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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 90-103

Medical simulation and the surgical resident: Creating synergies through focus on education and morbidity reduction in general laparoscopy

1 Department of Surgery, The Ohio State University, Columbus, Ohio, USA
2 Department of Surgery, University of Nebraska, Omaha, Nebraska, USA
3 Department of Surgery, School of Medicine, Northwestern University, Chicago, Illinois, USA
4 Department of Surgery, Cooper University Hospital, Camden, New Jersey, USA
5 Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
6 Department of Surgery, Division of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
7 Department of Anesthesiology, University of Toledo, Toledo, Ohio, USA
8 Department of Medicine, Division of Gastroenterology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

Date of Web Publication7-Jul-2017

Correspondence Address:
Stanislaw P Stawicki
Department of Research and Innovation, St. Lukefs University Health Network, EW.2 Research Administration, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_76_16

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Minimally invasive surgery continues to grow in terms of overall case volumes and clinical applications, with ever-evolving operative indications. Despite obvious advantages, numerous implementation challenges and diverse complications associated with laparoscopy exist. The understanding of technical nuances, anesthesia-related considerations, and perioperative physiologic alterations is paramount to acquisition and maintenance of skills for minimally invasive surgery specialists. To effectively meet the increasing demand for laparoscopic procedures, it is important that surgeons are adequately trained in operative techniques, requisite cognitive skills, safety practices, and the management of associated complications. This task can be accomplished through medical simulation of appropriate scenarios which can emphasize education and prevention in a safe learning environment. This focused review outlines key complications of laparoscopy and how medical simulation can be of assistance in the residents' educational experience.
The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice.

Keywords: Patient simulation, surgical education, complication prevention, laparoscopy, morbidity, minimally invasive surgery

How to cite this article:
Strosberg DS, Latchana N, Kindel TL, Swaroop M, Chaudhry UI, Noria SF, Choron RL, Seamon MJ, Lin MJ, Mao ML, Cipolla J, Scantling D, Martin ND, Evans DC, Papadimos TJ, Martins N, Stawicki SP. Medical simulation and the surgical resident: Creating synergies through focus on education and morbidity reduction in general laparoscopy. Int J Acad Med 2017;3:90-103

How to cite this URL:
Strosberg DS, Latchana N, Kindel TL, Swaroop M, Chaudhry UI, Noria SF, Choron RL, Seamon MJ, Lin MJ, Mao ML, Cipolla J, Scantling D, Martin ND, Evans DC, Papadimos TJ, Martins N, Stawicki SP. Medical simulation and the surgical resident: Creating synergies through focus on education and morbidity reduction in general laparoscopy. Int J Acad Med [serial online] 2017 [cited 2022 Aug 17];3:90-103. Available from: https://www.ijam-web.org/text.asp?2017/3/1/90/209862

  Introduction Top

Since its introduction nearly four decades ago, surgical volumes and applications for minimally invasive procedures continue to increase and evolve.[1],[2],[3],[4],[5],[6] Despite many potential advantages, laparoscopy is associated with a number of challenges and complications.[7],[8],[9],[10] In one large series describing laparoscopic surgical experience, morbidity exceeded 13%, with associated mortality of 0.2%.[11] Technical aspects of surgery, anesthesia-related considerations, and physiologic alterations should be thoroughly understood by laparoscopists.[12],[13],[14] The importance of surgical education in this context must be both appreciated and emphasized, from teaching of basic skills to providing advanced simulation experiences and clinical mentoring.[15],[16],[17],[18] The current manuscript provides a high-level overview of morbidity associated with general laparoscopy, focusing on the role of targeted educational tools to prevent adverse occurrences.

