How to prevent and deal with the complications of endoscopic surgery

Ⅰ. Subcutaneous emphysema

Subcutaneous emphysema is the most common pneumoperitoneum complication, and the incidence of subcutaneous emphysema is as high as 2.7%.

1. Common reasons

(1) Patient factors: patient weight and thickness of subcutaneous fat are closely related to the occurrence of subcutaneous emphysema, mainly due to the lack of subcutaneous adipose tissue in extremely emaciated patients, the weak blocking effect of adipose tissue on gas, and the rapid diffusion of gas along the subcutaneous to form subcutaneous emphysema.

(2) Puncture technique, pneumoperitoneum needle is located in the extraperitoneal space: During the establishment of pneumoperitoneum needle blind penetration, the patient was obese and the abdominal wall was thick, the needle did not enter the abdominal cavity and injected gas, which directly formed subcutaneous emphysema.

(3) Due to the complicated operation and long operation time, frequent replacement of instruments and removal of puncture apparatus increased the occurrence of subcutaneous emphysema.

2. Performance

(1) In mild cases, the skin around the casing is swollen, and there is a feeling of twisting or holding snow when pressed:

(2) In severe cases, the skin swelling is more obvious and extensive, spreading up and down along the chest and abdominal wall, reaching the neck, head and face, down the perineum and lower limbs (men can appear scrotal emphysema), which can lead to hypercapnia, acidosis, and even cardiopulmonary dysfunction;

(3) The injection of little star gas but quickly reach high pressure or abdominal expansion is not uniform, percussion drum sound is not obvious should be highly suspected that the pneumoperitoneum needle is located in the extraperitoneum.

3. Prevention and treatment

① During the operation, the position of the pneumoperitoneum needle should be ensured correctly, and CO2 injection should be avoided in the extraperitoneal space after entering the abdominal cavity. When the pneumoperitoneum is initially connected, the pressure usually does not exceed 7~8mmHg, and a small pneumoperitoneum pressure should be applied during the operation to maintain the operating space. When the pneumoperitoneum was established, water injection test was performed with the syringe to confirm that the pneumoperitoneum needle really entered the abdominal cavity and then CO2 gas was filled.

② If the pneumoperitoneum needle is suspected to be extraperitoneal, it should be stopped immediately and re-punctured.

③ Tap each quadrant of the abdomen to determine the symmetrical drum sound;

④ After the pneumoperitoneum needle enters the abdominal cavity, the puncture needle is fixed to prevent external migration, and the change of flow rate of the pneumoperitoneum machine should be observed;

⑤ When suturing the fixed cannula, the muscle layer and fascia should be sutured simultaneously;

⑥ Try to shorten the operation time, especially in the elderly, the abdominal wall is relaxed, and the gas is easy to spill;

⑦ Normal cardiopulmonary function, mild subcutaneous emphysema more need not be treated, 24 to 48 hours self-absorption;

⑧ Severe subcutaneous emphysema, need to give hyperventilation, ventilator pressure oxygen, reduce the pneumoperitoneum pressure (10mmHg below), if necessary, temporarily suspend the operation

Ⅱ. Hypercapnia and hypoxemia

1. Common reasons

(1) Inappropriate artificial pneumoperitoneum pressure (too high abdominal pneumoperitoneum pressure (>15mmHg))

(2) Special positions of laparoscopic surgery, such as the use of low head and high foot during the operation (pelvic and gynecological operations, etc.), can elevate the diaphragm, restrict the movement of the bottom of the lung, and reduce lung compliance, affecting ventilation function, resulting in hypercapnia and hypoxemia in patients. It mainly occurs in patients with pre-existing lung dysfunction and in the case of longer operation time.

2. Prevention and treatment

(1) During the operation, blood oxygen saturation and arterial blood gas analysis can be detected early. Once found, hyperventilation, inhalation of high concentration oxygen and intravenous infusion of 5% sodium carbonate should be given;

(2) Strictly grasp the indications of laparoscopic surgery, and patients with poor cardiopulmonary function should be cautious during surgery;

(3) pneumoperitoneum pressure should not be too high, 10~15mmHg can be;

(4) Shorten the operation time as much as possible. For patients with more than 4 hours of operation, the blood gas analysis results should be dynamically detected during the operation, and the pneumoperitoneum should be temporarily interrupted if necessary to discharge CO2.

Ⅲ. Pneumothorax and mediastinal emphysema

Laparoscopic pneumoperitoneum is rare, but it is a very dangerous complication.

1. Common reasons

(1) High pneumoperitoneum pressure and negative thoracic pressure allows gas in the abdominal cavity to enter the mediastinum and pleural cavity through the abdominal gap at the aorta or esophageal hiatus.

