Operative problems

Operative problems

Intraoperative perforation of a viscus or vascular injury Perforation of any viscus, such as bowel, is a potential hazard that may occur inadvertently and go unrecognised or be of a severity that may require emergency conversion. The added time required for this to take place may result in increased blood loss and haemodynamic instability that would not have occurred should the same injury have occurred in an open setting. With surgical experience, education, preparation and patient selection many of these emergencies and their resultant complications can be avoided. It is vital for the surgical team to both recognise its own limitations and continually reflect throughout the procedure on the surgical progress and oper ative di ffi culty . Bleeding Bleeding is the most common cause of conversion to open surgery . The impact of light absorption is particularly import ant in robotic surgery , and regular haemostasis is paramount to facilitate dissection and surgical progress. Risk factors that predispose to increased bleeding include: /uni25CF liver disease impacting on the production of vitamin K-dependent clotting factors, e.g. cirrhosis, autoimmune liver disease; /uni25CF inflammatory conditions (acute cholecystitis, diverticulitis); /uni25CF patients on anticoagulants; /uni25CF coagulation defects: these may be contraindications to both open and minimal access surgery and require thorough dis cussion with haematology colleagues to determine, where possible, how to optimise the patient for surgery . Damage to a large vessel requires immediate assessment of the magnitude and type of bleeding. It is paramount that as soon as b leeding is identified this is communicated clearly to all members of the theatre and anaesthetic team. There should be a relatively lo w threshold for early conversion; however, this will depend on the expertise of the operating team. It is per tinent to achieve early control by whatever means necessary . trol may be achieved by clipping, stapling or use of an energy device, depending on vessel size. Occasionally suturing may be possible; however, this may be significantly more complex - via a minimal access approac h. When the vessel is not identi - fied, compression should be applied immediately with a blunt instrument, a cotton swab or with the adjacent organ. Good suction and irrigation are of utmost importance. Once the area has been cleaned, pressure should be released gradually y to identify the site of bleeding. Insertion of an e xtra port may - be required. There should be no delay in converting to an open procedure when necessary . This is of particular importance in robotic surgery as some or all of the robotic arms may need to be urgently undocked to facilitate the surgeon gaining bedside - access to the patient. The bedside assistant should be confident to perform this process. It is sometimes appropriate for a single robotic arm to be left in place to help maintain pressure on the bleeding vessel while direct access is achieved. Alternatively , pressure may be maintained via an assistant port (if present), allowing the robot to be undocked completely and removed from the surgical field. Bleeding from organs encountered during surgery Excessive retraction can tear a visceral surface, resulting in bleeding. This is particularly so in robotic surgery , where instrument graspers have a small surface area, increasing the potential for injury to retracted tissue. Here rolled swabs may be inserted into the surgical field and held within the grasper, producing a larger surface for retraction and reducing ® tissue injury . Surgicel (absorbable fibrillar oxidised cellulose polymer) or other clot-promoting strips, tissue glues or other haemostatic agents may also be used to aid haemostasis, e.g. from the gallbladder bed during cholecystectomy . - Bleeding from a trocar site Bleeding from the trocar sites is usually treated by localised diathermy or applying upwards and lateral pressure with the trocar itself. Considerable bleeding may occur if a vessel - such as the inferior epigastric or intercostal artery is injured. Haemostasis can be accomplished either by pressure or by suturing the bleeding site. Devices such as the EndoClose™ may also be used to apply transabdominal sutures under direct laparoscopic view to close port sites that bleed. When a bleeding vessel cannot be easily identified, mass ligation of the vessel around the port site can be performed. This manoeuvre is accomplished by extending the skin incision by 3 /uni00A0 mm at both ends of the bleeding trocar site w ound. Two figure-of-eight sutures are placed in the path of the vessel at both ends of the wound ( Figure 10.5 ). Alternatively , pressure - can be applied using a Foley balloon catheter. The catheter is introduced into the abdominal cavity through the bleeding trocar site wound, the balloon is inflated and traction is placed on the catheter, which is bolstered in place to keep it under ten - sion. T he catheter is left in situ for 24 hours and then removed. If significant continuous bleeding from the falciform lig - ament occurs, haemostasis is achieved by percutaneously