  Complications of Laparoscopy: Focus on Simulation Top

High-quality, structured laparoscopic education is critical to improving and maintaining operative skills.[19],[20],[21] It may also offer an avenue to prepare surgeons to better deal with various complications.[20],[21],[22] Within the overall context of simulation, it is important to maintain a balanced approach, with the level of experience being appropriate to the learners' skills, goals, and needs.[23] Finally, the advent of advanced simulation and virtual reality-based training tools will likely provide the added advantage of a realistic, high-fidelity experience that closely approximates actual clinical scenarios.[24] Laparoscopic simulation offers an important avenue for proficiency level assessment and personalized skills development.[25],[26] Furthermore, virtual reality experiences have now been shown to produce significant improvement in task-specific skills rating (e.g., fewer errors and better economy of movement) as well as substantial reductions in operative times.[27],[28] Throughout the current discussion, the authors will refer to educational resources relevant to each respective manuscript section.

  Supplementary Materials Top

Because the discussion of many procedure-specific complications is beyond the scope of the current article, the readers are directed to [Supplementary Materials Exhibit A] [Additional file 1] and [Supplementary Materials Exhibit B] [Additional file 2] for a more comprehensive listing of sources pertaining to the most common discipline-specific and operation-specific items, respectively. In addition, a high-level overview of complications outlined in this report is provided in [Table 1].
Table 1: Summary of major complications of laparoscopy discussed in this report (listed alphabetically)

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  Contraindications for Laparoscopy: from Absolute to Relative Top

Consistent with established surgical principles for patient-centered care, consideration should always be given to operative feasibility before commencing a potentially difficult laparoscopic procedure.[29],[30],[31] This understanding should be an important component of surgical residency curricula and continuing education for laparoendoscopists. For example, laparoscopic splenectomy in a patient with splenomegaly, laparoscopic resection of hepatocellular carcinoma, or laparoscopic colorectal procedures in patients with advanced frailty are among clinical scenarios where careful preoperative planning is prudent.[29],[30],[31],[32],[33],[34] Operator skills and comfort continue to be among the most important factors influencing the choice of operative approach.[35] Consequently, excellent knowledge of one's laparoscopic capabilities and comfort levels becomes a critical cognitive surgical skill, and the performance of honest and accurate self-assessment should again be emphasized in residency, fellowship, and continuing education curricula. Finally, due to the evolving character of absolute and relative contraindications to laparoscopy, frequent reviews of the topic focusing on new developments and clinical updates should be conducted on routine basis at each institution that performs minimally invasive procedures.

Absolute contraindications

As laparoscopic techniques and devices have evolved, absolute contraindications to laparoscopy have become rare. The following factors have been proposed as absolute contraindications to laparoscopy: (a) patient who is not expected to tolerate increased intra-abdominal pressures and simultaneous general anesthetic administration; (b) significant bowel dilatation (despite attempts at preoperative decompression); (c) generalized peritonitis in the presence of massive intra-abdominal contamination.[6],[36] In addition, some consider hemodynamic instability, increased intracranial pressure, and ocular hypertension as absolute contraindications.[36],[37],[38],[39]

Relative contraindications

Uncorrected coagulopathy, hypovolemia, congestive heart failure, or other conditions that may compromise hematologic or cardiopulmonary function during laparoscopy represent relative contraindications.[40],[41] Prior history of open abdominal surgery with dense intraperitoneal adhesions may constitute a relative contraindication.[42] In severe cases, mechanical bowel obstruction is also a relative contraindication to laparoscopy because safe access to the peritoneal cavity may be prohibitively difficult and associated with disproportionate risk of iatrogenic injury.[43] Patients with cirrhosis and portal hypertension are considered poor candidates because increased portal venous pressures combined with coagulopathy may increase the risk of hemorrhage and make laparoscopic control of bleeding very challenging.[44]

Pregnancy may be considered a relative contraindication for nonemergent laparoscopic procedures, especially during the first and last trimesters.[45] Thus, elective surgery during pregnancy should be delayed until the second trimester or postpartum. However, in emergent situations, laparoscopy can be performed in all trimesters with a reasonable safety margin.[46] In such cases, the rate of complications is comparable between laparoscopic and open surgery during pregnancy.[47] From a maternal-fetal hemodynamics perspective, a left lateral decubitus position can reduce inferior vena cava compression attributable to the gravid uterus.[48] In addition, an open (“cut down”) abdominal entry technique is recommended to avoid injury to the uterus and fetus, which can reach the level of the umbilicus by approximately 20 weeks of gestation.[49] In terms of simulation resources for operative skills training, virtual reality tools now exist that are capable of projecting high-fidelity, three-dimensional (3D) scenarios applicable to laparoscopy in pregnancy.[50]

