However, the open-entry technique was used on special indications and in only 2. These 81 gynecologists reported 20, closed-entry procedures and open-entry procedures and complication rates of 0. Therefore there is no evidence to prefer one technique in laparoscopic access.
To select the kind of access a recent study gives some useful recommendations: 1 use left upper quadrant entry in patients with suspected adhesions or umbilical hernia 2 limited movement of the inserted Veress needle 3 an intraperitoneal pressure less than 10 mmHg is a reliable indicator of correct placement of the Veress needle 4 the angle of the Veress needle should be at entry 45 degrees in non-obese patients and 90 degrees in obese patients.
Direct insertion of the trocar without prior pneumoperitoneum is associated with less insufflation-related complications such as gas embolism, is faster to perform and is a safe alternative. The visual entry cannula system may provide advantages over the traditional techniques but has to be fully explored in the future [ 59 ]. The seriousness of vascular injury is high in comparison to visceral injuries during the abdominal access. These cases are rare and no evidence based recommendations of treatment can be given.
Injuries to the main vascular structures need an immediate conversion and surgical repair. Small bowel injuries can be treated laparoscopically. Severe lesions sometimes require segment resections and conversion to open surgery. Injuries of the liver or spleen are manageable with laparoscopic devices. If severe bleeding continues a pre-emptive laparotomy is recommended see also next section. There is limited data regarding iatrogenic injuries in colorectal surgery. The main fears of the surgeon are vessel injury, damage to the spleen during colorectal surgery incidence of 0.
Injuries to the abdominal or pelvic veins occur mainly in patients undergoing oncologic resections, and those with difficult anatomic exposure, owing to previous operation, recurrent tumor or radiation therapy.
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Most of the injuries can be repaired by primary suture or end-to-end anastomosis. Few injuries need interposition grafts, patch venoplasty or venous ligation. Therefore a vascular surgeon should be available in hospitals where cancer resections are frequently performed [ 61 ].
Iatrogenic perforation of the bowel occurs either during adhesiolysis or inadvertently due to thermic lesion, the latter are often not recognized during the operation. The surgeon should prefer primary repair or resection with anastomosis. In laparoscopic cases the bowel injury should be sutured immediately as it might be difficult to localise later [ 62 , 63 ]. In general, the incidence of iatrogenic splenic injury is underestimated because of poor documentation. Splenectomy is considered a poor prognostic factor [ 55 , 64 ].
Splenic injury results in increased blood loss, longer hospital stay and higher mortality and infection rates. Splenic injury can be reduced by achieving good exposure, avoiding undue traction and careful division of splenic ligaments and adhesions. If the spleen is injured preservation is desirable and often feasible [ 65 ]. To date, data available concerning studies which compare the safety of surgical devices are limited. Conventional monopolar electro-surgery has several short-comings in laparoscopic surgery including the risk of thermal injury, difficult hemostasis and disturbing smoke production, making the use of additional tools like bipolar graspers, sutures or clips necessary.
To overcome these problems and to reduce instrument changes, number of trocars and operation time, several multifunctional tools have been developed. The most popular devices are electro thermal bipolar vessel sealers and ultrasonically coagulating shears. In a recent prospective randomized study we could show that bipolar vessel sealers and ultrasonic coagulation shears shorten dissection time in laparoscopic left-sided colectomy and are cost-effective compared to monopolar electro surgery. Other studies showed less operative blood loss and a decrease in operating time when the ultrasonic dissection device were used.
For now it is still the preference of the surgeon as to which device is used [ 66 , 67 ]. Preoperative anemia and intraoperative blood transfusion are independent risk factors for intra- and postoperative complications in colorectal surgery [ 5 ]. To prevent intraoperative blood loss and postoperative complications some laparoscopic surgeons prefer ultrasonic dissection with produces significantly less blood loss and thereby iron supplementation in preoperative anemic patients two weeks prior to surgery [ 69 ]. One of the initial arguments to discredit laparoscopy was the index of conversion, which was interpreted as operative failure.
However, today conversion is no longer considered a failure, but as result of good clinical judgment. Independent predictive risk factors for conversion are BMI odds ratio of 2. The Laparoscopic Colorectal Surgery Study Group showed in a multicenter study with 1' patients a conversion rate of only 5. Converted patients were significantly heavier body mass index Specific indications for conversion were technical problems, adhesions, bleeding, abscess, fistula, inflammatory mass and bowel perforation.
