Laparoscopy for the Detection and Treatment of Early Complications from Minimally Invasive Urologic Surgery

Introduction

Since the first reported laparoscopic urologic surgeries in the early 1990s, the use of minimally invasive procedures has expanded dramatically. ^1,2 In contemporary series that include pelvic and intraperitoneal procedures at high-volume centers, the reported complication rate is 12% to 19%, with postoperative intervention needed in 0.7% to 2.4% of patients. ^{3 –6} As more complex procedures are performed, increased surgeon experience may not result in fewer postoperative complications. ³ Furthermore, procedures with increasing complexity have been associated with higher postoperative reintervention rates. ⁷

Laparoscopic exploration is an accepted treatment in various surgical emergencies. ⁸ The use of laparoscopy for the detection and treatment of complications after initial open and laparoscopic surgery has been described in the general surgery literature. ^{9 –13} Few reports of laparoscopic exploration for early complications from minimally invasive urologic surgery have been published. ^6,14,15

After initial experience in treating complications from minimally invasive urologic surgery, our institution adopted a policy of laparoscopy as the first-line intervention in patients with proven or suspected acute intra-abdominal complications. We describe our experience in treating early postoperative complications laparoscopically with a focus on the safety and efficacy of this approach.

Patients and Methods

From October 2003 to September 2008, a total of 1962 laparoscopic or robot-assisted urologic procedures were performed at our institution. After Institutional Review Board approval, data were prospectively collected for all patients needing surgical intervention within 21 days of their initial procedure. No patients needing surgical intervention during this period were excluded. There was a preference to perform a minimally invasive exploration in all hemodynamically stable patients in whom pneumoperitoneum could be established.

Data accrued included patients demographics (age, sex, American Society of Anesthiologists score), indications for initial procedure, nature of complication, imaging studies, intraoperative data (operative time, estimated blood loss, access, conversion to open surgery), and postoperative data (complications, length of hospital stay, need for additional procedures, mortality).

Results

During the 5-year study period, 1962 minimally invasive procedure for various urologic conditions were performed at our institution. There were 815 procedures (41% of total procedures) performed robotically with an increasing number of robotic procedures toward the end of the study interval. The majority of cases (65.6%, 1287 cases) were prostatectomies with kidney-related surgeries (28.0%, 549 cases) comprising the majority of other procedures performed (Table 1).

From October 2003 to September 2008, 14 (0.7%) patients were operated on for early complications within 21 days of a minimally invasive procedure. The surgery was initiated and completed laparoscopically in 12 patients. Two patients were explored via open laparotomy because of marked intestinal distention that prohibited establishing effective pneumoperitoneum.

The mean patient age was 52 years (range 23–75 years). The mean American Society of Anesthiologists score before the initial procedure was II (range I–III). Twelve of the 14 patients explored were men.

Three patients who underwent renal surgery were explored for suspected bowel injury (Table 2). One patient was found to have a thermal injury with perforation of the gallbladder after a right partial nephrectomy with pyelolithotomy. The patient was treated with a laparoscopic cholecystectomy at the time of laparoscopic exploration. All three of these patients avoided laparotomy and were discharged within 4 days of their exploratory surgery.

Three patients underwent laparoscopic exploration for bleeding after renal surgery (Table 2). In two patients who were explored within 24 hours of their initial surgery, the source of bleeding was identified and treated during the laparoscopic exploration. The third patient had a delayed bleed from an acquired vitamin K deficiency and did not have an obvious bleeding source identified at the time of exploration; a significant hematoma was evacuated, which provided symptom relief. All three patients were discharged within 4 days of their exploratory surgery. Two complications after laparoscopic reexploration occurred in this group. In the aforementioned patient with an acquired coagulopathy, a wound infection developed at the specimen extraction site that was used as a hand port during the exploration to evacuate the hematoma. An anastomotic stricture after pyeloplasty also occurred in a different patient who was explored for bleeding. In this patient, the ureteropelvic anastomosis was revised during the exploration after an incidental discovery of a small suture line separation.

Four patients underwent laparoscopy for pelvic collections after radical prostatectomy and/or pelvic lymph node dissection (Table 3). In one patient, an urinoma developed from a distal ureteral injury at the urethrovesical anastomosis. After percutaneous drainage of the urinoma and nephrostomy tube placement, the patient underwent a successful robot-assisted extravesical ureteral reimplantation. Symptomatic lymphoceles ceveloped in three patients after extraperitoneal pelvic lymph node dissections, and they underwent uncomplicated fenestration of lymphoceles. The decision to pursue surgical intervention as opposed to percutaneous lymphocele drainage was made at the discretion of the attending surgeon based on the size and location of the collection. No complications occurred, and there were no lymphocele recurrences.

Operative and postoperative data are summarized in Table 4. Mean duration of the laparoscopic intervention was 110 minutes (range 60–205 min). No procedures were converted to open. The previous trocars sites were used in all procedures, and no additional trocars were needed. Hand ports were placed in two procedures, however. Both of these procedures were explorations after nephrectomies. The hand port was used in evacuating a hematoma in one patient and helped facilitate inspecting the bowel in the other patient who was explored for suspected abdominal sepsis. Estimated blood loss equaled 70 mL (range 50–100 mL). The mean length of hospital stay after exploration was 2 days (range 5 hours–5 days). Two complications occurred in the 12 patients who underwent laparoscopic exploration. There was one wound infection necessitating antibiotics, and one patient who needed an endopyelotomy after pyeloplasty. There were no deaths in the group treated laparoscopically. One patient who underwent open exploration died from sequelae of abdominal sepsis from a bowel injury during a laparoscopic prostatectomy.