  Anesthesia and Physiological Considerations Top

Gas insufflation of the abdomen can be associated with rare but potentially severe morbidity. Because cylinders used for storage and transport of carbon dioxide (CO2) can develop particulate contaminants (both inert and microbial) over time, insufflation equipment should feature a 0.3 μ filter to capture any potential contaminating particles or bacteria that may have colonized the circuit and become aerosolized in the insufflation gas.[51] Peritoneal insufflation requires the use of an inert gas. While nitrous oxide has been demonstrated to be safe for insufflation of the abdomen, CO2 is the most studied and the most commonly used inert gas for achieving pneumoperitoneum.[52] CO2 is favored due to its high solubility in blood, rapid absorption by the peritoneal lining, and subsequent elimination during ventilation. Patients with chronic obstructive pulmonary disease (COPD) can experience intraoperative CO2 retention with resultant acidosis, but generally, CO2 insufflation has been safe, even during prolonged cases in patients with mild/moderate COPD.[53]

Insufflation with gas increases the intra-abdominal pressure (IAP), potentially impeding venous return to the heart and promoting venous stasis.[54] In turn, associated physiologic alterations can lead to bradycardia and hypotension. When encountered, these manifestations are managed by evacuation of pneumoperitoneum and administration of intravenous fluids to augment intravascular volume.[55] Increased airway pressures usually do not appear at the lower IAPs routinely used in laparoscopy.[56] Thus, acute airway pressure elevations may indicate a more serious complication (e.g., tension pneumothorax).[57] It is also important to remember that these phenomena can be actively modulated by Trendelenburg and reverse Trendelenburg positioning, both utilized frequently in laparoscopic surgery.[58],[59],[60]

Compared to open surgery, abdominal insufflation with CO2 has been shown to create fewer immunologic alterations and less severe postoperative inflammatory response.[61],[62] Precise physiologic mechanisms responsible for this difference are not yet fully understood.[63] Both anesthesiologists and surgeons must be aware of the impact of insufflation, including capnothorax, pneumomediastinum, and subcutaneous emphysema (SE). These can usually be treated nonoperatively. However, in an event of acute cardio-respiratory instability, appropriate intervention(s) may be required.[64] SE is rarely of clinical consequence unless it affects airway patency.[65]

Bag-mask ventilation during induction can increase gastric distension and may lead to increased risk of emesis or iatrogenic injury to the stomach upon surgical abdominal entry.[66] Nasogastric or orogastric tube placement after induction, but before commencement of the surgical procedure, can minimize these risks. Gastric decompression can also improve surgical visualization of upper abdominal structures (e.g. gallbladder, diaphragm, and spleen). Although very rare, esophageal intubation and ventilation must be immediately recognized and corrected.[67] Finally, nausea and vomiting are common after laparoscopy, mediated largely through vagal afferents.[68] Prophylactic ondansetron and dexamethasone are routinely used to mitigate this risk.[69]

The use of simulation in various anesthesiology-related applications is emerging as a powerful educational tool.[70] It has been suggested that highly realistic virtual reality scenarios may help improve patient safety by exposing anesthesiology (and surgical) trainees to a broad variety of simulated intraoperative and perioperative complications.[71] In addition, early experiences with advanced digital image processing techniques suggest that simulated abdominal insufflation may become an option for laparoscopic surgery planning.[72]

