Minimally Invasive Gynecological Surgery

20. Complications

Frank Willem Jansen 


Department of Gynaecology, Leiden University Medical Center, 9600, 2300RC Leiden, The Netherlands

Frank Willem Jansen


20.1 Introduction

20.2 Risk Factors

20.2.1 Surgeon’s Experience

20.2.2 Patient Characteristics

20.2.3 Type of Procedure

20.2.4 Equipment and Tools

20.2.5 Anesthesia and Pneumoperitoneum

20.3 Intraoperative Complications

20.3.1 Abdominal Wall Bleeding

20.3.2 Intra-abdominal Bleeding

20.3.3 Gastrointestinal Lesions

20.3.4 Bladder Lesions

20.3.5 Ureter Injuries

20.3.6 CO2 Insufflation Complications

20.4 Postoperative Complications

20.4.1 Postoperative Hernia

20.4.2 Infection

20.4.3 Thrombosis

Suggested Reading

20.1 Introduction

In the past decades, an enormous increase in number of laparoscopic approaches in surgery is observed at debit of the conventional open procedures. Furthermore, in gynecology, a shift from diagnostic procedures to therapeutic interventions is perceived. Despite the great enthusiasm at the introduction of this surgical technique, in both within the field of gynecology and general surgery, one should not lose sight of the fact that complications can also occur during this surgical approach and even during (simple) procedures where they are not expected.

The incidences of complications in literature are generally collected from retrospective obtained data. Whereas approximately half of all complications in laparoscopy are a result of the introduction of the Veress needle or the blind insertion of the first trocar and are therefore inherently an entry-related complication. The other half is a result of the applied surgical technique and is similar to the conventional approach operating technique related. Entry-related complications are however mainly vascular and/or gastrointestinal lesions. To define a complication as a result of a surgical intervention, one has to be aware that there has to be similarity in definition and severeness. Some authors classify for example complications in minor and major. The latter are complications that need a laparotomy or when mortality occurs. Minor complications are classified as lesions or problems which can be solved during the regular laparoscopic procedure. This classification has the disadvantage that there is an under classification of some complications, which are classified as “minor” although they can lead to subsequent morbidity, both intra- and postoperatively. Therefore, it is of utmost importance to specifically define a complication so that its definition can be applied at the exact same way and everywhere. Currently, an internationally accepted definition of a (surgical) complication is: a complication is an unintended and undesirable event or condition during or following medical intervention, to such an extended disadvantage to the patient’s health condition that adjustment of medical intervention is necessary, and/or irreparable damage has occurred. The results of the actual medical intervention, the probability of the complication, and the possible presence or absence of human error are of no concern. Responsibility period ranges from the (first) day of admission until 6 weeks after discharge. Furthermore, the severity or impact of the complication has to be weighted. The latter varies from no surgical reintervention (grade A), surgical reintervention (grade B), everlasting damage (grade C) to death (grade D).

When we use this internationally accepted definition, more unity on incidences and prevalence on complications can be collected.

A number of complications can be avoided by a consistent application of the preoperative protocols (e.g., catheterization of the bladder for each procedure). As proclaimed by Nezhat: an ounce of prevention is worth a pound of cure. Unfortunately, complications may occur in relatively ‘simple’ procedures when they are least expected. Negligence may be the cause of these complications and can be blamed.

In literature, conversion to laparotomy is usually used as the indicator for the severity of the complication. However, converting to a laparotomy does not necessarily mean that the procedure failed. Most of the time, the patients (as well as the surgeon) have a better clinical outcome when the operation is converted to the conventional procedure as per laparotomy, instead of persisting in the original laparoscopic surgical procedure leading to a complicated postoperative course.

In this chapter, risk factors which lead to complications are discussed. Intraoperative and postoperative complications as a result of laparoscopic procedure are highlighted.

