Complications are the limiting factors of all surgeries. More than performing the actual surgery, learning how to avoid complications before, during, and after surgery is the most important task of every surgeon. Severe complications can lead to patient death. Complications such as ureterovaginal fistulas, resulting from <2 s of inattentive preparation, can lead to years of hardship, suffering, accusation, and litigation. Excellent surgery is about performing the right surgery for the right patient without any complications. Minimally invasive surgery in complex cases is technically challenging. This article details the major causes of complications in laparoscopy for the gynecologic cancer patient and present strategies for prevention, early detection, and intra- and postoperative management.
Highlights
- •
In minimally invasive gynecologic oncology, all classically open surgical procedures for endometrial and cervical cancer can now be performed laparoscopically.
- •
A large body of literature has shown laparoscopic oncosurgery to be advantageous.
- •
Intraoperative complications are similar or less when compared to open surgery.
- •
The proper approach to complication-free laparoscopy requires a different mindset from open surgery.
- •
Particularly, improvements of visualization such as three-dimensional imaging systems have the potential to further reduce already low complication rates in advanced laparoscopy cases.
Incidence of and literature about complications: general considerations
Traditionally, intraoperative complications in advanced laparoscopic and minimally invasive surgery are thought to be no more common than in open surgery, whereas postoperative complications, mostly involving the abdominal wall, are much rarer . Additional evidence indicates that for endometrial cancer, the rate of severe intraoperative complications might actually be lower for laparoscopic surgery than for either abdominal or vagina surgery .
The literature, however, mostly excludes the more difficult learning curve of advanced laparoscopy, documenting only the results of very experienced surgeons, thereby making it difficult to assess the surgical reality in the field .
Studies dealing with surgical complications, specifically laparoscopic, are rare. The well-known “prospective randomized trial” that could – theoretically – identify complication-prone technology, techniques, or surgical approaches, does not appear to be useful, although some trials have examined the situation, mostly describing the status quo .
It is important to understand that contrary to conservative medicine, randomized treatment is not possible in surgery. The surgeon him/herself is the most important part of the treatment and thus cannot be randomized. Factors such as whether the surgeon is young or old, experienced or still learning, familiar or not with this particular surgery, tired that particular day, distracted, in a hurry, and under emotional pressure will cause surgical complications. Elaborate classification systems have been developed to reach at least a minimum of standardization with regard to complications .
However, the patient’s individuality in surgery is also different from that in conservative medicine. Height, weight, and comorbidity index can be controlled for, but not the myriad anatomical variations occurring in surgery daily. A patient who has undergone a midline laparotomy for diffuse peritonitis might present with the worst intra-abdominal adhesions possible or have no adhesions at all. How the surgeon might quantify adhesions depends more on his or her level of experience than on the actual extent of adhesive disease. As every surgeon knows, some patients who “should be easy” can present excruciatingly difficult anatomy, whereas some “difficult,” obese patients yield themselves to surgery far more than their slimmer counterparts – although in general, obese patients are more likely to be challenging cases .
Surgery is not merely a science but a craft and an art form. Not all aspects of surgical excellence can be scientifically assessed, as witnessed by the lack of extensive literature on the subject.
However, this subject can be investigated further.
Is laparoscopy different from open or vaginal surgery?
Laparoscopic surgery is mentally and physically more demanding on the surgeon and tends to have a longer learning curve than open surgery. This is mostly due to the more difficult management of intraoperative bleeding.
In open surgery, pressure can be applied to control (excessive) bleeding, often allowing for a short break and a moment of relaxation in surgery; laparoscopic surgery becomes more difficult with every additional amount of blood obscuring the surgical field. The generally low rates of laparoconversion observed in the literature reflect mostly on the fact that surgeons attempting laparoscopic advanced surgery tend to be experienced surgeons using additional caution when facing a new and challenging situation .
Laparoscopic surgery requires a completely different approach from open or vaginal surgery. Most surgeries require a refined technique, but laparoscopy requires a refined approach, especially in oncology cases.
Is laparoscopy different from open or vaginal surgery?
Laparoscopic surgery is mentally and physically more demanding on the surgeon and tends to have a longer learning curve than open surgery. This is mostly due to the more difficult management of intraoperative bleeding.
In open surgery, pressure can be applied to control (excessive) bleeding, often allowing for a short break and a moment of relaxation in surgery; laparoscopic surgery becomes more difficult with every additional amount of blood obscuring the surgical field. The generally low rates of laparoconversion observed in the literature reflect mostly on the fact that surgeons attempting laparoscopic advanced surgery tend to be experienced surgeons using additional caution when facing a new and challenging situation .
Laparoscopic surgery requires a completely different approach from open or vaginal surgery. Most surgeries require a refined technique, but laparoscopy requires a refined approach, especially in oncology cases.
Complications of indication
Laparoscopy has been well established for the treatment of an early-stage endometrial cancer: laparoscopic hysterectomy and laparoscopic pelvic and para-aortic lymphadenectomy. It has also been shown to be feasible in the treatment of early-stage cervical cancer: laparoscopic radical hysterectomy and laparoscopic pelvic lymphadenectomy . Diagnosis and staging are other important stages prior to laparoscopy in the oncologic population; the procedure involves simple diagnostic laparoscopy to assess the intra-abdominal situation or obtain a histologic diagnosis in unclear cases to lymph-node assessment in advanced cases in the preparation of radiation therapy.