In patients who were evaluated with CT before laparoscopic intervention, the CT results were consistent with intraoperative findings. Two patients were explored without preoperative imaging because of the severity and constellation of their symptoms. One patient explored for pain after a left donor nephrectomy had a questionably clinically significant small splenic hematoma without evidence of other visceral injury. The second patient had a thermal injury to the gallbladder and underwent a laparoscopic cholecystectomy.

Discussion

Historically, exploratory laparotomy has been used to treat early postoperative complications needing operative intervention. To our knowledge, this study details the first prospective study in the urologic literature of minimally invasive intervention after initial laparoscopic or robot-assisted surgery. To be considered an alternative to exploratory laparotomy, minimally invasive intervention must be both effective and safe.

Our reintervention rate of 0.7% is comparable with previously reported ranges of 0.7% to 2.4%. ^{3 –6} In the literature, exploratory laparotomy is more frequently performed for acute postoperative complications compared with laparoscopic exploration, unlike our present series (12/14 patients with early complications were treated laparoscopically). ^{3 –6,16} The spectrum of complications in this study is similar to those in the literature with hemorrhage, concern for visceral/bowel injury, anastomotic disruption/urine leak, and symptomatic lymphoceles as the frequent indications for intervention. ^{4 –6,17}

In our series, minimally invasive surgery was effective in diagnosing and treating a varied spectrum of early postoperative complications. There were no missed injuries, and no additional procedures or interventions were needed to treat the initial indication for exploration. Fourteen percent (2/12 patients) had postoperative complications in our study, which is similar to published complications rates for initial minimally invasive urologic surgery. ^{3 –6} The benefits of minimally invasive surgery were maintained with minimal intraoperative blood loss (mean 70 mL, range 50–100 mL) and short length of hospital stay (mean 2 days, range 5 hours–5 days).

Previous studies have examined the role of laparoscopy in treating hemorrhage after initial laparoscopic urologic surgery. In these reports, patients with hemodynamic instability within 10 hours postoperatively underwent open exploration, usually for arterial bleeding. ^15,16 Laparoscopic exploration was attempted in eight hemodynamically stable patients who were explored >10 hours postoperatively. Open conversion was needed in one patient. Generalized surface oozing and abdominal wall bleeding were the most frequent sources of bleeding in this group, although in one patient, a bleeding source was not identified. ^15,16 Our findings are consistent with these studies. All three patients explored for bleeding occurred at >10 hours postoperatively. All three were hemodynamically stable, and no source of arterial bleeding was identified. Consequently, laparoscopic exploration appears to be the treatment of choice when feasible in this subgroup of patients to detect and treat the source of bleeding as well as for hematoma evacuation.

A study by Yaycioglu and associates ⁶ correlated clinical, radiographic, and surgical findings in patients explored after laparoscopic urologic surgery. Preoperative CT scan findings suggesting the etiology of the complication correlated with surgical findings. In addition, two patients were explored laparoscopically because of concern for bowel injury despite unremarkable preoperative CT scans. Both patients underwent diagnostic laparoscopies with negative results. Our study supports the general accuracy of CT in detecting and diagnosing postoperative complications. Nonetheless, in hemodynamically stable patients with clinical findings highly suggestive of a complication necessitating surgical intervention, preoperative imaging may be forgone and diagnostic laparoscopy may be performed for both diagnostic and therapeutic purposes.

In our series, the previously placed trocar sites were used in all patients, and in no patient was conversion to open surgery needed during laparoscopic intervention. To avoid conversion to laparotomy, the surgical extraction site may be used as a hand port if needed. In two patients after kidney surgery, a hand port at the extraction site was used to evacuate a hematoma in one case and to facilitate systematic inspection of the intestine in a patient during a negative exploration for presumed abdominal sepsis.

Two patients did not undergo an attempt at laparoscopic exploration because of abdominal distention that prohibited the establishment of effective pneumoperitoneum. Both patients had signs of abdominal sepsis and needed resections of injured small bowel. As such, laparoscopic exploration cannot be considered the standard approach in all patients needing acute surgical intervention for postoperative complications based on our study. Although our experience suggests that laparoscopy can be safely applied to most patients with early postoperative complications necessitating surgical intervention, our findings may not be applicable to circumstances such as marked abdominal distention, hemodynamic instability, or surgeon inexperience.

Our study has several limitations. The relatively small number of patients is a result of the rare indications for acute postoperative surgical intervention. In addition, our series represents a large volume, single institution's experience. Whether laparoscopic exploration would be safe or feasible if extended to less experienced surgeons is debatable. Comparative statistics between minimally invasive intervention and open exploration were not performed because of the nonrandomized study design.

Conclusion

Laparoscopic intervention for the detection and treatment of early postoperative complications appears safe and effective in hemodynamically stable patients without significant abdominal distention. This technique should be used with appropriate discretion based on surgical experience.