The effect of conversion on morbidity and mortality is discussed controversially in the literature. Recent studies describe similar outcome after conversion compared to the open access [ 71 , 73 ]. However, large randomized trials clearly demonstrate increased morbidity and loss of short-tem benefits in converted patients [ 49 , 74 ]. Obesity is associated with a higher conversion rate but the outcome of converted patients seems to be similar to the open cases [ 26 ].
In another study obesitiy was not a risk factor for conversion [ 75 ]. The value of prophylactic drainage in colorectal surgery has been studied extensively. Currently available data from randomized controlled trials point out that a routine prophylactic drainage provides no benefit after uncomplicated major colon and rectal surgery [ 76 ]. On the contrary, a no drain policy was associated with less wound infections and a fewer anastomotic leaks. These studies underscore the low sensitivity of drains in detecting leakage and bleeding, which questions the putative warning function of a prophylactic drain.
In summary, there is sufficient evidence showing that routine drainage after colorectal anastomoses does not prevent leaks or other complications [ 77 , 78 ]. A stoma may be a temporary solution when there is a dysfunction of a colostomy or ileostomy however the advantages are still under debate.
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One group argues that a protective stoma is only indicated in low rectal resections in patients with significant comorbidities, neoadjuvant radiochemotherapy and feculent peritonitis [ 79 ]. If adjuvant radiochemotherapy is considered postoperatively in patients with a colorectal carcinoma the closure of the temporary loop ileostomy should be performed before the chemotherapy to minimize complications [ 80 ]. Other groups do not recommend a stoma at all or only when the colorectal anastomosis is in the lower third of the rectum [ 81 , 82 ].
In emergency situations with peritonitis and perforation of the left colon primary anastomosis and protective ileostomy should be performed rather than a Hartman's procedure [ 83 , 84 ]. The duration of the operation is influenced by many factors such as; surgical technique open or laparoscopic , intraoperative complications, prior abdominal surgery, surgeon's experience and the operating team. Many studies showed that prolonged operating time correlated with higher intra- and postoperative complications. In a series of colorectal anastomoses between and at a single colorectal unit, univariate analysis showed that a prolonged operating time had an odds ratio of 2.
Probably, the negative effect of the prolonged operating time in laparoscopic surgery is overrun by advantages such as decreases in-hospital stay, wound infection, postoperative ileus and postoperative pain. However, there is a lack of well designed studies evaluating the influence of the operating time on postoperative outcome as a primary endpoint. The majority of advancements in the care and survival of surgical patients have occurred in the postoperative period.
These advances include changes in postoperative feeding, activity, pain control, ulcer and deep venous thrombosis prophylaxis. Here, we give a short update of current trends in postoperative analgesia and diet. The decreased length of hospital stay due to more cost effective outpatient procedures necessitates good postoperative pain management. It has been demonstrated that well managed pain control supports respiratory function and lowers the risk of complications [ 87 ].
In colorectal surgery the major modalities of postoperative pain control are patient-controlled anaesthesia, opioids, nonsteriodal anti-inflammatory drugs, and epidural anaesthesia. Some studies show that pain control, patient satisfaction and bowel function are improved after abdominal surgery under epidural analgesia [ 88 ]. Carli et al. Postoperative complication rates and length of hospital stay was not shown to be improved in this study [ 89 ].
Another study demonstrated that continuous epidural analgesia is superior to patient controlled opioid analgesia in relieving postoperative pain for up to 72 hours, but was associated with a higher incidence of pruritus [ 90 ]. Epidural anesthesia has a low complication rate, however, if complications occur they are mostly severe. The risk of a symptomatic spinal mass lesion after patient-controlled epidural analgesia was 0. Another recent study demonstrated that epidural analgesia reduced the need for prolonged ventilation or reintubation, improved lung function, increased blood oxygenation, reduced risk for pneumonia, to the contrary increases the risk of hypotension, urinary retention, and pruritus.
Despite the advantages of epidural anesthesia its use alone cannot prevent postoperative morbidity and mortality. It is therefore necessary to address its use in the context of multimodal intervention.
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The resumption of a diet is critical to the recovery. Traditionally, patients received a nasogastric tube decompression and were set on a "nil per os diet" postoperatively. Different trials failed to show that a nasogastric tube has any postoperative benefits for the patient, causing most surgeons to abandon its routine use [ 93 ]. There is much variability in regards to restarting enteral nutrition in patients undergoing colorectal surgery. Several trials demonstrated that the majority of patients tolerated oral intake in the immediate postoperative period, regardless of the presence or absence of traditional markers of normal gastrointestinal function.
In a metaanalysis of patients it was seen that reduced postoperative infections, reduced anastomotic complications and shorter length of stay was shown in patients who received immediate postoperative normal diet compared to patients who were fasted until gastrointestinal functions were resumed [ 94 ].