20.2 Risk Factors

Beside a critical look at the indication for the surgical laparoscopic intervention, several risk factors for a laparoscopic procedure have to be considered. They can be classified as:






20.2.1 Surgeon’s Experience

It is well established that the experience of the surgeon is related to the good clinical outcome of the procedure and is directly correlated to the occurrence of complications. However, it is also known that most complications occur in the learning phase. The training situation, where the resident is trained to learn diagnostics and simple laparoscopic procedures is at highest risk for a complication. However, this phase is usually performed under strict and skilled supervision. Unfortunately, there are hardly any good studies on this laparoscopic learning curve available. Just one study in the 1970s of the past century showed that the percentage of complications decreased from 14.7 (promille) to 3.8 (promille) when about 100 laparoscopies in total were performed by the surgeon concerned. Therefore, it is important that gynecologists in training perform these number of procedures under direct supervision during residency. In this way complications associated with inexperience of the surgeon can be reduced to a minimum. Furthermore, the laparoscopic surgeon has to be familiarized with the instruments he/she has to be trained in the basic skills preferably on an endotrainer in a skills laboratory and has to be familiar with the applied surgical techniques by observing the surgeon (preceptorship). Finally, he/she has to perform the first procedures under direct supervision (proproctorship) before starting to perform operations independently. Also, working in accordance to a protocol, results in a considerable reduction of complications. This was already described in 1973. A tenfold reduction of the number of complications in laparoscopic sterilization was noticed when the gynecologists started to work according to a standard protocol. Finally, a 3–4 times lower complication incidence was observed when the surgeon attended a course on specific operations and skills obtained at an animal laboratory.

In this context, recently studies came available on experience of the surgeon toward laparoscopic hysterectomy. This advanced surgical procedure is usually learned after obtaining enough experience with the basic skills for laparoscopic surgery. Nevertheless, these studies showed that the skills factor of the surgeon concerned was an independent predictor toward the occurrence of adverse events. That means not only experience counts as prevention to complications but also dealing with a skilled surgeon is a preventive item toward the occurrence of these side effects.

20.2.2 Patient Characteristics

In the past decades, a shift was observed from absolute to relative contraindications for a laparoscopic procedure. In the past century, oncology was considered an absolute contraindication for this approach due to the fear of spillage. Nowadays, this indication has changed to a relatively contraindication when spillage of content is expected. Only severe heart failure (class IV) has to be considered an absolute contraindication for laparoscopy. The latter is, however, also for the conventional open approach a relative contraindication. In general, all patients who have additional comorbidity do have a higher risk for an operation (e.g., diabetes mellitus, long failure, etc.), whether for the laparoscopic as the conventional approach. In this context, we have to consider that the laparoscopic approach has the disadvantages during its procedure (e.g., Trendelenburg position gives lung compression, prolonged operating time, etc.), whereas the conventional approach has usually negative impact on the postoperative phase (more postoperative infections, thrombosis, etc). Obesity and older age are not contraindications any more for a laparoscopic approach. Even a better clinical outcome has to be expected for this group of patients when compared to the conventional approach. Especially since the obese patient has a longer postoperative recovery time than those who have a normal BMI. The same trend is seen for elderly patients compared to their younger peers.

20.2.3 Type of Procedure

A higher complication rate can be expected, when more technically difficult laparoscopic procedures are performed. This is the reason that international societies [e.g., Royal College of Obstetricians and Gynaecologists (RCOG) and the Council on Residents Education in Obstetrics and Gynecology (CREOG)] developed guidelines and levels of difficulty for laparoscopic procedures. In summary, four levels are distinguished and shown in Table 20.1.

Table 20.1

Gynecologic laparoscopic surgery classified in difficulty in accordance with the ESGE (

1st level: Basic level

 Diagnostic laparoscopy


 Needle aspiration of simple cysts

 Ovarian biopsy

2nd level: Intermediate level (normal training during specialization in obs/gyn)

 Salpingostomies for ectopic pregnancy



 Ovarian cystectomies

 Adhesiolysis, including moderate bowel adhesions

 Treatments of mild or moderate endometriosis—salpingostomy and salpingo-ovariolysis

3rd level: Advanced level (advanced procedures requiring extensive training)



 Treatment of incontinence

 Surgery for severe endometriosis

 Extensive adhesiolysis including bowel and ureter

 Repair of simple intestinal or bladder injuries

4th level: (procedure under evaluation or practised in specialized centers)

 Pelvic floor defects

 Oncology procedures: lymphadenectomy, radical hysterectomy, and axilloscopy

 Rectovaginal nodules

 Other procedures not yet described

It is advised that the relatively simple procedures (level 1 and a part of level 2) can generally be performed by all credentialed gynecologists, whereas more difficult procedures (levels 3 and 4) have to be performed by gynecologists with a special interest and experience in laparoscopic surgery. For the level 4 procedures, it is advised to centralize these procedures in specialized institutions because of the multidisciplinary approach with general surgeons and urologists (e.g., severe endometriosis cases).

