A. G. Gordon
Honorary Consultant Gynaecologist, Princess Royal Hospital,Saltshouse Road, Hull
Consultant Gynaecologist, BUPA Hospital Hull & East Riding,Lowfield road, Anlaby, United Kingdom
Complications can occur with any form of surgery The prevalence is difficult to assess because there have been no national surveys since those carriedout by the American Association of Gynecologic Laparoscopists in 1976 and the Royal College of Obstetricians and Gynaecologists in 1977. At that time laparoscopy was virtually confined to diagnostic procedures and sterilisation. Only occasional other minor operative procedures were performed. A very few centres had begun to treat ectopic pregnancies, divide adhesions and perform salpingostomy.As operative laparoscopy becomes more widely accepted, new techniques are being developed and more surgeons are adopting this form of management, the complication rate can be expected to rise. The incidence of laparoscopic complications is 1.1% to 5.2% in minor procedures and 2.5% to 6% in major ones (Kane & Krejs, 1984). It is becoming increasingly evident that, in order to reduce theprevalence of complications, training programmes must include supervision at all levels of development and there must be a high degree of awareness of the potential risks of laparoscopic surgery.
Complications may be associated with:
1. The anaesthetic
2. The induction of pneumoperitoneum
3. Insertion of primary and secondary trocars
4. Thermal Instruments
5. Mechanical Instruments6. Other associated conditions
1. THE ANAESTHETIC
Complications directly attributable to the general anaesthetic are no different from those which may occur when any other type of surgery is performed. Some features of laparoscopic surgery predispose to specific anaesthetic complications.
The use of a steep Trendelenburg position and the distension of the abdomen may both reduce excursionof the diaphragm. Carbon dioxide (CO2) can be absorbed particularly during prolonged operations. Monitoring by pulse oximetry, the use of endotracheal intubation and positive pressure assisted ventilation reduce the risk of hypercarbia to a minimum. If arrhythmia occurs the anaesthetist will be responsible for its management and is at liberty to instruct the surgeon to return the patient to thesupine position, evacuate the pneumoperitoneum and discontinue the surgery.
Vasovagal reflex may produce shock and collapse especially if the anaesthetic is not deep enough. Again it may be prevented by efficient anaesthesia and should only be diagnosed when other causes of shock have been excluded.
Local anaesthesia may be used for tubal sterilisation and some other minor procedures. This mayproduce specific problems and complications:
Anxiety may be prevented by administration of Diazepam 20 mg orally about one hour pre-operatively.
2. Vasovagal reaction.
This may be associated with bradycardia and, in more severe cases, cardiac arrest, convulsion and shock. The treatment should include:
* Atropine 0.5 mg given intravenously (IV)
* Oxygen given by endotrachealtube at a rate of 4-6 litres/minute
* Adrenaline 0.5-1.0 ml of 1:100,000 solution given slowly IV
* Respiratory and cardiac resuscitation.
Pain may be prevented to some extent by the administration of non-steroidal anti-inflammatory drugs such as mefanimic acid, naprosene or fentanyl. It is prudent to have an anaesthetist available because about 2% of patients find the operationpainful and consideration must be given to completing it under general anaesthesia (Gordon, 1984).
4. Allergic reactions and anaphylaxis.
Any local anaesthetic should be given initially as a small test dose to determine if an unsuspected hypersensitivity exists. Obviously if it does, no more medication should be administered. If a reaction occurs it will be characterised by agitation,...