  Access-Related Complications Top

A significant proportion of laparoscopic complications occur at the time of abdominal entry.[8] Access into the peritoneum can be performed in a variety of methods including open entry (Hasson), Veress needle (VN), direct trocar insertion, and hybrid forms of entry.[7],[73] These techniques can each carry complications including intra-abdominal vascular injury, abdominal wall vascular injury, visceral injury, solid organ injury, and failed entry.[7],[74] Evidence does not favor open versus closed techniques for the prevention of major vascular or visceral complications.[73],[75],[76],[77] Other risk factors for access-related complications include previous laparotomy, obese or thin body habitus, and anticoagulation.[8] From an educational and surgical training perspective, virtually every step of the laparoscopic procedure can now be taught and simulated thanks to modern technological advances, including tasks such as trocar insertion.[78],[79]

  Subcutaneous Emphysema Top

SE is a well-recognized complication of laparoscopy [Figure 1]. Radiographically, some evidence of SE can be seen postoperatively in most laparoscopic cases; however, symptoms manifest in fewer than 3% of cases.[80],[81] Extraperitoneal CO2 is associated with changes in end-tidal CO2 and alterations in CO2 elimination, making end-tidal CO2 an early clinical indicator of SE.[82],[83] In some cases, SE may progress to pneumomediastinum or pneumothorax through dissection of CO2 along susceptible fascial planes.[83],[84] In some cases, pneumomediastinum or pneumothorax may also lead to SE. In extreme cases, air in the upper mediastinum and neck may be associated with airway compromise.[65] Although not specifically designed to simulate SE, various existing virtual reality training platforms may be easily modified to accommodate this particular scenario for educational purposes.[50],[70],[72]
Figure 1: An example of massive, persistent subcutaneous air 3 days after a laparoscopic left hemicolectomy. Source: Jones A, et al. Int J Surg Case Rep 2015;6:277-9. Used under the terms of the CC BY-NC-ND license (http://www.creativecommons.org/licenses/by-nc-nd/3.0/). Image displayed in its original form

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  Pneumothorax Top

Pneumothorax associated with abdominal laparoscopy is rare [Table 1]. Clinically, pneumothorax may manifest with a decrease in lung compliance, hypercarbia, hypoxemia, and hemodynamic instability requiring prompt recognition and emergent intervention.[85],[86],[87] Pneumothorax during laparoscopy may occur after an unrecognized puncture of the thoracic cavity, permitting entrance of CO2 into the pleural space.[85] In some cases, surgical dissection along the left crus of the diaphragm may also damage the parietal pleura and permit CO2 entry under pressure.[86],[88],[89] Finally, CO2 can also dissect along the retroperitoneal planes into the pleural space.[90]

The treatment of CO2-related pneumothorax is controversial. In the hemodynamically unstable patient, needle thoracostomy or chest tube insertion may be required.[91],[92] However, CO2 pneumothorax may also resolve spontaneously within several hours, without any invasive intervention.[93] Thus, clinical observation seems sufficient in most cases. Attention to proper intraoperative technique, limiting insufflation pressures below 10–14 mmHg, as well as close monitoring of airway pressures and end-tidal CO2 will help minimize the incidence of pneumothorax associated with laparoscopy. Similar to SE, existing virtual reality platforms can be modified to simulate visual findings and physiologic alterations associated with tension pneumothorax in the laparoscopic setting.[50],[70],[72],[94]

  Gas Embolism Top

Venous gas embolism (VGE), a rare (1 in 64,800 procedures) but potentially life-threatening complication of laparoscopy,[95] can occur rapidly through a direct defect in an abdominal vessel,[96] or gradually via incremental accretion of gas within the circulatory system.[97] Embolization of gas leads to its accumulation within the pulmonary outflow tract of the right heart, which could potentially affect cardiac output. Sudden, profound hypotension, cyanosis, and tachycardia are indicators of a potential underlying VGE.[98]

Despite the low incidence of VGE, a high index of suspicion for this complication should always be maintained during pneumoperitoneum. All members of the surgical team should be vigilant for early, subtle signs (e.g., hypercarbia) suggestive of this diagnosis before overt manifestations become apparent.[97] Late clinical findings include a characteristic “mill wheel murmur,” cardiac arrhythmias, elevated central venous pressure, decreased end-tidal CO2, worsening hypercapnia and hypoxemia, and even cardiovascular collapse.[14],[99] Transesophageal echocardiography is the best confirmatory test for intracardiac VGE.[100]