Data in scientific literature expose that both complication rate and conversion rate increase when the laparoscopic procedure turns to be more difficult. However, we have to take into account that the incidence of complications is also higher for these procedures when they are performed primarily by laparotomy.

20.2.4 Equipment and Tools

Due to the often ‘blind’ insertion of sharp instruments at laparoscopy (Veress needle and first trocar), this inherently can lead to complications which are not completely avoidable. To decrease the chance of such a complication, a number of standard precautionary measures have to be made.





A low initial abdominal pressure (<10 mmHg), followed by a free influx of CO2, is a reliable indicator of correct intraperitoneal Veress needle placement. Still, however, there are only insufficient high-quality comparative studies available on safety and effectiveness of the different aspects in these specific open- and closed-entry techniques. Furthermore, the peritoneal hyper distention has only been studied and found to be safe in healthy female patients with low ASA score (e.g., score 1 or 2). The latter technique (application of an intra-abdominal pressure of 20–24 mmHg) results in an increase size of the gas bubble and creates more distance between the abdominal wall and the organs at risk.

An internationally adapted open Hasson technique is an alternative for the closed entry technique. However, the number of specific entry complications has not been diminished with either approach. Both, the number of vascular and gastrointestinal injuries are equal at each technique applied.

20.2.5 Anesthesia and Pneumoperitoneum

Due to the relatively high intra-abdominal CO2 pressure and the (steep) Trendelenburg position, inherently anesthesiological problems may occur. Furthermore, the extensive use of cold fluids intra-abdominally can lower the patient’s temperature with its consequences.

20.3 Intraoperative Complications

20.3.1 Abdominal Wall Bleeding

A lesion of an epigastric vein or artery is the most common observed complications of a bleeding of the abdominal wall. The given incidence in literature varies between 0.17 and 6.4 per 1,000. This large range can to be explained to the fact that most studies on this subject are of retrospective origin and no discrimination is made between a superficial abdominal wall bleeding and an intra-abdominal bleeding. Prevention

Most bleedings of the epigastric veins are caused as a result of blind insertion of the additional side trocars. Precautions to avoid this complication are relatively simple. Knowledge of the anatomy of the abdominal wall veins (Fig. 20.2), transillumination of the abdominal wall by the laparoscope, and insertion of the secondary side trocars only under direct vision is one of them. However, an abdominal wall bleeding is not always directly recognizable due to the tamponade of the trocar during the surgical procedure. If this trocar is accidentally removed during the operation, a bleeding or the development of a hematoma could originate. Securing of the trocar with a screw (cave: diameter of the incision is enlarged) or a stitch can prevent the unintended removal of the trocar during the procedure.


Fig. 20.2

Anatomical pathway of arteries and veins in the abdominal wall Treatment

Usually, a reactive policy is recommended for an abdominal wall bleeding, especially since the trocar tamponades the manifestation of the bleeding. However, when the bleeding persists and is visible by dripping of blood into the abdomen, besides the trocar, this is usually a result of a lesion of the epigastric inferior vein. Several ways are described to stop the bleeding from the trocar side. First, the vein can be coagulated by bipolar coagulation. However, when the bleeding persists it is advised to leave the trocar in situ and apply a Foley catheter into the trocar, remove the trocar and clamp it at the abdominal side. Tamponade with a catheter balloon (filled with saline) tamponades the bleeding by pressure from the inside of the balloon toward the peritoneal side of the abdominal wall. Other alternatives are by applying a laparoscopic stitch to the abdominal wall or enlarging the incision to locate the bleeding and then the vein can be stitched in a conventional way.