Complications of indication are not concerned with laparoscopy. The decision to operate via any approach on a cervical cancer extending to the pelvic sidewall will lead surgical complications. “Indication is science, operation is art,” the proper indication for laparoscopic oncology is not different from that of open surgery. However, laparoscopy cannot be applied in all possible cases. Patients with multiple midline laparotomies and cancer recurrence can always be assessed laparoscopically through a Palmer’s Point incision, but the length of time required for laparoscopic adhesiolysis and the likelihood of its success need to be balanced against the overall time available and the willingness of the surgical team to proceed with this approach ( Table 1 ).
|
Intraoperative complications
Surgical complications must be avoided altogether. The following 20 “Frankfurt” points summarize the key issues to be addressed in the laparoscopic surgical theater for allowing a zero-tolerance atmosphere against laparoscopic complications. Such surgical “advice” always has a strong subjective component; consequently, this should not be viewed as rules, but rather as recommendations.
The assumption that experienced surgeons have fewer complications than inexperienced surgeons is probably true . This could be easily validated by devising a randomized trial; however, patients may be unwilling to participate in such a study on a daily basis.
Clinical experience combined with an extensive study of the existing literature has given rise to the following teaching points, which need not be practiced rigidly. Ultimately, the surgeon holds responsibility in every surgical theater. He or she must decide, case by case, the best guidelines and the best approach ( Table 2 ).
|
Intraoperative complications specific to laparoscopic oncology cases and how to avoid them
- a)
Entry-related Complications
Laparoscopic entry can potentially lead to catastrophic vascular or bowel injury, even though the overall incidence is very low. This is true for both benign as well as oncology cases. The incidence of entry injury is highly dependent on the surgeon’s experience and the attention that is being paid to this seemingly routine moment of the surgery.
The most recent Cochrane review of the subject did not find different rates of complications with either open laparoscopy or the direct Verres needle approach .
- b)
Cervical Cancer
Overall, the safety and efficacy of laparoscopic radical hysterectomy has been documented in many studies. The overall intraoperative complication rate tends to be lower than in open cases with the postoperative rate clearly lower as expected .
Laparoscopic radical hysterectomy for operable cervical cancer has two critical surgical steps: dissecting the ureters away from the cervix/vagina to allow for resection of a sufficient vaginal cuff and taking down the rectum posteriorly, developing the complete rectovaginal septum for that same reason.
The classical complications of radical hysterectomy apply for both open and laparoscopic cases: development of an ureterovaginal fistula and development of an atonic bladder (inability to void the bladder) .
In general, ureterovaginal fistula has become a rare complication in laparoscopy because of the better visualization and avoidance of suture material.
However, the use of thermic sealing instruments poses another threat: intraoperatively invisible thermic injury to the ureter, leading to postoperative necrosis and possibly fistula formation. Increased bleeding from the vessels surrounding the tunnel of Wertheim can create the need for extensive coagulation, leading to an increased chance of thermic injury. Constant gentle distancing of the ureter combined with classical protective tension on the ureter are two important strategies to protect the ureter during this difficult dissection.
By contrast, because of the “blood-less” approach combined with the magnifying effect of video laparoscopy, nerves can be better visualized, allowing for nerve-respecting or even nerve-sparing surgery.
At the same time, because of the easier access to the small spaces of the pelvis, radicality in laparoscopy must be well controlled.
Comparison with open radical hysterectomy has shown intraoperative complications to be slightly less than in open surgery. Vessel injuries lead to conversion to laparotomy rather than any other intraoperative complication. Postoperative complications, mostly due to problems secondary to laparotomy, were more common in open cases .
- c)
Endometrial Cancer
With regard to cervical cancer, the equivalency of the laparoscopic and open approaches has been amply documented .
The challenges in laparoscopic endometrial cancer surgery are mostly pelvic and para-aortic lymphadenectomy. A meticulous dissection of the internal iliac artery and the accompanying ureter is usually not necessary. A typical complication of pelvic lymphadenectomy is injury to the sensible nerves running along the psoas surface (genitofemoral nerve). Lymphocele formation involves long-term sequelae, but no intraoperative “wrong steps” have been found to explain their postoperative occurrence.
As part of pelvic and para-aortic lymphadenectomy, injury to the large veins is one of the most challenging complications, particularly injury to the vena cava perforators in the lower third of the inferior vena cava just above the bifurcation. Most of these bleeders can be controlled by applying prolonged pressure. The defect rarely needs to be reapproximated with a PDS 4/0 suture. These venous bleeders can be avoided by not applying much traction on the lymph nodes during dissection (i.e., no blunt dissection) and all structures must be coagulated before dissection .
- d)
Positioning -Injuries
The general assumption regarding the prevalence of positioning injuries in laparoscopic surgery remains unclear. Both padding and dry positioning are important for laparoscopy similar to other surgeries. The increase in the number of compartment syndromes due to the combined use of Trendelenburg positioning and leg rests has been speculated. No overall increase has been reported although occasional compartment syndromes have been described in conjunction with laparoscopy.
- e)
Conversion to Laparotomy
Conversion to laparotomy should not be considered as a complication as it only replaces one possible legitimate approach with another. In fact, not performing laparotomy where required can lead to unnecessary complications. Laparotomy should not be considered either as a complication or as a failure ( Table 3 ).
