video laparoscopy complication

stevierae · Apr 17, 2005

I appreciate your detailed info....I have been out of the O.R. for 12 years and am busting my brain to keep up with all the procedures and materials. There is really no official training program....it is a sink or swim type of thing. We DO do video Nissen surgery and it is the attending doc who does it....so far so good... Thanks for the info on the splenic hemorrhage complication... I will know where the Argon Laser is when I am present....

NO--NOT the Argon Laser--that's an different device---(unless that's what you call your Argon Beam Coagulator, which is a type of cautery.) It has its own ground pads, hand held cautery units (one of which directs a beam of Argon gas directly onto a bleeder) etc. You can also connect a regular hand held cautery to it, and it only requires a single ground pad, even though you are using 2 hand held cauteries.

The Argon Beam Coagulator ALSO makes a handpiece to use during laparoscopic procedures. If you do this, make CERTAIN that you switch the Argon flow from "automatic" to "manual," start with a low flow rate, (ask the rep what he recommends) and make certain that all ports connected to the patient are VENTED---otherwise, you run the very real risk of filling the patient's abdomen with both CO2 from the insufflator and a possibly uncontrolled amount of Argon, both of which can't escape unless there are ports open to vent. The result can be a ruptured diaphragm, which has also occurred. This is a true surgical emergency.

Of course, any time one is doing laparoscopy, there must be at least one port open to vent, otherwise the CO2 can't escape. Don't depend on the alarms on the insufflator to tell you that intraabdominal pressure is too high--sometimes they fail.

Anybody using the Argon Beam Coagulator should make absolutely certain that he or she has had a thorough inservice about the device, and understands it completely. Always be cognizant of the fact that there are 2 flow rates--automatic and manual---and know when each is indicated.

shodobe · Apr 18, 2005

Who uses lasers for any Lap procedure anymore? We haven't even considered it since day one waaaaay back when we first started Lap procedures. Patients still ask if the procedure is going to done using a Laser, we just tell them no. Does anybody still do these procedures using a Laser? Just kind of curious. Mike

stevierae · Apr 18, 2005

Who uses lasers for any Lap procedure anymore? We haven't even considered it since day one waaaaay back when we first started Lap procedures. Patients still ask if the procedure is going to done using a Laser, we just tell them no. Does anybody still do these procedures using a Laser? Just kind of curious. Mike

I have never seen a laparoscopic procedure done using laser. Come to think of it, the only procedures I've ever been involved in using laser were vaporization of condyloma accuminata, and various intracranial surgeries--I think for vaporization of tumors. However, the CUSA has largely taken over for that purpose.

But, people often--all the time, in fact--- call the Argon Beam Coagulator the "argon laser" by mistake. We use the Argon Beam Coagulator (ABC) routinely on thoracoscopic wedge resections and very often on lap Nissens---it's a very, very efficient way to control bleeding and ensure a dry field---and subsequent good visualization on the video screen. It's virtually smoke free, and the beam can be directed at the bleeder in a very controlled fashion, zapping it instantaneously.

akor · Apr 18, 2005

NO--NOT the Argon Laser--that's an different device---(unless that's what you call your Argon Beam Coagulator, which is a type of cautery.) It has its own ground pads, hand held cautery units (one of which directs a beam of Argon gas directly onto a bleeder) etc. You can also connect a regular hand held cautery to it, and it only requires a single ground pad, even though you are using 2 hand held cauteries.
The Argon Beam Coagulator ALSO makes a handpiece to use during laparoscopic procedures. If you do this, make CERTAIN that you switch the Argon flow from "automatic" to "manual," start with a low flow rate, (ask the rep what he recommends) and make certain that all ports connected to the patient are VENTED---otherwise, you run the very real risk of filling the patient's abdomen with both CO2 from the insufflator and a possibly uncontrolled amount of Argon, both of which can't escape unless there are ports open to vent. The result can be a ruptured diaphragm, which has also occurred. This is a true surgical emergency.
Of course, any time one is doing laparoscopy, there must be at least one port open to vent, otherwise the CO2 can't escape. Don't depend on the alarms on the insufflator to tell you that intraabdominal pressure is too high--sometimes they fail.
Anybody using the Argon Beam Coagulator should make absolutely certain that he or she has had a thorough inservice about the device, and understands it completely. Always be cognizant of the fact that there are 2 flow rates--automatic and manual---and know when each is indicated.