20.3.2 Intra-abdominal Bleeding

In general, intra-abdominal bleeding is a result of the applied technique or, similar to conventional surgery, a result of ‘bad’ luck during the procedure. The incidence of this complication as a result of the blind insertion of Veress needle or first trocar is 2.7/1,000 or 2.4–2.7/1,000, respectively. Sometimes, an intra-abdominal bleeding is not visible or manifest during the procedure because of a combination of factors. The Trendelenburg position and the high intra-abdominal pressure (14–16 mmHg) give a relative supine hypotension. At the end or after the procedure, when this combination of factors is dissolved, intra-abdominal bleeding can become manifest. Prevention

Apart from the application of general preoperative precautions, there are not many means to prevent a bleeding. Like in conventional surgery, one surgical procedure has more bloody course than the other. Some preventive measurements to comply within laparoscopic surgery are that at the end of the operation the intra-abdominal overpressure as well as the Trendelenburg position have to be released. By inspecting the operating field, an intra-abdominal bleeding can be seen and arrangements for stopping the bleeding can be made. One has to be aware that a manual overshoot during the blind insertion of either the Veress needle or the first trocar can occur. Precaution to overshoot is that when the Veress needle has passed the peritoneum (after two clicks), no further application is necessary intra-abdominally. The same is applicable for the first trocar. The extreme thin patient (BMI < 18) and children are especially at risk for lesions of aorta and vena cava because these structures are situated just under the skin. Also, the angle in which the instruments are applied is of importance. The fatter the patient, the more at 90° angle the instruments have to be introduced. Treatment

The occurrence of an intra-abdominal bleeding does not mean that the planned laparoscopic procedure has to be abandoned. Many bleedings can primarily be treated and stopped with bipolar coagulation. Also, clips or stitches can be used to stop the bleeding as well as the application of an endoloops. Furthermore, a sterile gauze can be applied toward the diffuse bleeding surface to tamponade the bleeding for a while. Lastly, there are several hemostatic products available which are laparoscopically applicable.

20.3.3 Gastrointestinal Lesions

Gastrointestinal lesions can be a result of the blind insertion of the Veress needle or the first trocar and are therefore entry-related complications. Furthermore, gastrointestinal lesions can occur due to the technique used in the procedure. One of the biggest problems of gastrointestinal lesions is that they are not always immediately noticed. Some described that only in 1/3 of cases these lesions are observed intraoperatively. When, after the operation, abdominal pain occurs as a result of generalized peritonitis, the lesion becomes manifest. When the lesion is a result of a sharp trauma (e.g., Veress needle, trocar or laceration during sharp adhesiolysis), clinical signs will be manifest within 72 h. In contrast, thermo damage due to electric coagulation or laser coagulation are manifest sometimes just after 4 or 10 days. At reintervention, it is from macroscopic point of view difficult to distinguish if the lesion is a result of a sharp or a coagulation trauma. In both cases, the perforation has a macroscopic whitish area of necrosis at the lesion. At microscopic level, however, a distinction between lesions can be made. At electrocoagulation trauma, dead amorphous tissue without polymorphic core infiltration is visible. Perforation lesion as a result of sharp trauma shows capillary ingrowth, leukocyte infiltration, and fibrin deposition at the edges of the wound.

Gastrointestinal lesions can occur both on the small intestine and on the colon. Small intestinal lesions usually occur as a result of a trauma by the first trocar, usually in patients with a history of prior laparotomy. However, also blunt dissection of small intestines may result in lesions of these organs. Colon lesions usually occur as a result of introducing too blunt trocars with too much force, usually in absence of an adequate pneumoperitoneum. Prevention

An adequate pneumoperitoneum (>20 mmHg) ensures that the gastrointestinal organs are located far from the abdominal wall. This decreases the risk that these gastrointestinal organs can be damaged. The stomach has to be emptied before the operation starts. In this context, it is interesting to see that gastrointestinal lesions at the open-entry technique usually are recognized earlier than in blind technique. In general, it is found that patients with a prior laparotomy have a higher incidence of gastrointestinal lesions and operations where extensive adhesiolysis is performed are at risk.

