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How to ID and treat intraoperative complications Part 2

How to ID and treat intraoperative complications Part 2 Stapler misfire, ischemic segment, bladder invasion, small bowel invasion, intraoperative bleeding. Morris E. Franklin Jr MD. F.A.C.S. Director Texas Endosurgery Institute Karla Russek , MD. Research Fellow. MISS meeting 2010.

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How to ID and treat intraoperative complications Part 2

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  1. How to ID and treat intraoperative complications Part 2 Stapler misfire, ischemic segment, bladder invasion, small bowel invasion, intraoperative bleeding Morris E. Franklin Jr MD. F.A.C.S. Director Texas Endosurgery Institute Karla Russek, MD. ResearchFellow MISS meeting 2010

  2. Industry relationships • W.L. Gore & Associates • Grant/research support, consultant and speaker bureau • Covidien • Grant/research support, consultant and speaker bureau • Striker • Consultant, advisory board • Ethicon • Consultant and speaker bureau • Atrium • Consultant • Aesculap • Consultant • KCI • Consultant The Authors do not have financial interest with the above mentioned companies

  3. The pessimist sees difficulty in every opportunity. The optimist sees the opportunity in every difficulty. Winston Churchill

  4. Laparoscopic Colectomy • Conversion rate of 23.5% • Unclear anatomy Actually….. • Stapler misfire Are all these still • Bleeding reasons for • Cystostomyconversion???? • Enterostomy • Adhesions • Adjacent organ invasion Indications for Conversion to Laparotomy S Pandya, MD; JJ. Murray, MD; JA. Coller, MD; LC. Rusin, MD Arch Surg. 1999;134:471-475

  5. Adjacent Organ invasion

  6. Possible invasion to: • * Bladder • * Small intestine • Peritoneum (parietal and visceral) • Uterus, ovaries • Stomach • Omentum • Pancreas • Abdominal wall

  7. Statistics • Until 50 years ago, colorectal carcinoma infiltrating surrounding tissue was considered nonresectable • Most of the time the diagnosis is made in the OR

  8. Tumor subsite location and adjacent organ invasion Multivisceral resection for locally advanced primary colon and rectal cancer. Thomas Lehnert, MaschaMethner, Andreas Pollok. Annals of Surgery, 2002

  9. Transection of tumor and spreading of tumor cells must be avoided whenever possible The removal of all carcinoma-bearing tissue, including the regional lymph nodes, is ideal Multivisceral resection for colon carcinoma. Roland Croner, Susanne Merkel, Thomas Papadopoulos, et al. Dis Col & Rectum, Aug 2009

  10. Bladder invasion

  11. Abdominal wall invasion

  12. Abdominal wall invasion

  13. Intraoperative bleeding

  14. Intraoperative bleeding • Vascular injury • Tamponade with pressure • Irrigate • Inform anesthesia team

  15. Intraoperative bleeding • Slow to open if controllable with pressure • Venous injury may bleed more while converting to open if there is no intraabdominal pressure • Always think of gas embolism

  16. Intraoperative bleeding • Keep calm • Make sure the anesthesiologist is aware of the problem • Ask for help

  17. Some tips to prevent it: • Know the anatomy other than Netter!!! • If possible, dissect the artery from the vein

  18. Vascular control

  19. Stapler Misfire

  20. Colonoscopy and anastomosis leak test Intestinal clampsLiberal use of colonoscope

  21. Colonoscopy and anastomosis leak test Anastomosis Air leak testID Bleeding Integrity

  22. The Use of Bioabsorbable Staple Line Reinforcement for Circular Stapler (BSG “Seamguard”) In Colorectal Surgery. Initial Experience. “We consider these first 5 cases using bioabsorbable Seamguard for circular stapler reinforcement an initial experience perhaps helping to alleviate the most devastating complication of gastrointestinal surgery. Longer follow up and a larger number of patients are obviously needed; however the initial data is very promising and has encouraged us to continue using this device on further patients “ Franklin Jr, M.E. MD, FACS; Portillo G. MD; Surg Laparosc Endosc Percutan Tech;2006;16:411-415

  23. Ischemic segment

  24. Loose anastomosis

  25. “You can not depend on your eyes when your imagination is out of focus” Morris E. Franklin Jr.

  26. www.texasendosurgery.com

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