Intraoperative Complications

Intraoperative complications during minimally invasive surgery include those related to creation of pneumoperitoneum through intraperitoneal CO₂ insufflation, patient positioning, and surgical instrumentation

Cardiopulmonary Complications
1. Hemodynamic complications associated with laparoscopic procedures include dysrhythmias and alterations in arterial blood pressure (Table 43-7: Differential Diagnosis of Cardiovascular Collapse During Laparoscopy). (Bradyarrhythmias are attributed to increased vagal tone after peritoneal stretching, especially associated with “lighter” levels of anesthesia, and tachyarrhythmias may be caused by hypercapnia as a result of intraperitoneal CO₂ insufflation.)
2. Creation of pneumoperitoneum and Trendelenburg positioning is associated with cephalad movement of the carina, which may lead to endobronchial intubation (Table 43-8: Causes of Hypoxemia During Laparoscopy).
3. Pneumoperitoneum and position changes can cause significant hypoxemia and hypercarbia (end-tidal CO₂ [ETCO₂] >50 mm Hg) (Table 43-9: Differential Diagnosis of Hypercarbia During Laparoscopy).
4. Treatment of hemodynamic dysfunction should include confirmation that the IAP has not exceeded 15 mm Hg and vascular injuries are ruled out accompanied by supportive therapy, including reduction in anesthetics, fluid administration, and pharmacologic interventions (Table 43-10: Prevention of Cardiopulmonary Changes in Patients with Significant Cardiopulmonary Disease).
Subcutaneous emphysema can occur from inadvertent extraperitoneal insufflation in the subcutaneous, preperitoneal, or retroperitoneal tissue or from extension of extraperitoneal insufflation.
1. If the emphysema extends to the chest wall and the neck, the CO₂ can track to the thorax and mediastinum, thereby resulting in capnothorax or capnomediastinum (chest x-ray).
2. Because of similar blood solubilities of CO₂ and N₂O, N₂O should not cause further expansion of a CO₂-filled space.
3. Development of hypercarbia (somnolence, increased sympathetic output, respiratory acidosis) in the recovery room may develop in patients with subcutaneous emphysema.
Capnothorax, Capnomediastinum, and Capnopericardium
1. Capnothorax is a potentially life-threatening complication (Table 43-11: Causes of Capnothorax).
  1. Capnothorax may be undetected intraoperatively or may present as unexplained increased airway pressure, hypoxemia, hypercapnia, surgical emphysema, or (if tension capnothorax occurs) severe cardiovascular compromise with profound hypotension (Table 43-12: Diagnosis of Capnothorax).
  2. Treatment of capnothorax includes deflation of the abdomen and supportive treatment (Table 43-13: Management of Capnothorax During Laparoscopic Procedure).
2. Capnomediastinum and capnopericardium may be associated with significant hemodynamic derangement. The diagnosis of these complications is based on the chest x-ray, and the management depends on the degree of hemodynamic compromise (observation, hyperventilation to washout CO₂).
Gas Embolism
1. The proposed mechanisms of gas embolism include inadvertent intravenous placement of the Veress needle, passage of CO₂ into abdominal wall and peritoneal vessels during insufflation, or passage into open vessels on the liver surface during gallbladder dissection.
2. Appropriate monitoring and maintenance of a high index of suspicion should allow early detection and prevention of serious adverse sequelae from CO₂ embolism.
  1. Signs and severity of effects of CO₂ embolism are variable and may include cardiac arrhythmia, hypoxemia, and hypotension and an associated decrease in ETCO₂.
  2. Cyanosis of the head and neck resulting from inflow obstruction to the right side of the heart may also occur.
  3. Paradoxical embolism through a probe-patent foramen ovale or an atrial septal defect may result in cerebral CO₂ embolism.
3. If gas embolism is suspected, the abdomen should be deflated, and hyperventilation and rapid CO₂ washout should result in rapid absorption of the CO₂ embolus. The patient should be turned to the left lateral decubitus with a head-down position to allow the gas to rise into the apex of the right ventricle and prevent entry into the pulmonary artery.
Hypothermia. The incidence of hypothermia during laparoscopic procedures is similar to that of open abdominal operations. Heating and humidifying CO₂ to a physiologic condition may be a consideration in prolonged surgical procedures.
Complications Related to Positioning
1. In patients undergoing robotic-assisted prostatectomy, prolonged steep head-down positioning may lead to facial, pharyngeal, and laryngeal edema, which might lead to upper airway obstruction, including laryngospasm.
2. Prolonged head-down positioning and increased IAP along with large crystalloid administration could increase venous congestion in the optic canal and potentially reduce optic nerve perfusion pressure.
3. Prolonged caudad displacement of the shoulders can cause brachial plexus injury.
Complications from Surgical Instrumentation
1. Hemorrhage may occur because of insertion of the Veress needle or trocar into major intra-abdominal vessels (aorta, common iliac vessels, or inferior vena cava) or because of injury to abdominal wall vasculature.
2. Disruption or avulsion of the cystic or hepatic artery may cause major bleeding during laparoscopic cholecystectomy.
3. Concealed bleeding, particularly into the retroperitoneal space, may result in delayed diagnosis of vascular injury, which may be indicated initially by unexplained hypotension and a fall in hematocrit values. (An anesthesiologist is crucial in early diagnosis.)
4. Stomach injuries can be reduced by gastric decompression before surgery. Similarly, decompression of the urinary bladder by placement of a urinary catheter or asking patients to void before surgery should decrease the possibility of bladder trauma.

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