video laparoscopy complication

  1. Want to know how many times in your institution has the first inserted trocar nicked the aorta? I would like to know because it happened in our institution today and I heard that it had happened once before....it is a tragic thing when it happens...it's just that the surgeon who was operating didn't realize right away that she punctured the aorta....she thought that she was having some reaction to the anesthesia so they didn't just convert right away....the patient is now in intensiv e critical care
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  2. 21 Comments

  3. by   shodobe
    Not once during the past 7-8 years of doing scope procedures. We do alot of Lap Choles and have never had a complications due to trocar placements. mike
  4. by   akor
    Quote from shodobe
    Not once during the past 7-8 years of doing scope procedures. We do alot of Lap Choles and have never had a complications due to trocar placements. mike
    That's SO nice to hear...it is a real tragedy when it happens...I just kept on thinking throughout the day of that woman's family members and it's effect on them....I work with a nurse who had that happen to her mother....she did not work in the operating room at the time but she was a nurse on tha floor and she was in the operating room accompaning her. Her mother died of that complication . Now she is an excellent O.R. nurse...

    Here in my institution the attending doc was written as the first operator but was not there at the time it happened...he was operating in the room I was in...Alyce
  5. by   grimmy
    [font=book antiqua]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.
  6. by   suzanne4
    Have never seen it in any of the facilities that I have worked at over the years............
  7. by   stevierae
    I've seen it happen once. It was probably 15 years ago, and it was a quick and routine GYN procedure--I believe a lap tubal. The surgeon was using a technique that some other GYN docs were also playing around with at the time---it involved NOT insufflating the abdomen at the time of the initial "stick" with a Verres needle, and, in fact, using the large trocar INSTEAD of a Verres needle. This patient was probably too thin to have a lot of margin for error; therefore was probably not the best candidate for this technique. I haven't seen any docs use that technique in many years. The patient did fine. You just have to be aware that it can happen and have a knife, major set, a major vascular set, vascular suture (bring the vascular cart in the room) suction, cautery, lots of laps at the ready--and set up the cell saver and call for blood to be typed and crossed STAT. Put in a call to the vascular surgeon on call. Lots of excitement initially, but it's no different than any other unexpected arterial bleed or major trauma--once the aorta is cross clamped, everybody can relax while the hole is repaired.

    Actually, come to think of it, I have seen it happen twice--once when I was in the Navy--clear back in '75-also on a laparoscopic GYN procedure, which is all we were doing laparoscopically in those days. That was before we were using video, and all our trocars were non-disposable. Probably too much force exerted with a dull trocar. Blood "spurted" out of the trcoar sleeve once the trocar was removed--everybody recognized that it was arterial blood, by the "spurting" and moved accordingly, as described above. When you see spurting arterial blood from the abdomen, (it "spurts" in synch with each heartbeat, of course) you assume the worst, and the obvious--aorta.

    I wonder why the surgeon the o.p. referenced did not recognize that there was an arterial puncture--the video screen should have been immediately obliterated by a sea of bright red (arterial blood,) and suction and irrigation would not have cleared it.

    I could see where he or she attributed the profound hypotension which I am certain resulted to "reaction to anesthesia" (vasovagal) perhaps, but, putting the patient into Trendelenberg and hyperventilating the patient, increasing the rate of IV fluids and possibly a dose of Ephedrine would have reversed that problem, (since the problem WASN'T vasovagal, however, it wouldn't have)---but I am certain anesthesia must have recognized that the problem was an iatrogenic hemorrhage, not a "reaction to anesthesia."
    Last edit by stevierae on Apr 14, '05
  8. by   akor
    Quote from stevierae
    I've seen it happen once. It was probably 15 years ago, and it was a quick and routine GYN procedure--I believe a lap tubal. The surgeon was using a technique that some other GYN docs were also playing around with at the time---it involved NOT insufflating the abdomen at the time of the initial "stick" with a Verres needle, and, in fact, using the large trocar INSTEAD of a Verres needle. This patient was probably too thin to have a lot of margin for error; therefore was probably not the best candidate for this technique. I haven't seen any docs use that technique in many years. The patient did fine. You just have to be aware that it can happen and have a knife, major set, a major vascular set, vascular suture (bring the vascular cart in the room) suction, cautery, lots of laps at the ready--and set up the cell saver and call for blood to be typed and crossed STAT. Put in a call to the vascular surgeon on call. Lots of excitement initially, but it's no different than any other unexpected arterial bleed or major trauma--once the aorta is cross clamped, everybody can relax while the hole is repaired.

    Actually, come to think of it, I have seen it happen twice--once when I was in the Navy--clear back in '75-also on a laparoscopic GYN procedure, which is all we were doing laparoscopically in those days. That was before we were using video, and all our trocars were non-disposable. Probably too much force exerted with a dull trocar. Blood "spurted" out of the trcoar sleeve once the trocar was removed--everybody recognized that it was arterial blood, by the "spurting" and moved accordingly, as described above. When you see spurting arterial blood from the abdomen, (it "spurts" in synch with each heartbeat, of course) you assume the worst, and the obvious--aorta.

    I wonder why the surgeon the o.p. referenced did not recognize that there was an arterial puncture--the video screen should have been immediately obliterated by a sea of bright red (arterial blood,) and suction and irrigation would not have cleared it.

