trocar with sleeve was inserted perpendicularly, with the index finger as protection. The laparoscope was introduced and tissues under the entry point visualized for intactness or mesenteric vessel injury. Occasionally the pneumo-omentum was seen, which could be easily corrected by positive pneumoperitoneum pressure. The secondary (ancillary) trocars, 5 mm, usually short with flower valve, were put under vision with a laparoscope.
After 30 o trendelenburg position, a continuous insufflation at 7 to 10 liters/min was done. The proper placement of electrosurgical footswitches was confirmed.
The conversion to open surgery is not a complication, but just the inability to operate laparoscopically, due to improper case selection, dense adhesions, inability to suture visceral injury laparoscopically (bladder, bowel injury), and due to excessive bleeding.
Out of two epigastric vessel injuries, one was managed with bipolar coagulation [Figure 3] and [Figure 4] and the other required intracorporeal suturing [Figure 5] and [Figure 6]. One primary trocar vessel injury was seen from 10 mm trocar site. Same could be managed with bipolar coagulation [Figure 7] and [Figure 8].
Bladder injury was seen in two cases. In one case, due to two previous lower segment Cesarian sections (LSCS), the bladder was densely stuck to the uterus and got injured during bladder dissection, while performing hysterectomy [Figure 9]. In another case it got injured accidentally with a monopolar scissors [Figure 10] and [Figure 11]. Both were sutured laparoscopically by intermittent single layer suturing, with polygalactin 3-0 [Figure 12].
One ureteric injury occurred with a new vessel sealing device in the first case, with untitrated current, due to lateral spread. It became apparent after 12 days of surgery, with symptoms of dribbling of urine from the vagina. It manifested as a ureterovaginal fistula. She was managed, along with a urologist, with a DJ stent. Injury to the ureter is one of the serious complications of endoscopic surgery, more so if it is not detected in time. ,
Two bowel injuries were seen during the study period. In one, due to multiple previous surgeries, the bowel (small) was adherent to the abdominal wall. The primary trocar accidentally entered into the small bowel, but was sutured laparoscopically [Figure 13] and [Figure 14]. The actual complications in different laparoscopic surgery in study group are tabulated in [Table 2]. Another was a sigmoid colon injury during adhesiolysis, in endometriosis [Figure 15]; laparotomy was performed to repair the defect, which was below the peritoneal fold. Both the patients had had proper bowel preparation.
Port site infection was seen in three patients. One was found to have port site tuberculosis and was treated with antitubercular medicines for six months, along with local dressings. The other two cases required few dressings for 15 days. The comparison of complications of laparoscopic surgery by Clinical assistant & experienced endoscopist are tabulated in [Table 3].
In hysteroscopic surgeries, the lithotomy position is given after anesthesia. Under all aseptic precautions, the cervix is dilated with half millimeter Hegar dilators from 7.5 to 9.5 mm. For all hysteroscopies, the distension pressure is kept at 120 - 180 mm Hg with a flow rate of 300 ml/min. The suction is kept at - 50 mm Hg. All these are controlled with electronic Endomet, mostly using 1.5 % glycine.
The different hysteroscopic surgeries done in this study group are tabulated in [Table 4]. The various hysteroscopic complications in the study group are tabulated in [Table 5] and comparison of complications by clinical assistant and endoscopic expert are tabulated in [Table 6].
Among six patients of fluid overload, five were treated with simple diuretics and had normal or negative inflow/ outflow balance at the end of surgery. One had a sudden 1000 ml of positive balance of glycine (in myoma resection of a 4.5 cm fundal fibroid). CBC and S. electrolytes were sent. It suggested hyponatremia and was treated with hypertonic saline. She however had altered sensorium and developed ammonia toxicity leading to convulsion. She was managed in the ICCU with Lactulose bowel wash and higher antibiotics.
Uterine perforation was seen in three patients - one during the cervical dilatation of a stenosed cervix, one during adhesiolysis with a Collins knife, and one during transcervical resection of the endometrium (TCRE) at the cornual end. All perforations were detected quickly and managed conservatively, with monitoring, and none required laparotomy.
One case of isthmic submucous myoma resection had more than expected bleeding. This was controlled with a Foley catheter inflated balloon (6 - 8 cc), which acted as a tamponade. It was deflated after five hours.
The complications in endoscopic surgeries can be minimized by adopting certain methods, but cannot be totally avoided. Though the Veress needle has been blamed by many as a cause of complication, our experience disagrees with this view. Avoiding manipulation of the inserted Veress needle and following the rules of creating a pneumoperitoneum prevents complications. The trocar insertion in the previous laparotomy can be performed two inches above the upper limit of the scar or umbilicus. Sometimes when bowel adhesions are expected, it is good to use a Ternamian blunt tipped cannula. It is inserted after creating the pneumoperitoneum and then rotated under the vision of a laparoscope, entering the peritoneal cavity. The only disadvantage is, it remains fixed in the same position due to serrations. Nezhat et al. ,  compared direct trocar (safety shield) entry with Veress needle insertion with insufflation, and found that there was no difference in the incidence of bowel or vessel injury in both these groups.
In case the trocar enters an important undesirable structure, it should not be withdrawn; instead a 5 mm trocar is introduced through the palmer's point to visualize the situation. If it is identified as a bowel injury then laparoscopic suturing is done or laparotomy is done with the help of a surgeon. In rare case if it is a major vascular injury then a vascular surgeon is called and the patient is prepared for an emergency laparotomy.
To minimize the complications due to electrocautery, a dedicated electrosurgical unit has to be used. The monopolar cautery is kept at 80 - 100 watts cutting current and 40 - 60 watts coagulation current. The bipolar cautery is kept at 25 - 30 watts current. The lateral spread in the monopolar cautery is greater  and in the bipolar is 5 mm beyond the point of contact.  Hence, the monopolar cautery can be most hazardous if used excessively or out of vision, on account of capacitance burns, that is, leak of current through hole/breach in insulation.
In hysteroscopic surgery, a sound knowledge of the fluid dynamics, the pressure gradients of the distension media, and the physiological effects of the media are mandatory and help to minimize complications such as fluid overload. A vigilant anesthetist and nursing staff are required to keep a close watch on the total inflow and outflow of the fluid.
The clinical assistant evaluated the actual incidence of complications in endoscopic surgery, and management and preventive measures were suggested. Out of 3204 cases of endoscopic surgery, done over four years and six months, the total number of significant complications were in nine cases, that is, <0.3%. The significant complications by a clinical assistant in laparoscopic surgeries were 0.57% and in hysteroscopic surgeries were 0.92%. The significant complications by an experienced endoscopic surgeon were 0.2% and hysteroscopic surgeries were also 0.2%. There was a marginal difference in the complication rate between the assistant having more than three years experience in this field and an experienced endoscopic surgeon with more than ten years of experience in endoscopy. The learning curve of the present group of endoscopists has been made acceptable by the foundation laid by pioneers in India and by international teachers.
In moments of complications or crisis, proper teamwork is necessary. In the event of a complication, a quick decision to perform an open surgery reduces the patient's morbidity.
Similar to any surgery, if you believe in results, you can have complications as well. Endoscopic surgery can be minimally invasive in the hands of skilled dedicated gynecologists, but could be maximally traumatic in the hands of an inexperienced, overenthusiastic, and sporadically careless surgeon.
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