Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Handling Complications without Converting

MODERATOR

Mitsuru Shiota, MD

FACULTY

Eugenio Solima, MD & Thomas L. Lyons, MD

Professional Education Information   Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology.  Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.  The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.   DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As  a  provider  accredited  by  the Accreditation  Council  for  Continuing Medical  Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification  of  CME  needs,  determination  of  educational  objectives,  selection  and  presentation  of content,  selection  of  all  persons  and  organizations  that will  be  in  a  position  to  control  the  content, selection  of  educational methods,  and  evaluation  of  the  activity.  Course  chairs,  planning  committee members,  presenters,  authors, moderators,  panel members,  and  others  in  a  position  to  control  the content of this activity are required to disclose relevant financial relationships with commercial interests related  to  the subject matter of  this educational activity. Learners are able  to assess  the potential  for commercial  bias  in  information  when  complete  disclosure,  resolution  of  conflicts  of  interest,  and acknowledgment of  commercial  support are provided prior  to  the activity.  Informed  learners are  the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.   

Table of Contents 

 Course Description ........................................................................................................................................ 1  Disclosure ...................................................................................................................................................... 2  Handling Complications without Converting T.L. Lyons ....................................................................................................................................................... 3  Handling Complications without Converting E. Solima ........................................................................................................................................................ 6  Cultural and Linguistics Competency  ......................................................................................................... 14 

Surgical Tutorial 7 Handling Complications without Converting

Moderator: Mitsuru Shiota

Eugenio Solima & Thomas L. Lyons

To safely master a surgical procedure also means to master problems and difficulties that may be encountered in specific situations. Adhesions, anatomical distortions and surgeon’s fatigue may be the cause of complications. In some conditions, panic may arise and lead to an unnecessary laparotomy. Sutures, clips, coagulators and hemostatic agents can be used to manage complications when performing a laparotomy or laparoscopic surgery. Proper laparoscopic surgical technique includes a confident use of these tools, reducing the need for conversions. This course provides the participants with the knowledge needed to safely master the correct technique to avoid complications, to use the available surgical armamentarium to manage complications, and complete most of the procedures without conversion. Finally, we will discuss conditions when a conversion is mandatory. Learning Objectives: At the conclusion of this course, the participant will be able to: 1) Assess the most frequent situations that may cause GI, GU and hemorrhagic complications; 2) implement the skills to manage complications that may occur during laparoscopic surgery; and 3) recognize complications that may require laparotomy.

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Kimberly A. Kho* Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathan Solnik* Johnny Yi*

SCIENTIFIC PROGRAM COMMITTEE Ceana H. Nezhat Consultant: Ethicon Endo-Surgery, Lumenis, Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Arnold P. Advincula Consultant: Blue Endo, CooperSurgical, Covidien, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical Linda D. Bradley* Victor Gomel* Keith B. Isaacson* Grace M. Janik Grants/Research Support: Hologic Consultant: Karl Storz C.Y. Liu* Javier F. Magrina* Andrew I. Sokol* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Thomas L. Lyons Grants/Research: Olympus Consultant: Ethicon Endo-Surgery, Ethicon Women’s Health & Urology, Gynecare, Olympus, SurgiQuest Other: Royalties: CooperSurgical, Olympus, UpToDate Mitsuru Shiota* Eugenio Solima* Asterisk (*) denotes no financial relationships to disclose.

Handling Complications Without Converting

Thomas L. Lyons MS, MD, FACOG, COEMIG Center for Women’s Care & Reproductive 

SurgeryAtlanta, GA

• Grants/Research Support: Olympus 

• Consultant: Ethicon Endo‐Surgery, Ethicon Women’s Health & Urology, Gynecare, Olympus, SurgiQuest 

• Other: Royalties: CooperSurgical, Olympus, UpToDate

• 1) Assess the most frequent situations that may cause GI, GU and hemorrhagic complications 

• 2) implement the skills to manage complications that may occur during laparoscopic surgery.  

• 3) recognize complications that may require laparotomy.

What complications may require conversion?

• Damage to viscera or other structures.

– GI

– GU

– Vascular

• Bleeding

• Adhesive disease

• Tissue Removal

Keys to avoiding conversion

• Preparation, preparation, preparation

– Mental 

– Mechanical

– Equipment

– Team

Mental Preparation

• Patient selection

• Pathology expected

• Experience required

– Learning curve – 75% cerebral, 25% manual

– Hard to teach judgement

3

Mechanical Preparation

• Patient positioning

Mechanical Preparation

• Trocar positioning

• Trocar placement

– The obese patient

– Robotic variables

Equipment• Hemostatic & vessel sealing devices

– Clips

– Hemostatic materials

– Sponges

• Suturing sets

• Stapling devices

• Knowledge of the use and ability to troubleshoot all equipment.

Team

• Experienced

• Established working relationship

• Group knowledge of alternatives and comfortable in continued pursuit of minimally invasive approach.