When, during the closed entry, a bowel lesion occurs or is suspect, it is advised to leave the Veress needle or trocar in situ to identify the lesion during laparotomy. Finally, at the end of the laparoscopic procedure, trocars have to be removed under direct vision in order to prevent slippage of the small gastrointestinal organs in the abdominal defect due to the evolved negative abdominal pressure. At removing the trocars, this can lead to herniation and incarceration of the bowels or omentum. Treatment

Instantly noticed perforation of small intestines or colon can be repaired immediately by stitching the defect. It is well established that bowel preparation does not play a role anymore for the clinical results after repairing a gastrointestinal lesion. However, when a bowel lesion has to be repaired after a longer period of time, this preparation is debatable. When at the fifth or sixth postoperative day, a patient reports abdominal tenderness, slight fever, nausea and/or vomiting with diminished appetite, and a progression in these symptoms, it is suspect for an (unnoticed) gastrointestinal lesion. Lesions with a later manifestation have a higher morbidity and are usually treated by laparotomy. Small intestine lesions are usually treated with an end-to-end anastomosis. However, the latter depends if the blood supply is not damaged. Treatment of lesions of the colon, recognized at a later date, depends on the stage of the peritonitis and will still be treated in the conventional way with a Hartman procedure.

20.3.4 Bladder Lesions

The occurrence of a lesion of the bladder is rare and usually occurs only when a patient had prior abdominal surgery (e.g., a Caesarean section) or when the bladder is preoperatively not emptied. Furthermore lesions can also occur after coagulation. Operations at risk for the occurrence of bladder lesions are the treatment of endometriosis (ablation), adhesiolysis, bladder suspension operations, and the laparoscopic hysterectomy. The incidence found in literature varies between 0.06 and 1.2 %, which includes the occurrence of fistulas postoperatively. For many years, the laparoscopic hysterectomy (LH) was considered at risk for bladder lesions. For the latter, a recently published study from Finland showed that when experience with this surgical procedure increases, a decrease of these lesions was found. Nowadays, an incidence of 0.34 % is given for lesions at the urogenital tract including bladder and ureter lesions. This is at the same level as given for the abdominal or vaginal hysterectomy. Specifically for bladder lesions, they can stay unnoticed. However, in most cases (90 %) these lesions are directly recognized. This is in contrast with ureter lesions, which become manifest in most cases (80 %) after initial operation. Prevention

For gynecological laparoscopic procedures, it is mandatory to empty the bladder before the procedure starts. Long-lasting procedures require a catheter a demeure. A procedure, very close to the bladder, or when there is doubt about the exact location of the boundary of the bladder a retrograde filling of the bladder is optional. With 350 cc saline solution the edges of the bladder are easily found. When secondary trocars are removed, it is important to visualize intra-abdominally if there is no leakage of urine. Tamponade of the lesion intraoperatively holds the lesion occult. When after a procedure hematuria is found, or gas (CO2) is seen in the catheter bag, this could direct to a bladder lesion. Treatment

Treatment options depend on the size of the lesion. When the lesion is very small (<5 mm), a catheter can be put into the bladder for 5–7 days and a spontaneous healing can occur. However, when a big laceration is found this can be stitched laparoscopically. This stitching can be done in one layer with continuous running sutures. Some advise to control the stitch with cystoscopy, especially to evaluate the orifices of the ureter. Drainage for 7 days and antibiotic prophylaxis followed by a cystogram postoperatively after 7 days are advised. The latter option depends on the severeness of the lesion and its location.