inserting a large, straight needle at one side of the ligament. - A monofilament suture attached to the needle is passed into the abdominal cavity and the needle is exited at the other side compression is achieved. Maintaining compression throughout the procedure usually su ffi ces. After the procedure has been completed, the loop is removed under direct laparoscopic visu alisation to ensure complete haemostasis. Evacuation of blood clots Careful haemostasis is important as even small, localised pools of blood or clot absorb light and can significantly impair the surgical view . Carefully directed suction is usually su ffi cient in open cases; however, suction may be problematic in laparo scopic and robotic procedures that are reliant on carbon diox ide insu ffl ation to maintain the surgical field. It is important that suction is applied below a fluid level, or, if used in the operative field, only in short bursts as required. Should tissue be inadvertently sucked into the end of the suction device, the tubing can be kinked to allow the tissue to dr op away before removing. Rolled swabs or sponges can be used to remove blood from the surgical field without need for suction ( Figure 10.6 These can also be used for gentle retraction, minimising tissue damage and thus further reducing blood loss. Such swabs may be inserted and removed via a 15-mm assistant port or in some cases a 12-mm robotic trocar with the port cap r emoved. Care should be taken to avoid carbon dioxide loss during extraction. Finally , the surgeon may choose to use a specially designed robotic sucker that integrates with the robotic system. Alterna tively , non-wristed suction can be provided via an assistant port if included in the operative set-up. Operative problems

Intraoperative perforation of a viscus or vascular injury Perforation of any viscus, such as bowel, is a potential hazard that may occur inadvertently and go unrecognised or be of a severity that may require emergency conversion. The added time required for this to take place may result in increased blood loss and haemodynamic instability that would not have occurred should the same injury have occurred in an open setting. With surgical experience, education, preparation and patient selection many of these emergencies and their resultant complications can be avoided. It is vital for the surgical team to both recognise its own limitations and continually reflect throughout the procedure on the surgical progress and oper ative di ffi culty . Bleeding Bleeding is the most common cause of conversion to open surgery . The impact of light absorption is particularly import ant in robotic surgery , and regular haemostasis is paramount to facilitate dissection and surgical progress. Risk factors that predispose to increased bleeding include: /uni25CF liver disease impacting on the production of vitamin K-dependent clotting factors, e.g. cirrhosis, autoimmune liver disease; /uni25CF inflammatory conditions (acute cholecystitis, diverticulitis); /uni25CF patients on anticoagulants; /uni25CF coagulation defects: these may be contraindications to both open and minimal access surgery and require thorough dis cussion with haematology colleagues to determine, where possible, how to optimise the patient for surgery . Damage to a large vessel requires immediate assessment of the magnitude and type of bleeding. It is paramount that as soon as b leeding is identified this is communicated clearly to all members of the theatre and anaesthetic team. There should be a relatively lo w threshold for early conversion; however, this will depend on the expertise of the operating team. It is per tinent to achieve early control by whatever means necessary . trol may be achieved by clipping, stapling or use of an energy device, depending on vessel size. Occasionally suturing may be possible; however, this may be significantly more complex - via a minimal access approac h. When the vessel is not identi - fied, compression should be applied immediately with a blunt instrument, a cotton swab or with the adjacent organ. Good suction and irrigation are of utmost importance. Once the area has been cleaned, pressure should be released gradually y to identify the site of bleeding. Insertion of an e xtra port may - be required. There should be no delay in converting to an open procedure when necessary . This is of particular importance in robotic surgery as some or all of the robotic arms may need to be urgently undocked to facilitate the surgeon gaining bedside - access to the patient. The bedside assistant should be confident to perform this process. It is sometimes appropriate for a single robotic arm to be left in place to help maintain pressure on the bleeding vessel while direct access is achieved. Alternatively , pressure may be maintained via an assistant port (if present), allowing the robot to be undocked completely and removed from the surgical field. Bleeding from organs encountered during surgery Excessive retraction can tear a visceral surface, resulting in bleeding. This is particularly so in robotic surgery , where instrument graspers have a small surface area, increasing the potential for injury to