VGE should be differentiated from other serious conditions including acute coronary syndrome, venous thromboembolism, and cardiogenic shock.[99] If VGE is suspected, the laparoscopic procedure should be halted as soon as safely feasible, pneumoperitoneum should be released, and the abdominal cavity should be flushed with irrigation fluid to halt the uptake of gas into susceptible vessels.[97] The patient should then be placed either in the left lateral decubitus position with the head sharply down or in the Trendelenburg position, which will help keep air away from the cardiac outflow tract and toward the apex of the right heart where evacuation can be attempted via percutaneous transvenous aspiration.[95],[97] If percutaneous aspiration is not feasible, a central line or pulmonary artery catheter may be advanced into the right atrium and used to aspirate any air.[14],[95],[97],[100] Inotropes and aggressive fluid resuscitation may be required to combat the loss of cardiac output while increased FiO2 can ameliorate hypoxemia.[97] Hyperbaric oxygen may also be of benefit in some cases.[97] To create a high-quality training/didactic environment, practice VGE scenarios will have to incorporate elements of virtual reality procedural simulation with situation awareness and cognitive skills development.[70],[94],[101],[102],[103],[104],[105]

  Vascular Injury Top

Potentially life-threatening vascular injuries occur between 0.1% and 2.6% (depending on procedure type) of laparoscopic surgeries and may range from superficial abdominal wall vessel injuries to major injuries of the vena cava or aorta.[11],[76],[106],[107],[108] The majority of vascular injuries occur during initial entry into the abdomen, with the superior and inferior epigastric vessels involved in approximately 1.5% of cases.[109] Laparoscopic (e.g., using suture passer) or open (e.g., direct suture) ligation of the bleeding abdominal wall vessel may be required. If identified postoperatively in a stable patient, abdominal wall bleeding can be managed with interventional coil embolization if bleeding persists and/or is difficult to localize.[110] Major (e.g. aortic, vena cava) vascular injury occurs in approximately 1 in 1000 laparoscopic cases.[108] In such instances, immediate clinical recognition and prompt conversion to an open procedure are critical to achieve rapid proximal and distal vascular control in preparation for the definitive vascular repair.[111] Surgical management of visible hematomas should approximate approaches used in penetrating trauma.[112],[113] Less common sources of major hemorrhage have been associated with laparoscopic inguinal hernia repairs and include the artery of Sampson,[114] epigastric vessels,[115] and injuries of the iliac arterial system (including unnamed branches).[116] In addition to providing training directed at improving situational awareness and critical decision-making,[101],[102],[104],[117],[118] there is evidence that virtual reality laparoscopic simulation may help enhance the technical skills needed to effectively manage intraoperative bleeding complications.[22]

  Visceral Injury Top

Visceral injuries may be caused by trocar insertion, mechanical injury, and electrocautery.[119] Accidental bowel injuries attributable to off-camera instrumentation are estimated to occur in about 1% of laparoscopic cases.[120],[121] Previous abdominal surgery may be associated with increased risk.[120],[121] Clinical management depends on the extent of injury. For example, a VN injury can be repaired by placing a simple seromuscular suture over the puncture site.[7] On the other hand, full thickness tears involving >50% of bowel circumference may require segmental resection/reanastomosis. Bowel repairs can be performed laparoscopically or in an open fashion, depending on the surgeon's skills and comfort level. If the injury is secondary to electrocautery, the extent of tissue injury cannot be reliably determined by the appearance of visible serosal change. Electrocautery injury tends to progress away from the point of initial contact over a period of 24–48 h, often resulting in a much greater extent of injury than initially suspected.[122] Thus, some authors recommended excision of a generous segment (e.g., up to 5 cm on each side of the full thickness electrocautery injury) to reduce the risk of needing second operations from inadequate resection and reperforation.[123] Early recognition and immediate repair of iatrogenic visceral trauma is the best way to reduce associated morbidity and mortality.[124] Due to the heterogeneity of laparoscopic visceral injuries, surgical education in this area should involve multimodal approaches, from virtual reality simulation [50],[125] to targeted didactics that focus on required knowledge base, surgical “situational and self-awareness”, and complication-specific preventive strategies.[7],[123],[126],[127]