    I could see where he or she attributed the profound hypotension which I am certain resulted to "reaction to anesthesia" (vasovagal) perhaps, but, putting the patient into Trendelenberg and hyperventilating the patient, increasing the rate of IV fluids and possibly a dose of Ephedrine would have reversed that problem, (since the problem WASN'T vasovagal, however, it wouldn't have)---but I am certain anesthesia must have recognized that the problem was an iatrogenic hemorrhage, not a "reaction to anesthesia."
    Thanks for sharing your experience...I will be aware of where the vascular trays are the next time I am in one of those Videolap surgeries....the doc's weren't aware of the intial hemorrhaging because they didn't continue the surgery:after the initial blind trocar through the umbilica...they stopped the surgery to do BLS....heart massage...the surgeons realized it was an arterial problem when the hemogas analysis came back with a hemoglobin of 4 or something like that.....they opened her up immediately...but it was after a good 6 or 7 minutes.....I hear that they have extubated her and she seems to be fine neurologically....thank you for letting me know that it can be handled calmly because I heard there was much tension and yelling in the room at the time. ( I was not in the room but did walk in once. ) The scrub nurse had to ask for a second scrub nurse because of the yelling and tension to have everything right there in less then a second....
  9. by   Marie_LPN, RN
    The only thing that's happened in the past 12 years was a perforated uterus, and that happened almost a year ago. The pt. was opened and the perforation was stitched. The surgeon was since banned from the hospital, not for that specifically, but for the mistakes she made and the way she treated the staff.
  10. by   stevierae
    Quote from akor
    Thanks for sharing your experience...I will be aware of where the vascular trays are the next time I am in one of those Videolap surgeries....the doc's weren't aware of the intial hemorrhaging because they didn't continue the surgery:after the initial blind trocar through the umbilica...they stopped the surgery to do BLS....heart massage...the surgeons realized it was an arterial problem when the hemogas analysis came back with a hemoglobin of 4 or something like that.....they opened her up immediately...but it was after a good 6 or 7 minutes.....I hear that they have extubated her and she seems to be fine neurologically....thank you for letting me know that it can be handled calmly because I heard there was much tension and yelling in the room at the time. ( I was not in the room but did walk in once. ) The scrub nurse had to ask for a second scrub nurse because of the yelling and tension to have everything right there in less then a second....
    In this day and age, it really SHOULDN'T happen if the surgeons have insufflated properly and put in enough gas, and then watched their landmarks carefully on the video screen while inserting the larger trocar. Still, one can never be too careful, so it is indeed prudent to always have at least a major set, cautery, and plenty of laps at the ready, just in case one needs to convert to an "open" emergently. Then call out and ask for an extra pair of hands to bring in the vascular cart, vascular instruments, and set up the cell saver. You don't need to set up the actual machine--just set up your bag of Heparinized NS and the tubing that goes to the field, and hook it to your bag, collection cannister and suction. The desk can call for the cell saver tech, or whoever you use, to come and spin down and give back the collected blood as enough collects. Just worry about collecting as much as you can--as well as staying ahead on banked blood, possibly Hespan, and crystalloid.

    You are more likely to see inadvertent intraop hemorrhage on a lap Nissen these days. Splenic laceration is a known complication of this procedure, and it happens probably far more frequently then it should--particularly in people who have adhesions from previous surgeries (i.e., lap choles.) It often happens when those unskilled with a harmonic scalpel get too aggressive while attempting to use it to take down the short gastrics. In that case, you may need to rapidly convert to an open as well, and you may need to do an emergency open splenectomy. A good thing to have available for this type of case is the Argon Beam Coagulator--it can often cauterize splenic bleeders, if the laceration is not too severe, and allow for a splenorrhaphy, instead of having to do a splenectomy just because the rapid blood loss is obliterating the surgical field and compromising the patient's hemodynamic status.
    Last edit by stevierae on Apr 16, '05
  11. by   akor
    Quote from Marie_LPN
    The only thing that's happened in the past 12 years was a perforated uterus, and that happened almost a year ago. The pt. was opened and the perforation was stitched. The surgeon was since banned from the hospital, not for that specifically, but for the mistakes she made and the way she treated the staff.

    Here in Italy I don't think the surgeon can get kicked out so easily...I believe there will be a big lawsuit and she will be a bit more humblier.....
    Thanks for your reply.....
  12. by   Marie_LPN, RN
    She made a LOT of mistakes, way too many to ignore.
  13. by   akor
    Quote from stevierae
    In this day and age, it really SHOULDN'T happen if the surgeons have insufflated properly and put in enough gas, and then watched their landmarks carefully on the video screen while inserting the larger trocar. Still, one can never be too careful, so it is indeed prudent to always have at least a major set, cautery, and plenty of laps at the ready, just in case one needs to convert to an "open" emergently. Then call out and ask for an extra pair of hands to bring in the vascular cart, vascular instruments, and set up the cell saver. You don't need to set up the actual machine--just set up your bag of Heparinized NS and the tubing that goes to the field, and hook it to your bag, collection cannister and suction. The desk can call for the cell saver tech, or whoever you use, to come and spin down and give back the collected blood as enough collects. Just worry about collecting as much as you can--as well as staying ahead on banked blood, possibly Hespan, and crystalloid.

    You are more likely to see inadvertent intraop hemorrhage on a lap Nissen these days. Splenic laceration is a known complication of this procedure, and it happens probably far more frequently then it should--particularly in people who have adhesions from previous surgeries (i.e., lap choles.) It often happens when those unskilled with a harmonic scalpel get too aggressive while attempting to use it to take down the short gastrics. In that case, you may need to rapidly convert to an open as well, and you may need to do an emergency open splenectomy. A good thing to have available for this type of case is the Argon Beam Coagulator--it can often cauterize splenic bleeders, if the laceration is not too severe, and allow for a splenorrhaphy, instead of having to do a splenectomy just because the rapid blood loss is obliterating the surgical field and compromising the patient's hemodynamic status.
    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....
  14. by   stevierae
    Quote from akor
    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.
    Last edit by stevierae on Apr 17, '05

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