(2) Congenital diaphragm defect or diaphragm injury during surgery, so that the gas in the abdominal cavity directly into the pleural cavity:

(3) Congenital lung diseases, such as pulmonary bulla rupture during the operation;

(4) pneumothorax can also be caused by injury of trachea by general anesthesia intubation, excessive positive pressure breathing pressure and failure of pressure control of pneumoperitoneum machine.

2. Suspicious performance

① unexplained decrease of blood oxygen saturation;

② The tidal volume decreases with the increase of gas resistance;

③ Unexplained hemodynamic changes;

④ If signs of pericardial tamponade appear, the possibility of pericardial aeration should be highly suspected.

3. Prevention and treatment

In a small number of pneumothorax and mediastinal emphysema, breathing and SpO2 have not been affected, and can not be treated

Pneumothorax occurring at the beginning of surgery or during operation should be immediately suspended and pneumoperitoneum should be removed, and closed thoracic drainage should be performed. After the patient's condition has improved, the pneumoperitoneum can be re-established, and if the vital signs are stable at this time, the surgery can be continued.

If the pneumothorax occurs at the end of the operation, as long as the patient's vital signs are stable, the operation can be continued, and closed induction should be performed if necessary.

Ⅳ. Gas embolism

Gas embolism is a rare complication of pneumoperitoneum, but its consequences are very serious and mortality is high

Common cause

(1) The pneumoperitoneum needle strayed into the internal abdominal vein, and the gas directly rushed into the blood in a short time and entered the blood circulation;

(2) During the operation, large veins (such as writing veins, inferior vena cava, etc.) were injured, and high pressure gas entered the blood wave circulation through the venous tear, resulting in gas embolism.

2. Performance

(1) The end-tidal CO2 pressure increased sharply, the blood oxygen saturation suddenly decreased, and then the end-tidal CO2 pressure decreased significantly;

(2) Blood pressure decreased, central venous pressure increased, pulmonary artery pressure increased, cardiac auscultation can appear grinding wheel murmur;

(3) Precardiac ultrasonography and transesophageal ultrasonography can assist in diagnosis.

3. Prevention and treatment

(1) Before aeration, it should be confirmed that the pneumoperitoneum needle has not penetrated the blood vessel;

(2) If the vein rupture occurs during the operation, the tear should be clamped quickly, and repaired or ligation in time;

(3) Intraoperative detection of central venous pressure and pulmonary artery pressure is helpful for early diagnosis;

(4) Once a gas embolism occurs, it must be treated immediately.

① Suspend gas injection and relieve pneumoperitoneum to terminate the source of gas embolism;

② Inhale pure oxygen to reduce hypoxic damage to tissues and organs;

③ The left lying position ensures the blood supply of the left heart and systemic circulation;

④ The gas in the right atrium, right ventricle and pulmonary artery is aspirated by rapid central vein catheterization;

⑤ Air bubbles can be extracted by direct puncture of right atrium in emergency.

Ⅴ. Pneumoperitoneal arrhythmia

Pneumoperitoneum arrhythmia is not uncommon, but its exact cause is still unclear, in addition to the surgeon's own state, pneumoperitoneum should also be an important incentive.

1. Common reasons

A Rapid aeration of the abdominal cavity results in peritoneal dilation stimulation, and abdominal stretch receptors excite the vagus nerve, causing arrhythmia.

B. When the internal abdominal pressure increases, the inferior vena cava return is blocked, resulting in a decrease in the return blood volume and a change in cardiac systolic function, resulting in arrhythmia.

Prevention and treatment

Low flow gas injection first, and then gradually increase the gas injection speed after the body ADAPTS to it. Especially for the elderly, patients with cardiopulmonary diseases and other high-risk factors, the injection of heated CO2 gas can also be used to prevent the occurrence of pneumoabdominal arrhythmia.

Pneumoperitoneal arrhythmias can usually be improved by stopping gas injection and releasing the pneumoperitoneum, and medical treatment is required in severe cases.

Ⅵ. Postoperative shoulder pain

Right shoulder pain is common and occurs 1-2 days after surgery.

1. Common reasons

A. Continuous pneumoperitoneum leads to phrenic nerve tension.

B. Residual CO2 is absorbed into the blood to form carbonic acid, which stimulates the phrenic nerve and produces shoulder reflex pain.

2. Prevention and treatment

(1) pneumoperitoneum pressure was reduced during the operation.

(2) After operation, CO2 and fluid in the abdominal cavity were absorbed; Hypophrenic warm saline irrigation; Pulmonary reexpansion.

(3) Postoperative oxygen inhalation promoted O2 and CO2 exchange and accelerated CO2 discharge.