In a recently published analysis the advantages of early enteral feeding were not significant but showed a trend towards fewer postoperative complications [ 95 ]. Another metaanalysis of 13 trials 1' patients came to the conclusion that there is no obvious advantage in keeping patients 'nil per os' following gastrointestinal surgery.
Early enteral nutrition was associated with reduced mortality. This review supports the notion that early commencement of enteral feeding may be of benefit compared to the nothing by mouth policy [ 96 ]. In the last few years Kehlet et al. Current results from fast-track colonic surgery suggest that postoperative pulmonary, cardiovascular, and muscle function are improved and body composition preserved as well as a normal oral intake of energy and protein can be achieved.
Consequently, hospital stay is reduced to about days, with decreased fatigue and need for sleep in the convalescence period. Despite a higher risk for readmissions, overall costs and morbidity seem to be reduced [ 97 - 99 ]. A recent randomized study by our group compared the day complication rate of patients who underwent a fast track protocol or standard care after open colonic surgery.
The fast-track protocol significantly decreased the number of complications 16 of 76 in the fast-track group vs. Fluid restriction and effective epidural analgesia were the key factors that determine outcome in the fast-track program [ ]. In summary, there is a growing body of evidence that early enteral nutrition improves outcome and reduces postoperative complications.
Despite proven advantages of fast track surgery the implementation of a standardized and multidisciplinary care is difficult since resistance is still enormous. These complications have different influences on outcome and have to be diagnosed accurately. In order to meet certain quality standards it is essential to assess postoperative complications [ ]. Colorectal operations are, at best, clean-contaminated procedures, and at times there is contamination of both the peritoneal cavity and the surfaces of the surgical wound.
In addition, the diseases of the large bowel that require surgery tend to afflict elderly patients. Collectively, the combination of an unclean environment, major surgery and debilitated patients creates a situation that is associated with a very high incidence of wound infection. Some studies showed that perioperative oxygen supply and preoperative immunonutrition decreased SSI significantly [ , ]. It is widely accepted that a laparoscopic approach lowers the rate of SSI [ 36 , ]. As for laparoscopic appendectomies [ ], most surgeons use plastic wound protectors during specimen removal after laparoscopic resection.
This certainly facilitates extraction through a small incision, but there are no randomized controlled trials demonstrating a reduction in wound infection. The role of antibiotic prophylaxis in preventing postoperative complications in colorectal surgery is well established through many studies.
However, there is still a debate about the duration of the antibiotic treatment and the kind of antibiotic which should be used. In summary, most studies favour one to three intravenous doses of a second generation cephalosporine with or without metronidazole with the first dose being administered before skin incision [ , ]. Anastomotic leakage is the most serious complication specific to intestinal surgery and ranges from 2. At least one third of the mortality after colorectal surgery is attributed to leaks.
Within this context, knowledge of factors influencing anastomotic healing appear even more important [ 81 , ]. However, there is lack of a clear definition for what constitutes an anastomotic leak radiological proven, clinically relevant, with or without abscess. In general, the leakage rate for intraperitoneal anastomoses is significantly lower than for extraperitoneal anastomoses. Male gender, a history of previous abdominal surgery and the presence of a low cancer remained significant after multivariate analysis [ 13 ].
The risk of anastomotic leakage was 8. Most studies comparing high and low anterior resections have shown that the level of anastomosis is the most important predictive factor for leakage. There seems to be no significant difference in leakage when comparing a handsewn and a stapled technique regardless of the level of anastomosis [ ]. Intraoperative problems and postoperative strictures seem to be more frequent in stapled anastomosis [ ].
However, in a recent Cochrane review ileocolic stapler anastomoses were associated with fewer leaks than handsewn anastomoses [ ].
Prevention and Treatment of Complications in Proctological Surgery
The available data comparing the anastomotic leakage rate in laparoscopic or open operated patients showed no difference regardless of the level of the anastomosis [ ]. In cancer patients anastomotic leakage regardless of open or laparoscopic technique is associated with poor survival and a higher recurrence rate after curative resection [ , ].
Because of the severity of the complications associated with an anastomotic leak, it is imperative to identify the problem and act as early as possible. Most groups base the diagnosis on clinical symptomatic leakage, manifested as gas, purulent or fecal discharge from the drain, purulent discharge from the rectum, pelvic abscess or peritonitis. It is usually necessary to obtain objective tests of anastomotic integrity because of the non-specific clinical signs.