  Bladder and Ureteral Injuries Top

Laparoscopic urinary tract injuries may occur in over 8% of cases, depending on procedural and anatomic considerations.[124] The incidence of bladder injury varies between 0.40% and 8.30% of cases, depending on procedure extent and type. Significant morbidity may result from unrecognized bladder injuries.[11],[124],[128] Lower abdominal entry may be associated with an elevated risk of bladder injury, especially in the presence of lower abdominal adhesions or history of pelvic radiation therapy.[124] Given the overall surgical context, care must be taken during lower abdominal trocar and/or VN insertion to avoid trauma to the bladder.[129] Injuries may be minimized by ensuring bladder decompression prior to abdominal entry, either by having the patient void or through preoperative insertion of a urinary catheter.[124] Less commonly, bladder injuries can result from surgical stapling devices, overzealous retraction, or improper tissue-handling.[124] Early recognition and surgical repair reduces morbidity, including renal insufficiency, abdominal sepsis, urinary fistula formation, and potentially mortality.[130] In one series, 96% of bladder injuries were detected and treated intraoperatively.[128] Some injuries discovered postoperatively can be managed nonsurgically with prolonged urinary catheter drainage, but operative repair may still be needed if these measures are unsuccessful.[131],[132],[133],[134],[135],[136] It is important to maintain a high index of suspicion for bladder injuries in patients who exhibit unexplained abdominal or pelvic pain, or urinary complaints after laparoscopic procedures, especially if the index procedure is associated with known risk of said injuries.

Injury to the ureters during laparoscopic operations is also rare (0.1%–3%), generally involving colorectal, urologic, and gynecologic procedures.[124],[128],[137],[138],[139] Laparoscopic colectomy procedures may be associated with an increased risk of ureteral injury when compared to open colectomies.[138] Of note, the proportion of ureteral injuries identified and repaired during the index operation is much lower (50%) than that for bladder injuries (e.g., 96%).[128] Ureteral stenting may help identify injuries intraoperatively but does not necessarily reduce the injury incidence itself.[140],[141],[142],[143] Management of ureteral injuries is beyond the scope of the current manuscript but depends on the extent of iatrogenic damage, timing of detection, and the location of the injury.[142],[143],[144]

Sound educational foundation is required to help reduce the incidence of bladder and ureteral injuries. Due to the heterogeneous nature of potential injury mechanisms, including trocar insertion, retraction, and electrosurgical trauma, a comprehensive, multi-pronged approach is required to adequately train residents in strategies to avoid these iatrogenic mishaps. With the advent of mechanical simulators, surgical tasks that carry increased risk of intraoperative injury, including trocar insertion, can be realistically taught to trainees.[78],[79] Combined with high-fidelity virtual reality simulation and targeted didactic sessions, the ability to simulate tactile feedback encountered during trocar placement may provide the missing component needed to achieve the desired reduction in related complications.[27],[50],[127]

  Diaphragmatic Injury Top

Although iatrogenic diaphragmatic injuries are rare [Table 1], they have been reported in a variety of upper abdominal laparoscopic procedures.[145],[146],[147] In one series of laparoscopic splenic procedures, the incidence of diaphragm injuries was noted to be approximately 0.9%.[148] In abdominal urologic laparoscopy, the incidence was cited at about 1.1%.[11] Overt diaphragmatic injuries are usually identified intraoperatively by direct visualization of the pleural space while less obvious injuries may be suggested by the presence of diaphragmatic billowing under decreased pneumoperitoneum, also known as the “floppy diaphragm sign.”[147],[149] Excessive air bubbles during upper abdominal irrigation, diminished ipsilateral breath sounds, decreased arterial oxygen saturation, elevated airway pressures, and acute rise in end-tidal CO2 may also be suggestive of a diaphragmatic injury, especially if present in conjunction with a clinically relevant pneumothorax.[145],[149]