Your great!!! I love explanations.... It has happened that we have had to convert because the patient's CO2 expired ventilation is way to high. I would have never even thought of a ruptured diaphragm. I will not count on the alarms to go off first before the intraabdominal pressure is too high....We have had also subcutaneous emphysema happen in the chest area.....that was when we were doing a video left colon resection and the patient is Trendelenburg position for a couple of hours. I will definitely be aware of the Argon laser versus Argon Beam coagulator....we do not use it too often however I think I saw the laser in one open procedure on the liver maybe....have to get it straight....THANKS a million....

stevierae · Apr 18, 2005

Your great!!! I love explanations.... It has happened that we have had to convert because the patient's CO2 expired ventilation is way to high. I would have never even thought of a ruptured diaphragm. I will not count on the alarms to go off first before the intraabdominal pressure is too high....We have had also subcutaneous emphysema happen in the chest area.....that was when we were doing a video left colon resection and the patient is Trendelenburg position for a couple of hours. I will definitely be aware of the Argon laser versus Argon Beam coagulator....we do not use it too often however I think I saw the laser in one open procedure on the liver maybe....have to get it straight....THANKS a million....

Sure. Anytime you see subcutaneous emphysema, there is generally a pneumothorax. Need to get a chest tube in right away, and hook it to Pleurevac, if taking the patient immediately out of Trendelenberg does not help-- often, switching from Trendelenberg back to supine will quickly simply dissipate the sub-q emphysema into the abdomen and even the scrotum or vulva. If anyone doubts that what they are seeing is a pneumo, (the patient's skin will look and feel like bubble wrap) tell them to quickly insert a 14 or 16 G IV catheter quickly between 2 ribs, up at the level of the nipple (can't recall which intercostal space that is, by number.) If there is a pneumo, they will hear and feel air. The patient needs a chest tube, right away. Grab a trocar chest tube, Pleurevac, suction tubing, and fluid with which to fill the Pleurevac water seal chamber.

This type of tension pneumothorax, if not quickly relieved, will cause the patient to deteriorate into PEA---pulseless electrical activity. Relieve the cause of the PEA--that is, the tension pneumo--and you will quickly convert the patient back into NSR. Stand around wondering what the problem is, and the patient will deteriorate into a lethal dysrhythmia--often VT followed by Vfib, unresonsive to shock. Don't let that happen. Always, of course, remember airway, first and foremost! Fortunately, in the OR, PEA occurs AFTER the patient has already been intubated, so at least his airway is secure.

I am thinking you more likely saw the Argon Beam Coagulator used on a liver resection. It is very, very commonly used on cases involving liver trauma (lacerations, lobectomies) and also on liver transplants. It is truly a godsend in today's operating room. In the '80s, we had to depend on pledgets sewed directly to the surface of the liver, and tons and tons of Avitene, to control oozing. Nowadays, a simple directed arc of Argon zaps the bleeders and provides instant visualization.

You probably converted to open on the case you described well before the diaphragm ruptured (or in the nick of time.) When this happens, (I am only aware of it happening once at a hospital where I worked long ago; not in my room; patient survived due to quick thinking and highly skilled surgeon) it can be seen on the video screen; often the patient arrests, and the surgeon may need to do an ememrgency sternotomy and possibly do open chest cardiac massage and/or apply defib paddles directly to the heart.

Just remind everybody to keep ports open to vent, on any laparoscopy, and that's a tragedy you can most likely avoid in your career.

liveintheOR · Apr 19, 2005

I have never seen the aorta punctured with a trocar. However, I have seen the iliac artery punctured while doing a laparoscopic appy on an eight yr. old. The surgeon was new to our facility and we had used his partners preference card to set up the case--as an open appy. The surgeon comes in and insists that our setup be changed to laparoscopic. He had told the patient's mother that he would not make an incision, just a couple of small punctures and about 20 minutes!! I explained to her that in any laparoscopic case that there was always the possibility of having a incision. She insisted that the doctor promised her that he would not make an incision. Long story short, he punctured the iliac artery with a 5mm trocar. Blamed us for having lousy equipment. Of course he ended up with a large incision, came back a week later with a huge abcess ( the appendix had ruptured), had to be packed open. The surgeon even bragged after the case how good he was at sewing the artery --- he does not, thank God, have vascular priviledges. What a mess!! I still worry about a lawsuit on that one.