20.3.5 Ureter Injuries

Ureter lesions are usually a result of the laparoscopic applied technique (technique related) and not a result of the laparoscopic approach (entry related). Although the incidences are low, it is expected to increase in the future when more complex laparoscopic procedures will be performed. Especially the LH is the operation at risk not only for injury of the ureter, but also the laparoscopic sacrocolpopexy and procedures to extensive endometriosis treatment. The ureter is anatomically located close to the sacrouterine ligament and is therefore inherently at risk at this stage of the procedure. Ureter injury can be a result of direct (e.g., cutting, stitching, coagulating, and stapling) or indirect (e.g., coagulating near the ureter and kinking) application of used techniques. Coagulating a bleeding or endometriosis near the anatomical location of the ureter is often not only the cause of the injury, but also the use of staplers and laser in that field is risk factors. Prevention

Anatomical knowledge of the course of the ureter in the pelvis as well as knowledge of the moments when the ureter is at risk for injury during the surgical steps is of importance (Table 20.2). Especially when additional (occult) diseases are present (e.g., endometriosis may thicken the peritoneum locally and make the ureter hard to locate) and anatomical awareness of the course of the ureter is important. Endometriosis, adhesions, and prior surgery are pitfalls during the surgery. When the procedure takes place at a risky location and it is not possible to explore the ureter, a retroperitoneal dissection might enable this. This can be succeeded through hydrodissection. In this way, the ureter can be moved to a more lateral position or by positioning the ureter further away from the operating field. At adnexexttirpation or ovariectomy, usually bipolar coagulation is used to coagulate the ligamentum infundibulo pelvicum. During this step is important that the ligament has to be moved under traction to median. Herewith, it is possible to visualize the ureter and to prevent lateral thermal injuries toward the structure.

Table 20.2

Laparoscopic procedures at risk for ureter injury

1. Infundibulo-pelvicum ligament and fossa ovarica


 Adhesions at pelvic side wall

 Presacral neurectomy

 Ablation or vaporization of endometriosis

 Extended bowel adhesions

2. Ureter


 Sacrouterine ligaments

 Transection of uterosacral nerve


3. Cardinal ligament


 Vaginal cuff closure

The use of ureter catheters is debatable. These catheters have to be applied preoperatively and due to transillumination the course of the ureter can be visualized during the procedure. A disadvantage of the use of catheters is that a specialized and skilled gynecologist or urologist has to be present to introduce these catheters. Furthermore, they give additional expenses to the surgical procedure. Treatment

Early recognition of the injury is important. One has to be aware that ureter injuries can be suspected when leakage of the urine is seen in the abdomen, bloody urine is found in the catheter bag, or when leakage is found in intravenously applied indigo carmin. Injuries are usually repaired by the urologists with an ureteroureterostomy or an ureteroneocystostomy. Usually these procedures are still performed by laparotomy. However, conservative and laparoscopic procedures are also performed to handle these injuries. Sometimes, thermal injuries can be handled with expectant management without any side effects.

20.3.6 CO2 Insufflation Complications

Subcutaneous emphysema and CO2 embolism can be a result of misplacing the Veress needle. Also, overpressure of CO2 can penetrate in the tissues or by (extensive) manipulation of the trocars during the operation. CO2 causes subcutaneous emphysema. Continuous reintroduction of the trocar during the operation may also cause application of CO2 at the wrong places (subcutaneous). Furthermore, at manipulating the diaphragm (e.g., cholecystectomy), a pneumomediastinum can occur. In this line also the occurrence of a pneumothorax is described.

The incidence of this side effect (incidences 0.43–2 %) is considered to be rare. However, from daily practice it is actually the most observed side effect of laparoscopic surgery. On the other hand, the CO2embolism is the most dangerous complication, but given as very rare event. The mechanism of CO2 embolism by insufflating CO2 in the venous circulation is described as follows. When a CO2 embolus enters the central (venous) circulation, this will cause a gas lock in the right cardiac atrium. When this gas lock has enough volume, the whole venous circulation toward the heart will be blocked with a total cardiovascular collapse as a result. Also due to this gas lock, a block of the pulmonary outflow in the right cardiac ventricle occurs with a pulmonal hypertension as a result. Due to this mechanism, a lowering of the pressure in the left ventricle and aorta occurs with a chance of a myocardial infarction. The clinical signs are acute hypotension, cardiac arrhythmia, tachycardia, or supraventricular tachycardia, which result in a cardiac arrest and breath arrest. Due to the blending of CO2 in the blood during auscultation, millstone murmurs are heard. When the pCO2 is measured, it is found that this starts to decrease first and higher up afterwards. The oxygen saturation lowers. Prevention