retracted tissue. Here rolled swabs may be inserted into the surgical field and held within the grasper, producing a larger surface for retraction and reducing ® tissue injury . Surgicel (absorbable fibrillar oxidised cellulose polymer) or other clot-promoting strips, tissue glues or other haemostatic agents may also be used to aid haemostasis, e.g. from the gallbladder bed during cholecystectomy . - Bleeding from a trocar site Bleeding from the trocar sites is usually treated by localised diathermy or applying upwards and lateral pressure with the trocar itself. Considerable bleeding may occur if a vessel - such as the inferior epigastric or intercostal artery is injured. Haemostasis can be accomplished either by pressure or by suturing the bleeding site. Devices such as the EndoClose™ may also be used to apply transabdominal sutures under direct laparoscopic view to close port sites that bleed. When a bleeding vessel cannot be easily identified, mass ligation of the vessel around the port site can be performed. This manoeuvre is accomplished by extending the skin incision by 3 /uni00A0 mm at both ends of the bleeding trocar site w ound. Two figure-of-eight sutures are placed in the path of the vessel at both ends of the wound ( Figure 10.5 ). Alternatively , pressure - can be applied using a Foley balloon catheter. The catheter is introduced into the abdominal cavity through the bleeding trocar site wound, the balloon is inflated and traction is placed on the catheter, which is bolstered in place to keep it under ten - sion. T he catheter is left in situ for 24 hours and then removed. If significant continuous bleeding from the falciform lig - ament occurs, haemostasis is achieved by percutaneously inserting a large, straight needle at one side of the ligament. - A monofilament suture attached to the needle is passed into the abdominal cavity and the needle is exited at the other side compression is achieved. Maintaining compression throughout the procedure usually su ffi ces. After the procedure has been completed, the loop is removed under direct laparoscopic visu alisation to ensure complete haemostasis. Evacuation of blood clots Careful haemostasis is important as even small, localised pools of blood or clot absorb light and can significantly impair the surgical view . Carefully directed suction is usually su ffi cient in open cases; however, suction may be problematic in laparo scopic and robotic procedures that are reliant on carbon diox ide insu ffl ation to maintain the surgical field. It is important that suction is applied below a fluid level, or, if used in the operative field, only in short bursts as required. Should tissue be inadvertently sucked into the end of the suction device, the tubing can be kinked to allow the tissue to dr op away before removing. Rolled swabs or sponges can be used to remove blood from the surgical field without need for suction ( Figure 10.6 These can also be used for gentle retraction, minimising tissue damage and thus further reducing blood loss. Such swabs may be inserted and removed via a 15-mm assistant port or in some cases a 12-mm robotic trocar with the port cap r emoved. Care should be taken to avoid carbon dioxide loss during extraction. Finally , the surgeon may choose to use a specially designed robotic sucker that integrates with the robotic system. Alterna tively , non-wristed suction can be provided via an assistant port if included in the operative set-up. Operative problems

Intraoperative perforation of a viscus or vascular injury Perforation of any viscus, such as bowel, is a potential hazard that may occur inadvertently and go unrecognised or be of a severity that may require emergency conversion. The added time required for this to take place may result in increased blood loss and haemodynamic instability that would not have occurred should the same injury have occurred in an open setting. With surgical experience, education, preparation and patient selection many of these emergencies and their resultant complications can be avoided. It is vital for the surgical team to both recognise its own limitations and continually reflect throughout the procedure on the surgical progress and oper ative di ffi culty . Bleeding Bleeding is the most common cause of conversion to open surgery . The impact of light absorption is particularly import ant in robotic surgery , and regular haemostasis is paramount to facilitate dissection and surgical progress. Risk factors that predispose to increased bleeding include: /uni25CF liver disease impacting on the production of vitamin K-dependent clotting factors, e.g. cirrhosis, autoimmune liver disease; /uni25CF inflammatory conditions (acute cholecystitis, diverticulitis); /uni25CF patients on anticoagulants; /uni25CF coagulation defects: these may be contraindications to both open and minimal access surgery and require thorough dis cussion with haematology colleagues to determine, where possible, how to optimise the patient for surgery . Damage to a large vessel requires immediate assessment of the magnitude and type of bleeding. It is paramount that as soon as b leeding is identified this is communicated clearly to