GU Damage Vaginal ‐ GI damage

4

GI damageBleeding

• Gain control

• Make a plan

• Have a backup

Adhesive disease

• Find an open area. Using an operating scope continue to create open sites until adequate adhesiolysis is accomplished. 

– THERE ARE SOME ABSOLUTES!

Tissue Removal

• Morselators

– Bipolar

– Mechanical

• Percutaneous Extraction

– Old but hasn’t failed yet!

Morselators Remember as minimally invasivesurgeons, we are are the only ones that consider laparotomy

a COMPLICATION

Let he who is without sin cast the first stone.John 8:7

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Surgical Tutorial 7

Handling Complications without Converting

Eugenio Solima

Gynecology Oncology UnitOspedale Fatebenefratelli‐Macedonio Melloni

University of Milan ‐ Italy

Neither I, nor a member of my family, have a financial interest, arrangement or affiliation with anycommercial organizations that offer support and/or participate in any of the entities

• This course provides the participants with the knowledge needed to safely master the correct technique to avoid complications

• to use the available surgical armamentarium to manage complications, and complete some of the procedures without conversion

• Discuss conditions when a conversion is mandatory

Complication

a new problem or illness that makes treatment of a previous one more complicated or difficult

Oxford English Dictionary

Laparoscopic Conversion:Is it always a complication?

• Risks of laparoscopic access

• Risks of a laparotomic access

Complications

• Preoperative

• Entry related

• Surgical

• Postoperative

6

Complications prevention: Adequate skill and  instrumentation before 

starting the procedure

• Laparoscopic view (camera, scope/s, light cable)

• Laparoscopic instrumentation 

– Clamps, needle holders, clips, atraumatic manipulation

• Laparoscopic energy delivery systems knowledge

• Laparoscopic team (surgeons, nurses, anaesthesiologists)

Most frequent causes of complications

• Adhesions

• Anatomical distortions 

• Surgeon’s fatigue 

Acta Obstet Gynecol Scand. 2012; 91:620–624.

Video

• If you do not see intraperitoneally, check the retroperitoneum! 

If you wont to go fast go slowly!

J Magrina

Complications in Gynecologic LPS Surgery

• Vascular

• GI

• GU

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Bowel lesions•Previous Surgical procedures

•PID

•Endometriosis

•Bowel Manipulations (GYN ONCO)

•Previous RT

Bowel injuries: Treatment

•Type

•Site

•Bowel segment

•Anamnesis

•General conditions

Small bowel injuries: treatment

• Adhesiolysis and adequate visualization of the lesion

• <50% circumference

• 3‐0 reabsorbable monofilament Suture

• >50% of lumen size 

• Multiple lesions

• Mesenteric vessels damage, devascularization irradiated 

• 3‐0 reabsorbable monofilament 

• Automatic suturing devices

Resection and AnastomosisSmall bowel injuries: teatment

Small bowel injuries: teatmentVIDEO

Ileostomy: When

• Previous RT

• Spillage?

• Carcinomatosis?

8

Colon injuries

• Less frequent, more frequent sequelae

• Bowel preparation

• Colostomy if >2 cm??

Single/double layer 3‐0 reabsorbablemonofilament

Colon Injuries

• TRAUMA Procedure

• <30‐40% no contamination Double layer suture

• <30‐40% contamination Suture + enterostomy

• >30‐40% o devasculariz.

• No contamination Resection + anastomosis

• >30‐40% o devasculariz.

• contamination Res, anastomosis enterostom

• Prev RT  esteriorization as  colostomy

Rectal Injuries1,4‐2,1% in Gyn procedures

• Reabsorbable dual layer suture

• Resection and anastomosis

• Colostomy??

Jo J Minim Invasive Gynecol. 2013 Mar;20(2):166‐71

GU complicationsIncidence

• 90% are iatrogenic

• 82% during pelvic sugery

• 74% during benign

• 75% during gyn procedures

• 75% during laparotomy

Laparotomy/Laparoscopy

• IP ligament

• Cervix

• Vaginal fornices

• U‐S Ligament

Bladder Injuries

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Bladder Injuries• 1,8% of abdominal Hysterectomy

• 0,4% of Vaginal Hysterectomy

• 1‐3% TLH ‐ LAVH

• Mostly recognized and sutured intraoperatively

Ureter

• 0,4‐2,5% benign surgery (<0,5% TLH – LAVH)

• 1/3 intraoperatively recognized 

• Coagulation or ligation no leacks and normal peristalsis!

