How to spot a complication
Whilst laparoscopic surgery confers many advantages to patients, abdominal complications have more subtle clinical presentations than is usual after an equivalent operation carried out by a traditional laparotomy incision. This is probably because the patient has not been subject to the stress of a major laparotomy and thus has near normal and resilient physiological responses. It is thus vital that intraperitoneal complications are recognised rapidly and corrected expeditiously. If remedial surgery is performed promptly the patients recover quickly. Sadly, bile leakage, bleeding and peritonitis often remain undiagnosed until circulatory collapse and septic shock occur.
Remember, that the majority of patients who undergo a laparoscopic operation will have relatively little pain and they are eager to mobilise. Appetite is hardly depressed at all and pain is usually localised to the site of specimen extraction.
It is vital to think of an abdominal complication if any of the following symptoms/signs develop after 12 hrs of surgery.
- Pain requiring opiate analgesia
- Anorexia or reluctance to drink
- Reluctance to mobilise
- Nausea & vomiting
- Abdominal tenderness (may not have guarding)
- Abdominal distension
- Poor urine output
- Cardiac arrythmia
If no action is taken, it is likely that precipitous circulatory collapse and organ failure will occur.
The nursing and house staff should ensure that any patient who exhibits any of these signs should be reviewed ASAP by a senior member of the surgical staff (consultant if necessary) who needs to evaluate the patient in the context of the individual procedure that they have undergone. Whilst few patients will come to any harm if they undergo an unnecessary investigation, most will if a complication goes unrecognised for an unwarranted period of time.
- Ultrasound is extremely unreliable
- Re-laparoscopy offers prompt diagnosis and the possibility of laparoscopic lavage and corrective surgery.
- Whilst CT can be appropriate it is often wrong and mearly gives a false reassurance
Remember, do not deceive yourself. If the patient is not wanting to go home something has happened. Sort them out ASAP and all will be OK.
Bristol Laparoscopic Associates policy is to ensure that all patients on discharge are given appropriate contact details of the NBT (Frenchay) or BRI emergency on-call SpR and are instructed to attend the hospital direct (A&E) rather than visit their GP or another hospital if they feel unwell.
Minor complications include:
Scrotal bruising is common and is largely a function of hernia size. It will resolve in a week. In large hernias, a haematoma frequently collects in the sac remnant - unlike a hernia recurrence there is no cough impulse. Occasionally there will be some bruising around the umbilicus and very rarely a haematoma will drain through the wound. Reassurance and conservative management is the order of the day.
Sutures are dissolvable and drop off - sometimes it takes a few weeks
The wound edges are always a little red when using absorbable material
35/1000 develop exercise induced, self-limiting (4-8 wks) thigh pain (lateral cutaneous nerve neuropraxia). This responds to Amitriptyline 10-30mg nocte.
2/1000 develop palpable scar tissue around the mesh.
Bristol Laparoscopic Associates place no restrictions on postoperative activity. Most patients can drive within 3 days and return to sedentary employment. Contact sports and physical employment can be resumed after 2 weeks.
Laparoscopic pelvic floor corrective surgery.
Evacuatory problems are common (present preoperatively) and usually respond to oral senna ii nocte & ii glycerine supps following breakfast. Occasional a microlax enema is required. Movicol is occasionally required.
An occasional patient develops genuine stress incontinence and will require urological workup eg., TVT
Bruising around the ports is common (esp the 12mm)
The RIF port may cause nerve irritation/neuropraxia - Amitriptyline 10mg can help
Laparoscopic resectional surgery
Small bowel obstruction (colic, vomiting) through a 12mm port occurs in 1%
Anastomotic disruption occurs in approx 4% cases. May be subtle with malaise, anorexia, incontinence, vaginal discharge (see above). If the patient is not right ask for them to be reviewed.
Constipation. If the patient is well (see above) is generally safe to prescribe mild laxatives