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Chapter: Clinical Cases in Anesthesia : Laparoscopy

What are the complications of laparoscopic surgery?

The complications associated with laparoscopic surgery are:

What are the complications of laparoscopic surgery?


The complications associated with laparoscopic surgery are:


·  Overall mortality rate 0.1–1.0 per 1,000 cases

·  Postoperative nausea and vomiting (40–75% of patients)

·  Shoulder pain

·  Bowel perforation 0.06–0.4% with a mortality rate of 5%

·  Bladder/ureter injuries 2 per 10,000 cases

·  Vascular injuries

·  Gynecologic injuries 0.64%

·  Gastrointestinal, urologic injuries 0.03–0.06%

·  Significant hemorrhage in 2–9 per 1,000 cases, often delayed

·  Nerve injuries from improper positioning: peroneal/ femoral neuropathies, meralgia paresthetica

·  Subcutaneous emphysema from extraperitoneal insufflation

·  Pneumothorax, pneumomediastinum

·  Venous gas embolism

·  Volume overload from excessive fluid administration, decreased insensible losses and decreased urine production


Deep vein thrombosis

·           Increased risk of regurgitation from IAP along with the Trendelenburg position

Subcutaneous Emphysema


Subcutaneous emphysema (SQE) is a known complica-tion of laparoscopic surgery. It may occur as a result of acci-dental extraperitoneal insufflation or may be considered unavoidable in certain laparoscopic procedures that require intentional extraperitoneal insufflation, such as inguinal her-nia repair. SQE is identified by the development of crepitus over the abdominal wall, excessive changes in airway pres-sures, or by increasing ETCO2 concentrations over time.

When SQE does occur, the area for diffusion of CO2 increases and this may lead to hypercarbia and respiratory acidosis.


In most cases, no specific intervention is necessary other than the discontinuation of N2O, if it is being used. SQE resolves soon after deflation of the abdomen. However, as there exists a “continuum of fascial planes,” SQE could potentially extend from the abdomen to the thorax and neck, resulting in pneumothorax or pneumomediastinum. If SQE is suspected, a chest radiograph should be obtained for confirmation. Although the treatment may not change, having the diagnosis is important for future management of untoward events, for example, cardiovascular collapse. The presence of SQE does not necessarily contraindicate extubation, yet it should be emphasized that it may predis-pose to laryngeal swelling, difficult spontaneous respira-tions, and difficult reintubation. It is recommended that controlled mechanical ventilation be maintained until hypercarbia is corrected to avoid the increase in work of breathing, especially in compromised patients.




Pneumothorax is a rare yet potentially life-threatening complication of laparoscopic surgery with increasing inci-dence over recent years as a result of an increasing number of procedures involving dissections at the esophageal junc-tion (e.g., Nissen fundoplication). Pneumothorax occurs when gas traverses into the thorax, either through a tear in the visceral peritoneum, disruption of the parietal pleura during dissection around the esophagus, or through a con-genital defect in the diaphragm. Pneumothorax may be asymptomatic or may be associated with hypotension or cardiac arrest resulting from the impairment of cardiac filling and limitation of lung excursion. When CO2 pneumothorax occurs without pulmonary trauma, spontaneous resolution may occur within 30–60 minutes after abdominal defla-tion. If the pneumothorax is large or symptomatic, thora-cocentesis should be performed without delay. N2O, if used, should be discontinued and the IAP should be reduced. Ventilation should be adjusted to correct hypox-emia, applying positive end-expiratory pressure (PEEP) if necessary. If the pneumothorax results from trauma to the lung itself, PEEP should be avoided.

Venous Gas Embolism


A rare, yet potentially fatal complication of laparoscopy is that of venous gas embolism (VGE). The estimated incidence is 0.002–0.08%. When it occurs, it brings with it the potential for significant hemodynamic compromise. VGE develops most commonly during the first few minutes after the devel-opment of the pneumoperitoneum. This occurs more frequently in patients who have had prior abdominal surgery.


Gas bubbles enter the venous system via vessel tears in the abdominal wall or peritoneum and enter the heart and pulmonary circulation. When clinically significant, the right ventricular outflow tract is obstructed, producing a constellation of signs and symptoms: a “mill-wheel murmur,” sudden hypotension, decrease in cardiac output, tachycardia or other dysrhythmias, pulmonary edema, hypoxemia, increased airway pressures, and jugular venous distention and facial plethora/cyanosis from inflow obstruction to the right heart. The ETCO2 response is biphasic. Firstly, an initial increase in ETCO2 occurs secondary to the pulmonary excretion of CO2. Then, a decrease in ETCO2 occurs because of a decrease in cardiac output and an increase in physiologic dead space. When this occurs, the N2O should be discontinued (if being used), and the patient should be placed in the left lateral decubitus position, with steep head-down tilt to prevent entry of the bubbles into the pulmonary arterial circulation. The patient should be hyperventilated to eliminate CO2. If a central venous catheter is in place, it should be aspirated in an attempt to remove gas emboli. Hyperbaric oxygen, cardiopulmonary bypass, and external cardiac massage are all measures that may be necessary in extreme situations.


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