After placement of the Veress needle and before starting to insufflate, it has to be proven that the needle is correctly placed. Several tests such as the Palmer test, drop test, etc. give relative information about the placement. By aspirating the Veress- needle after placement, it can be found if it is placed intravenously/arterially. It is shown in literature that the best option is that the CO2 flow has to be <10 mmHg to give the prediction of the best placement of the Veress- needle. Treatment

In case of occurrence of subcutaneous and/or mediastinal emphysema, expectant management is advised since the CO2 will be absorbed by the body itself. However, in case of a CO2 embolism, CO2application has to be stopped immediately, the pneumoperitoneum has to be released, and the patient has to be placed in a left tilted lateral position. The latter position is expected to advance the removal of the gas bubble from the right ventricle. Also, it is advised to suspend the general anesthesia and to apply 100 % oxygen and to perform heart massage.

20.4 Postoperative Complications

Gastrointestinal injuries, bleeding, bladder and ureteral injuries are prone to become manifest in the postoperative course. Especially the coagulation injuries occurring during the procedure are notorious for their late manifestation. One has to realize that even mortality may occur from this complication (incidence 4–8/100,000), which is described after a laparoscopic complication full course. Other most found postoperative complications are hernias, infection (abscesses, salpingitis, and peritonitis) thrombosis, lung embolism, and emphysema.

20.4.1 Postoperative Hernia

Although the incidence of occurrence of postoperative hernia, through a trocar scar, is low, the literature gives a diversity of incidences. This varies between 0 and 0.21/1,000. The use of different trocars (sharp versus blunt) and due to the removal of larger specimen (e.g., myomas), it is imaginable that in the near future an increase of postoperative herniation is found. It is observed that the use of blunt tip trocars and/or expending trocar systems gives less tissue damage of the abdominal wall and is therefore less at risk to give a herniation afterward. However, hernias may occur more often than diagnosed. This is due to the fact that the follow-up period after the procedure is usually not more than 6 weeks and a hernia does not always give clinical signs and complaints within that given timeframe. Patients at risk are, similar to conventional surgery, the very thin patient (especially the elderly), asthma patients, patients with a history of herniation, or patients with an inactive tissue ailment. Lastly, patients who have endured a wound infection postoperatively are at risk to develop a hernia. A hernia only causes trouble when small intestine, colon, or omentum slips into the hernia and get incarcerated. Hernias without clinical complaints do not need a surgical intervention. Prevention

It is well established that the use of smaller trocars (<5 mm) reduces the chance that a hernia occurs. However, several case reports describe even herniation after the use of trocars <5 mm. To prevent slippage of intra-abdominal structures in the opening of the trocar after the procedure, it is mandatory to remove all the trocars postoperatively under direct vision. Also, the first trocar has to be removed under direct vision with an open valve of the trocar to prevent negative pressure to which intra-abdominal structures can be slipped into the opening. It is not exactly established at what size of the trocar used the abdominal wall defect has to be closed. Latest consensus shows that trocar defects >10 mm have to be closed to prevent herniation.

There are two preventive methods to close the defect. First, the defect of the fascia can be closed with a simple Z-figure stitch with a conventional round needle. Second, both the peritoneum and the fascia can be closed with a J-needle. In both cases, the skin is not to be stitched into the thread. Furthermore, one has to be aware that the skin is loosened from the thread to prevent the development of worse cosmetic results. Final, it is mandatory to control the sewing inside abdominally to prevent slippage of gastrointestinal organs or omentum into the tread. Treatment

For the treatment of hernias, the conventional surgical procedure of hernia correction has to be applied, either by the gynecologist or by the general surgeon.