all members of the theatre and anaesthetic team. There should be a relatively lo w threshold for early conversion; however, this will depend on the expertise of the operating team. It is per tinent to achieve early control by whatever means necessary . trol may be achieved by clipping, stapling or use of an energy device, depending on vessel size. Occasionally suturing may be possible; however, this may be significantly more complex - via a minimal access approac h. When the vessel is not identi - fied, compression should be applied immediately with a blunt instrument, a cotton swab or with the adjacent organ. Good suction and irrigation are of utmost importance. Once the area has been cleaned, pressure should be released gradually y to identify the site of bleeding. Insertion of an e xtra port may - be required. There should be no delay in converting to an open procedure when necessary . This is of particular importance in robotic surgery as some or all of the robotic arms may need to be urgently undocked to facilitate the surgeon gaining bedside - access to the patient. The bedside assistant should be confident to perform this process. It is sometimes appropriate for a single robotic arm to be left in place to help maintain pressure on the bleeding vessel while direct access is achieved. Alternatively , pressure may be maintained via an assistant port (if present), allowing the robot to be undocked completely and removed from the surgical field. Bleeding from organs encountered during surgery Excessive retraction can tear a visceral surface, resulting in bleeding. This is particularly so in robotic surgery , where instrument graspers have a small surface area, increasing the potential for injury to retracted tissue. Here rolled swabs may be inserted into the surgical field and held within the grasper, producing a larger surface for retraction and reducing ® tissue injury . Surgicel (absorbable fibrillar oxidised cellulose polymer) or other clot-promoting strips, tissue glues or other haemostatic agents may also be used to aid haemostasis, e.g. from the gallbladder bed during cholecystectomy . - Bleeding from a trocar site Bleeding from the trocar sites is usually treated by localised diathermy or applying upwards and lateral pressure with the trocar itself. Considerable bleeding may occur if a vessel - such as the inferior epigastric or intercostal artery is injured. Haemostasis can be accomplished either by pressure or by suturing the bleeding site. Devices such as the EndoClose™ may also be used to apply transabdominal sutures under direct laparoscopic view to close port sites that bleed. When a bleeding vessel cannot be easily identified, mass ligation of the vessel around the port site can be performed. This manoeuvre is accomplished by extending the skin incision by 3 /uni00A0 mm at both ends of the bleeding trocar site w ound. Two figure-of-eight sutures are placed in the path of the vessel at both ends of the wound ( Figure 10.5 ). Alternatively , pressure - can be applied using a Foley balloon catheter. The catheter is introduced into the abdominal cavity through the bleeding trocar site wound, the balloon is inflated and traction is placed on the catheter, which is bolstered in place to keep it under ten - sion. T he catheter is left in situ for 24 hours and then removed. If significant continuous bleeding from the falciform lig - ament occurs, haemostasis is achieved by percutaneously inserting a large, straight needle at one side of the ligament. - A monofilament suture attached to the needle is passed into the abdominal cavity and the needle is exited at the other side compression is achieved. Maintaining compression throughout the procedure usually su ffi ces. After the procedure has been completed, the loop is removed under direct laparoscopic visu alisation to ensure complete haemostasis. Evacuation of blood clots Careful haemostasis is important as even small, localised pools of blood or clot absorb light and can significantly impair the surgical view . Carefully directed suction is usually su ffi cient in open cases; however, suction may be problematic in laparo scopic and robotic procedures that are reliant on carbon diox ide insu ffl ation to maintain the surgical field. It is important that suction is applied below a fluid level, or, if used in the operative field, only in short bursts as required. Should tissue be inadvertently sucked into the end of the suction device, the tubing can be kinked to allow the tissue to dr op away before removing. Rolled swabs or sponges can be used to remove blood from the surgical field without need for suction ( Figure 10.6 These can also be used for gentle retraction, minimising tissue damage and thus further reducing blood loss. Such swabs may be inserted and removed via a 15-mm assistant port or in some cases a 12-mm robotic trocar with the port cap r emoved. Care should be taken to avoid carbon dioxide loss during extraction. Finally , the surgeon may choose to use a specially designed robotic sucker that integrates with the robotic system. Alterna tively , non-wristed suction can be provided via an assistant port if included in the operative set-up.