One surgeon in our hospital uses KTP laser for cholecystectomies--always.

Don't know why. It's a pain in the backside. Can't see worth a darn with those dark laser glasses on. The surgeon of course won't wear the glasses.

stevierae · Apr 19, 2005

The surgeon even bragged after the case how good he was at sewing the artery --- he does not, thank God, have vascular priviledges. What a mess!! I still worry about a lawsuit on that one.

No kidding! What a prima donna and jerk this surgeon sounds like---must be a legend in his own mind. Even the very best, most experienced general surgeons are not afraid to admit they are in over their heads when something like this occurs. I've worked with some of the best general surgeons in the country--but if one of them sees, say, a chocolate cyst while he is in the abdomen doing some other procedure, he's not afraid to call for a GYN surgeon to consult, scrub in, and take over resecting the cyst--or, alternately, let the GYN surgeon make the decision to leave it alone. Likewise, if one of them was, God forbid, to inadvertently nick an artery, they'd count on one of us to immediately put in a call to the vascular guy on call--they know they don't even have to ask. They want the best patient care for their patient, and they want it delivered in the most expeditious way possible---not by themselves, who, albeit accidentally, caused the probelm, and really should not be attempting to fix it.

You say this surgon does not have vascular privileges--why, then, was he even allowed to repair the iliac artery--on a pediatric patient, yet? I think I would have gotten the desk involved--and, if they were reluctant to take a stand, I think I would have stepped out of the room and called the vascular surgeon on call and asked him to "stop by." I am betting this guy will not last long at your facility--he is probably destined to make similar future mistakes.

mcmike55 · Apr 21, 2005

We've been doing laparoscopies at our hospital, wow, I guess nearly 10 years, I think. Starting with a lens, and the surgeon looking thru it, they were the only ones that could see!!!! And then we would open, because there wasn't much in equipment to work with.

Most of our guys now do cut downs for the first trocar, inflate thru that and watch the other trocars in under direct visualization.

We've had one vascular hit that I can remember. And it wasn't too long ago.

The surgeon, quite good, hit an Iliac trying to do one of our first scope hernia repairs. Anes. doc, right on the ball, sensed something was wrong as soon as the trocar went in. We have a general emergency cart in the hall, ready to go in a snap. Scared the cra* out of us, but a good outcome.

Did hear of a GYN hitting the aorta during a tubal. They were at a free standing center, one that was not getting along with the local hospital from what I heard. Some problems, but I think they saved her.

As far as the ABC. I love that unit!!!! We don't use it that much, which is good I guess. You are right on with your advice. When using it thru the scope you have to turn the ABC gas flow to manual and low. Other wise you'll run the risk of over distention. Active venting is good too. If using the ABC a lot, just turn a port open just slightly.

Mike

shodobe · Apr 24, 2005

Guess what! Yesterday on call we did an exp lap for a perforated bowel due to a misplaced veres needle! This 25 year old was sick, sick, sick! She had a Lap tubal at another facility across town last week. She stared to have abdominal pain, high temp and nauseated. The other surgeon put her on antibiotics and sent her home. She went to him on Friday and he put her on Vicodin and sent her on her way! Yesterday she ended up in our ED a surgeon was called in and promptly suggested an ex lap to see what was wrong. He found a nice hole spilling junk into the abdomen. I hope this other guy has some good malpractice, he will need it.

akor · Apr 25, 2005

how did she place the trochar? did they use a veres needle or something else? i've never seen this happen. i have heard of an occasion where the aorta was compressed accidentally by a liver retractor (yanno, that viagra retractor)...but there are bladeless trochars...seems odd.

sorry replying so late....but i think they used a verres needle (they usually use a verres needle in this division) . i heard that when the trocar was going in through her umbilcal, her hand slipped where she was pulling up the skin...sometimes they use a clamp to hold up the skin and fascia while inserting the first trocar.....something like that....