Management of diaphragmatic injuries spans an entire spectrum of considerations, from close observation to surgical repair, depending on injury location, laterality (e.g., left versus right) and size (e.g., small puncture versus visible rent).[150],[151] Tube thoracostomy placement (or even needle chest decompression) may be indicated if hemodynamic instability develops or a large pneumothorax (>20% hemithorax volume) is evident on imaging.[93],[152] However, most patients remain hemodynamically stable and a decompressive intervention is not required.[149],[153] Most patients can safely tolerate a laparoscopic repair with closure of the defect in a primary or mesh-assisted fashion (including directed evacuation of pleural gas).[145],[154],[155] Diaphragm repair is usually performed under decreased pneumoperitoneum (≤10 mmHg) and may be deferred toward the end of the case, provided that the patient remains hemodynamically stable.[145],[156] From an educational perspective, the optimal approach to educate trainees about risk factors, recognition, and management of diaphragmatic injuries is the combination of targeted didactics and high-fidelity simulation.[23],[50],[157] Due to the fact that direct suture repair can adequately address the majority of laparoscopic diaphragmatic injuries identified at the time of surgery, the development of intracorporeal suturing skills is important in this domain.[150],[157],[158]

  Port-Site Hernias Top

Port-site hernias are among the more common complications of laparoscopy [Table 1] and [Figure 2], [Figure 3]. They usually contain bowel or omentum and involve a fascial defect located at a previous laparoscopic trocar site.[159] The incidence of port-site hernias is estimated to be between 0.74% and 1.7%, with the umbilicus being the most common site.[160],[161] Risk factors include elevated body-mass index, medical comorbidities (e.g., diabetes, long-term corticosteroid use), malnutrition, wound infection, as well as technical factors related to trocar placement and closure techniques.[162] Clinical presentation may include mild discomfort, bowel obstruction, or strangulation of hernia contents.[161],[163] Some asymptomatic hernias may be found incidentally on advanced imaging (e.g., computed tomography or magnetic resonance imaging).[164]
Figure 2: Computed tomography image showing an umbilical port-site hernia containing omentum. Source: Singh P, et al. J Minim Access Surg 2006;2:29-30. Used under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

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Figure 3: Computed tomographic images showing a left lower quadrant incisional hernia (circled) originating from a 5-mm appendectomy laparoscopic incision. The patient initially neglected symptoms of intermittent left lower quadrant pain, leading to significant enlargement of the hernia defect over time. Computed tomographic reconstructions demonstrate the extent of the hernia (circled). The hernia was repaired laparoscopically, via placement of a synthetic hernia mesh

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Larger port sizes, trocar location, longer case duration, failure to properly close trocar sites, and the need for extension of the wound during specimen extraction are among the technical factors associated with port-site hernias.[160],[162] It is generally accepted that fascial defects >10 mm require dedicated closure; however, pediatric port sites as small as 3 mm can be associated with herniation.[165],[166] Ideally, port-site closure should be accomplished under direct visualization, and the closure should be confirmed to be “air tight” under active pneumoperitoneum conditions. Regardless of closure method, adequate suture of fascia is mandatory. At times, trocar passage through the tissues of the anterior abdominal wall may be associated with a direct vessel injury, resulting in active bleeding that requires either surgery or endovascular angioembolization [Figure 4].[7] With increasing availability of high-fidelity simulators, laparoscopic tasks associated with high complication risk, including trocar placement and closure, can be realistically depicted in virtual reality environments.[78],[79] When bundled with targeted didactic sessions, the ability to recreate highly realistic surgical scenarios may help reduce the incidence of port-site hernias and related morbidity.[27],[50],[127]
Figure 4: Large left anterior abdominal wall intramuscular hematoma associated with laparoscopic port placement. Note active contrast extravasation in the medial-central portion of the hematoma on contrast-enhanced computed tomography imaging

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  Robotic-Assisted Laparoscopy: Better, but not Perfect Top