Water soluble enemas or CT scans are widely used for diagnosis of anastomotic leak. Interestingly, in two recent studies anastomotic leaks were more often diagnosed late in the postoperative period and more often after hospital discharge, or 12 days postoperatively [ , ]. Anastomotic leaks may be divided into those which are clinically significant and those which are not.
Subclinical leaks are more benign in their natural history compared with clinical leaks although quality of life and bowel function does not differ in these groups [ ]. With signs of free anastomotic leckage in the abdominal cavity by CT scan the indication for surgery is mostly given. Despite the good results with conservative therapy including antibiotics , the indication for surgical repair of anastomotic leakage should be made as early as possible to improve patient outcome.
Re-laparoscopy and lavage after laparoscopic operation is feasible and safe and has less postoperative complications than an open re-intervention [ ]. In general postoperative bleeding after colorectal procedures is a rare complication. The risk depends on the performed surgical procedure, the co-morbidities of the patient and in individual cases on an impaired clotting system.
In the initially postoperative phase abnormal heart rate and low blood pressure should be reported and interpreted by the surgeon. Haemoglobin and hematocrit measurements can help to determine a blood loss. Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment costs. The pathophysiology of postoperative ileus is multifactorial. The operating time and intraoperative blood loss are independent risk factors for a postoperative ileus [ ].
Postoperative ileus can develop after all types of surgery including extraperitoneal surgery. A variety of treatment options have been reported. However, it is difficult to compare these studies because of of the different anesthesia protocols used and patient comorbidities differed significantly. Paralytic postoperative ileus is usually treated with a combination of different approaches. These include limitation of narcotic use by substituting alternative medications such as nonsteroidals and the placement of a thoracic epidural with local anesthetic.
The selective use of nasogastric decompression and correction of electrolyte imbalances also are important factors to consider. Here, we summarize the main complications of colorectal surgery which are important to the specialist, the general surgeon and the gastroenterologist as well. We also tried to show strategies to minimize intra- and postoperative complications. Development in treatment strategies and technical inventions in the recent decade have been enormous.
This is mainly due to the laparoscopic approach, which is now well accepted. Training of the surgeon, hospital volume and learning curves are becoming more important to maximize patient safety, evaluate surgeon expertise and calculate cost effectiveness. In addition, standardization of postoperative care is essential to minimize postoperative complications.
PK has made substantial contributions to conception and design, acquisition of data and interpretation of data. DH has been involved in drafting the manuscript and has given final approval of the version to be published. PAC has revised the manuscript critically for important intellectual content and participated in its design. All authors read and approved the final manuscript. National Center for Biotechnology Information , U. A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results.
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Early quality of life outcomes following Doppler guided transanal hemorrhoidal dearterialisation: a prospective observational study. Acta Gastroenterol Belg ; 76 Suppl 2 Pak J Med Sci ; 29 Suppl 1 Advantages of transanal hemorrhoidal dearterialisation as compared to other surgical techniques for the treatment of hemorrhoidal disease. Khirurgiia ; Prospective randomized multicenter study comparing stapler hemorrhoidopexy with doppler-guided transanal hemorrhoids dearterialization for third degree hemorrhoids.
Colorectal Disease ; 14 Suppl 2 Comparison of transanal haemorrhoidal dearterialisation and stapled hemorrhoidopexy in management of hemorrhoidal disease: a retrospective study and literature review. Tech Coloproctol ; 18 Suppl 11 Personal experience. Minerva Chir ; 68 Suppl6 Transanal haemorrhoidal dearterialisation with mucopexy versus stapler haemorrhoidopexy: a randomized trial with long-term follow-up. Ratto C. THD Doppler procedure for hemorrhoids: the surgical technique. Archive of Clinical Cases.
Archive of Clinical Cases
Online Submission. Eugen Tarcoveanu. Mihai Danciu. Mariana Floria.
Prevention and Treatment of Complications in Proctological S : Diseases of the Colon & Rectum
Pascal Chastagner. Nicolae Ghetu. Cristina Gavrilovici. Madalina Ionela Chiriac. Mihaela Moscalu. Sonia Alexandru. Conclusion The low complication rate, near total absence of wound dehiscence, the compliance of the patients, the type of anaesthesia and the patient satisfaction makes this method effective. Volume 11 , Issue 1. If you do not receive an email within 10 minutes, your email address may not be registered, and you may need to create a new Wiley Online Library account.
If the address matches an existing account you will receive an email with instructions to retrieve your username. Colorectal Disease Volume 11, Issue 1. Read the full text. Tools Request permission Export citation Add to favorites Track citation. Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Abstract Aim The best surgical technique for treating sacrococcygeal pilonidal disease PD is still controversial.