Renal failure

Ureteral lesion with cystoscopyStudy Year  # Operations  # Ureteral  # Bladder

Timmons & Addison 1990  37  0 *

Councell et al  1994  171  1 (0.6)  0

Petit & Petrou  1994  236  5 (2.1)  2 (0.9)

Wiskind & Thompson 1995  1270  5 (0.4)  *

Siegal & Retsky  1996  334  0  7 (2.9)

Harris et al  1997  224  6 (2.7)  3 (1.3)

Miklos et al  1997  21  0  0

Pace et al 1997  112  0  3 (2.7)

Klutke et al  1998  97  0  0

Dwyer et al  1999  1164  2 (0.2)  5 (0.4)

Ribeiro et al  1999  118  4 (3.4)  0

Stevenson et al  1999  109  1 (0.9)  6 (5.5)

Tulikangas et al 2000  347  0  5 (1.4)

Total  4,146  5.8/1,000 10.9/1,000

Routine cystoscopy does not prevent completely misdiagnosed 

ureteral injuries

Gilmour DTObstet Gynecol. 2006Jun;107(6):1366-72Indraratna PL. Aust N Z J Obstet Gynaecol. 2011 Jun;51(3):272‐5

Ureteral Injuries

Ligation

Kinking

Resection

Grasping

Cauterization

Ischemia

Prevention = Anatomy knowledge

•Visualization and dissection

•Traction and countratraction

•Vascularity preservation

•CT Scan

•Prophylactic Stenting

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Identify InjuriesIntraoperative

• Visualization and dissection (best before)

• Indigo‐carminium/Methilene blue

• Cistoscopy

Postoperative• Pain

• Pyelonephritis

• Urinoma

• Fistula

UrographyCystogram

Bladder Injury identification

• SUSPECT IT!!

• Bladder distension (3 lines foley)

• Urinary Bag CO2

• Cystoscopy 

Bladder Injuries: TreatmentProcedure Stents

Serosal X X

Muscularis Suture 1 layer X

Mucosa running 2 layers Foley

Trigonus interrupted 1‐2 layers Stents + foley

Bladder Injuries: Laparoscopic Treatment Video

Ureteral Inj treatment ProcedureStents

L adventitia ? ?

Pinpoint injuries X X

Grasps ligations if no necrosis ureter

R.<5 cm from U‐BJ

no Loss Psoas Hitch. Ureter

R. >5 cm Ureter‐ureter stom. ureter

Loss Boari Flap Ureter

Large loss Uretero‐ ileocistostomy Ureter

Transuretero‐uretero stomyUreterostomy

Ureteral Injury Laparoscopic treatment Video

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Vascular complications

• The most alarming and serious laparoscopic complications with a 9–17% mortality rate

• 1.7% intra‐operative and a 1.5% postoperative incidence of internal bleeding or haematoma of the abdominal wall, and a 0.09% incidence of major vascular injuries

Swiss Association Laparoscopic And Thoracic Surgery

Vessel Injuries

• Veress/Trocar (optical, ancillary)

• Surgical

• Postoperative

Primary Trocar/Veress

• Bleeding on aspiration of the Veress needle or through the trocar, frank or concealed bleeding within the pelvis or abdomen and unexplained hypotension should warrant exploration and identification of the bleeding vessel immediately.Due to delayed recognition, vascular injury during the entry phase is associated with greater morbidity and mortality than injury during the surgical phase of a laparoscopic procedure

Ancillary trocar• superficial epigastric, superficial circumflex, Inferior epigastric or deep circumflex vessels from insertion of secondary trocars

• Diffuse haematoma within the abdominal wall or profuse haemorrhage into the peritoneal cavity.

• Tamponaded by the trocar and seems minimal during surgery but may present during the postoperative phase

SAAS• Stop the arterial bleeder immediately by occluding the vessel

• Alert the team so that resuscitation measures (IV access, blood cross‐matching and blood transfusion) can be commenced. (laparotomy tray and help from a vascular surgeon)

• Access the bleeding site by the quickest and safest route (Experience!)

• Secure the vascular injuryLAM A et al 2009 

Vascular Injuries: Laparoscopic Treatment Video

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• Opitz I, GantertW, Giger U et al. Bleeding remains a major complication during laparoscopic surgery: analysis of the SALTS database. Langenbecks Arch Surg 2005; 390(2): 128–133

• Lam A, Kaufman Y, Khong SY, Liew A, Ford S, Condous G. Dealing with complications in laparoscopy. Best Pract Res Clin Obstet Gynaecol. 2009 Oct;23(5):631‐46

• Song T, Kim TJ, Kang H, Lee YY, Choi CH, Lee JW, Kim BG, Bae DS Factors associated with complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy. Acta Obstet Gynecol Scand. 2012 May;91(5):620‐4

• Clarke‐Pearson DL, Geller EJ. Complications of hysterectomy. Obstet Gynecol. 2013 Mar;121(3):654‐73

• Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol. 2006 Jun;107(6):1366‐72

• Indraratna PL, Walsh CA, Moore KH. Intra‐operative cystoscopy in gynaecological surgery: a brief overview. Aust N Z J Obstet Gynaecol. 2011 Jun;51(3):272‐5

• Jo EJ, Lee YY, Kim TJ, Choi CH, Lee JW, Bae DS, Kim BG. Management and outcome of rectal injury during gynecologic laparoscopic surgery. J Minim Invasive Gynecol. 2013 Mar;20(2):166‐71

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

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