The increasing interest in robotic-assisted laparoscopy (RAL) deserves a special mention. While RAL may be the wave of the future, it is not without complications. Shields et al.[167] reviewed the Food and Drug Administration's Manufacturer and User Facility Device Experience from 2003 to 2012 and found that there were 455 injuries, 28 deaths, and 177 malfunctions (including 50 “adverse events”) associated with robotic cases. Of interest, injury rates may have risen over time.[167] Zakhari et al.[168] noted that despite greater costs, patient undergoing robotic-assisted hysterectomy for uterine cancer had shorter hospital admissions, with similar postoperative morbidity and mortality. Weinberg et al.[169] reviewed 14,275 patients with localized renal tumors of whom 70% had robotic-assisted partial nephrectomy and 30% underwent laparoscopic cryoablation. There were no differences between the groups in terms of perioperative complications, transfusions, length of stay, or median cost. Moreover, surgical technique was not predictive of complications.[169] Kader et al.[170] reported on 200 patients undergoing either robotic-assisted laparoscopic radical cystectomy (n = 100) or open radical cystectomy (n = 100). They found comparable outcomes but with fewer total complications in the RAL.[170] Regarding radical prostatectomy procedures, a recent systematic review and meta-analysis suggested that the rate of complications was similar with either robot-assisted resection or laparoscopic resection, although RAL compared favorably in terms of blood loss and transfusion rates.[171] In terms of specific training approaches, highly realistic 3D robotic surgery simulators are now available for trainees.[172],[173],[174] When combined with didactic sessions and training modules that focus on complications specific to various robotic-assisted operations, such high-fidelity, virtual reality resources may prove helpful in both reducing morbidity and improving clinical handling of complications.[175],[176]

  Education and Prevention: A summary Top

Given the ubiquitous nature of laparoscopy, one of the most important ways to reduce the occurrence of adverse events is the emphasis on prevention and education regarding both technical and nontechnical surgical skills.[177],[178] The process starts during residency training, with initiatives such as fundamentals of laparoscopic surgery.[179],[180] Equally important is the development of cognitive skills required to appropriately recognize and deal with complications, including the ability to accept mistakes, communicate effectively, perform honest self-reflection, and avoid costly delays in management of resultant morbidity.[181],[182] Additional training should include didactics on team safety, principles of surgical energy device use, simulation-based experience, and laparoscopic tissue-handling.[183],[184],[185],[186] Providers who maintain a certain level of skills tend to have better outcomes and fewer complications.[187] The emergence of advanced, high-fidelity, virtual reality simulation techniques is a potentially important step toward providing the much needed skills maintenance in various “low-volume, high-impact” operative and nonoperative settings.[27],[28],[50],[94],[172] Of course, validation of associated benefits will be required prior to more widespread deployment of such technologies. Emphasis should be placed by departmental and divisional surgical leadership on ensuring adequate laparoscopic case volumes.[188],[189],[190] Finally, complications associated with laparoscopy should be discussed on a regular basis at morbidity and mortality conferences, as well as other established performance/quality improvement platforms.[191],[192]

  Conclusion Top

As minimally invasive surgery volumes continue to grow and the associated breadth of surgical indications expands, we must ensure that surgeons are adequately trained in operative techniques, cognitive (nontechnical) skills, safety protocols, and the management of complications associated with laparoscopy. Greater awareness is needed among surgeons and trainees regarding a number of important, commonly encountered complications unique to laparoscopic surgery and related areas of expertise. Among key factors important to morbidity reduction are adequate patient selection, meticulous attention to surgical technique, awareness of potential complications, and high-quality team interactions that focus on patient safety throughout the perioperative period. Of critical importance is the surgeon's ability to promptly recognize complications, readily accept the proximal connection between potential surgical errors and morbidity, and institute appropriate remedies to avoid further iatrogenic harm. Regardless of their role in the operating room, members of minimally invasive surgery teams must be familiar with all potentially life-threatening complications of laparoscopy and be competent in promptly identifying and managing such events. The same team safety principles also apply to identifying complications in the postoperative period.

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  References Top

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