A 20-year experience in Minimally Invasive Surgery (MIS): learning from mistake

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AUTHORS: Mario Lima, MD, Sara Ugolini, MD.

Department of Pediatric Surgery, University of Bologna, Policlinico Sant’Orsola-Malpighi, Bologna, Italy

KEYWORDS: pediatric surgery; minimal-access injury; Minimal Invasive Surgery complications; Minimal Invasive Surgery; intraoperative complications; children

DOI: https://doi.org/10.1473/JEMIS23

Corresponding Author:

Professor Mario Lima, MD
Department of Pediatric Surgery
University of Bologna
Policlinico Sant’Orsola-Malpighi
via Massarenti 11, 40138 Bologna, ITALY
mario.lima@unibo.it

Date of initial submission: 31/08/2016

Abstract

Introduction: Minimum Invasive Surgery (MIS) has been largely adopted in pediatric surgical procedure and the overall rate of adverse events specifically related is low. The aim of this study is to report our experience within a twenty-year period. Material and Methods: Starting from 1995 to 2015 a total of 43.195 were carried out, of which 4.456 performed by the minimal – access.

Results: Of the total amount of 4.456 MIS procedures, up to 29 (0.6%) adverse events were recorded.

Discussion and Conclusions: The aim of this study was to enhance common knowledge and improve awareness of concerns for patient safety. We identified an incidence of adverse events of about 0.6%, which is consistent with previously reported series, being haemorrhage or hematoma the most frequent technical complication.

Introduction

Minimal Invasive Surgery (MIS) has been largely adopted over the last few years and the overall incidence of associated complications is low [1-5]. Nevertheless, multidisciplinary strategies supporting the patient along the preoperative, intraoperative and postoperative phases can be demanding. Short-term complications include vascular, nerve or visceral injury, infection and wound herniation, with a reported rate of about 1 to 2 percent [6-12] of which up to half occur when gaining the access to the cavity [13,14]. Laceration of major retroperitoneal vessels (aorta or inferior vena cava) and delayed recognition of bowel perforation are associated with high morbidity and mortality [15]. We present a twenty-year experience quantifying MIS complication at the Department of Pediatric Surgery in Bologna.

Materials and Methods

We aim to report our twenty-year experience in MIS in order to retrospectively review a collected database of all patients undergoing intervention starting from 1995 to 2015 at the Department of Pediatric Surgery of Sant’Orsola teaching hospital. A total of 43.195 consecutive patients presented within the study period for gastrointestinal, thoracic or urologic conditions; out of them, 4.456 cases have been performed by means of minimal-access. The recorded data were the indication for surgery, patient age and short term complications such as vessels, nerve or bowel injury, hematomas, wound infections, persistent pneumothorax, needle or instruments rupture.

Results

A total of 43.195 surgical procedures was carried out, starting from 1995 to 2015 (Tab.1). Out of the total amount of 4.456 MIS operation, 29 (0.6%) have developed complications such as needle rupture, trocar injury, instruments rupture, perforation, peritoneal injury, persistent pneumothorax and haemorrhage or hematoma being the most frequent (28%) as depicted in Tab.2 and Figures 1-9. Each case allowed rapid repair of the injury and was accompanied by an uneventful clinical course.