20.4.2 Infection

Postoperative infections after laparoscopic surgery are rare. However, there are no extensive comparable studies available. The risk of an infection increases if the procedure takes more time and when there are more trocars applied in the abdominal wall. Usually most infections are limited to the trocar sides which can be infected. Sometimes, a more fulminate infection occurs (peritonitis/salpingitis) usually after an operation or a diagnostic procedure with chromotubation. These infections may be a flare up because of a pre-existing infection (e.g., Chlamydia infection). The combination of extensive tissue destruction and necrosis with bacterial contamination (e.g., laparoscopic hysterectomy where the vagina is opened and endometriosis cases) is proned for secondary infection where a peritonitis may occur. Also, the spillage of cystic content can give (sterile) infection symptoms. Dermoid cysts are especially at risk for this clinical sign. The chemical peritonitis which occurs is a breeding ground for postoperative adhesion formation. Prevention

The application of antibiotic prophylaxis at an uncomplicated relatively simple laparoscopic procedure is not mandatory. When chromotubation or a tuboplasty for fertility reasons is performed, prophylaxis is dependent on the result of the Chlamydia screening. To prevent chemical peritonitis due to spillage of content of the cyst, it is advised to use laparoscopic endobags. Furthermore, extensive rinsing of the abdomen is advised at the end of the procedure. Spillage of content of the removed tissue can have severe consequences. Not only spillage of carcinoma with its adverse effects has been described, but also materials of ectopic pregnancy can give chorionic nestling of tissue elsewhere. Also, gallbladders stones which are not removed after spillage at the cholecystectomy are described to give afterward the signs of ovarian pathology. The spillage of myoma content after morcellation may give implants. In case of (occult) malignancy this may worsen the clinical outcome and need to be prevented. Treatment

When infectious contamination is expected, antibiotic prophylaxis is mandatory. This is similar to the conventional procedures. When, after the surgical procedure a salpingitis is diagnosed or an infection is manifest secondary treatment with antibiotics is mandatory.

20.4.3 Thrombosis

At average, a patient undergoing a laparoscopic gynecological procedure is a relatively young and healthy person. However, the combination of pneumoperitoneum, Trendelenburg position, and a relatively time-consuming surgical procedure introduces metabolic and hemodynamic changes and is therefore at risk for thrombosis. Hemodynamic changes are caused by the diminishing venous return of the blood supply from the pelvis with an increase of the central venous pressure and a dilatation of the distal veins. These factors predisposes for venous thrombosis, especially when the operation has a prolonged character. Prevention

Thrombosis prophylaxis has to be applied as the usual hospital and (inter-) national protocol describes. When prolonged laparoscopic procedures are performed, it is mandatory to give special attention to the position of the legs in the stirrups. These can disturb the venous return from the legs with an increased risk for venous thrombosis. Stirrups with massage abilities or the French position may diminish the chance of thrombosis in the legs. Treatment

When thrombosis occurs, this has to be treated as described in the standard protocol which is applicable in the (inter-)national guideline and adapted in every institute. Conversion

Inherent to each laparoscopic procedure, there is a chance for conversion to a conventional laparotomy. The risk to convert depends on a combination of factors such as indication, patient characteristics, experience, and skills of the surgeon. Hence, in the past, the rate of conversions was used to determine the feasibility of the laparoscopic approach. Nowadays, it could more specifically be used as a means of evaluation.

In general, compared to a totally performed laparoscopic procedure, conversion is associated with worse outcome measures such as a longer length of surgery, more postoperative adverse events, and a prolonged hospital stay. Additionally, the reason for conversion is also of importance. The outcomes after a conversion due to an adverse event (defined as ‘reactive’ conversion) are significantly worse in comparison to those after a ‘strategic’ reason to convert in order to prevent an intraoperative adverse event in case of operative difficulty. Therefore, it is mandatory in the registration of conversions that this distinction between strategic and reactive conversions is made.

Interestingly, also laparoscopic-assisted procedures in which only a small-target incision for specimen retrieval is made show a significantly higher postoperative morbidity and prolonged hospital stay compared to a total laparoscopically performed procedure. Although this type of procedures should not be regarded as a conversion, ideally they should also be registered separately from total laparoscopically performed procedures. With respect to the associated morbidity, this will allow adequate comparison between totally laparoscopic, laparoscopically assisted, strategically converted, and reactively converted procedures. Finally, conversion rate can be used as a quality parameter tool to evaluate surgical performance. However, precautions have to be made toward the correct definition and the mentioned distinction of this phenomenon.

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