Discussion

The minimally invasive surgery is becoming the access of choice for many pediatric procedures and the reported specific associated complications seem to be comparable to those described in adult series [1-5]. The aim of this study was to enhance common knowledge and improve awareness of concerns for patient safety. We identified an incidence of adverse events of about 0.6%, which is consistent with previously reported series, being haemorrhage or hematoma the most frequent technical complication. Complications can occur at any time: injury of abdominal wall vessels (minor bleeding) or of great vessels (major bleeding) when entering the abdomen, anesthesiological issues related to pneumoperitoneum (i.e. hypercapnia, hypothermia), organ injury within the dissection phase, spillage when retailing resected specimen or omental herniation or bleeding at the time of trocar withdrawal at the end of the procedure. In the specific, we’ve reported haemothorax, perforation of the duodenum while performing a pylorotomy, sliding of a wrap after a Nissen, persistent pneumothorax, candida postoperative infection after a pyloplasty and circular stapler and needle ruptures (Fig.1-9). Most of the morbidity is reported to be linked to the trocar introduction in the enclosed space where the blind insertion of the umbilical port may cause inadvertent severe injury [13-15], especially in small kids where the abdominal is thin and distance from the great vessels limited [16]. Nevertheless, failure of medical devices or instruments ruptures within the body cavity can be challenging and a meticulous preoperative control and cautious pressures and forces applied seem to be fundamental. Furthermore, some risk factors related to the patient (i.e. thin/obese, respiratory or cardiac diseases, adhesions due to previous surgeries) may contribute[17]. We observed that no technique or medical technology is without risks and no skilled surgeon is immune against complications [14]. In our opinion is crucial to recognize and manage an injury intraoperatively [18], and conversion to an open procedure may be needed, since an adverse event presenting in the delayed postoperative may have a severe effect on the outcome. Moreover, following the development of newly introduced medical devices, robot-assisted MIS may lower the risks associated with complex procedures in remote areas thanks to enabling features such as wristed arms and depth perception [19].

 

Nissen procedure (A, B) and postoperative haemothorax (C, D, E)

Fig. 1 Nissen procedure (A, B) and postoperative haemothorax (C, D, E)

 

 

 

 

 

 

Fig 2. Laparoscopic extramucosal pylorotomy: perforation

Fig 2. Laparoscopic extramucosal pylorotomy: perforation

 

 

 

 

 

 

Fig 3. Sliding of a wrap (C, D, E, F) in a Nissen procedure (A, B)

Fig 3. Sliding of a wrap (C, D, E, F) in a Nissen procedure (A, B)

 

 

 

 

 

 

Fig 4. Distal sliding of a wrap in Nissen procedure causing obstruction

Fig 4. Distal sliding of a wrap in Nissen procedure causing obstruction

 

 

 

 

 

 

 

Fig 5. Persistent postoperative pneumothorax after thoracoscopic pulmonary resection of CPAM

Fig 5. Persistent postoperative pneumothorax after thoracoscopic pulmonary resection of CPAM

 

 

 

 

 

 

 

Fig 6. Thoracoscopical repair of two cases of congenital diaphragmatic hernia and relapse of herniating viscera at postoperative X-rays

Fig 6. Thoracoscopical repair of two cases of congenital diaphragmatic hernia and relapse of herniating viscera at postoperative X-rays

 

 

 

 

 

 

 

 

Fig 7. Postoperative candida infection after a laparoscopic pyeloplasty

Fig 7. Postoperative candida infection after a laparoscopic pyeloplasty

 

 

 

 

 

 

Fig 8. Intra-wall needle rupture

Fig 8. Intra-wall needle rupture

 

 

 

 

 

 

Fig 9. Failure of a medical device (circular stapler) when performing an ileo-anal anastomosis

Fig 9. Failure of a medical device (circular stapler) when performing an ileo-anal anastomosis

 

 

 

 

 

 

 

Tab. 1 Case series within the study period at Department of Pediatric Surgery, Policlinico Sant’Orsola Malpighi

Tab. 1 Case series within the study period at Department of Pediatric Surgery, Policlinico Sant’Orsola Malpighi

 

Adverse event Laparoscopy Thoracoscopy Retroperito-neoscopy Number of events
Needle rupture 2 1 3
Trocar injury 2 2
Instruments rupture 4 2 6
Perforation 3 3
Peritoneal injury 4 4
Harmorrage / hematoma 3 3 2 8
Persistent pneumothorax 3 3
Total 15 9 6 29

Tab. 2 Number of adverse events occurred, illustrated by type of minimal-access

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