Complications of laparoscopic surgery for rectal cancer: avoidance and management

Since laparoscopy was first introduced as a diagnostic tool for pelvic pathology 15 years ago, the technique has been successfully adapted by general and specialty surgeons as a therapeutic tool for a variety of diseases. Laparoscopic surgery has been used to treat colon and rectal pathology since 1991. The introduction and acceptance of this new access technique also brought the realization of specific complications associated with a laparoscopic approach. Advanced laparoscopic skills are required for laparoscopic pelvic and, to minimize laparoscopic-associated complications, specialized training is required. We will review the specific complications of the laparoscopic approach in pelvic surgery with a view to their recognition, prevention, and treatment.

Complications and recommended practices for electrosurgery in laparoscopy

BACKGROUND

Electrosurgery is one of the most commonly used energy systems in laparoscopic surgery. Two major categories of potential complications related to electrosurgery in laparoscopy are mechanical trauma and electrothermal injury. The latter can result from unrecognized energy transfer in the operational field or, less commonly, to unnoticed stray current outside the laparoscopic field of view. Stray current can result from insulation failure, direct coupling, or capacitive coupling.

METHODS

We reviewed the literature concerning essential biophysics of electrosurgery, including electrosurgical waveform differentiation, tissue effect, and variables that determine tissue effect. The incidence of electrosurgical injuries and possible mechanisms responsible for the injuries are discussed. Different types of injuries may result in different clinical manifestations and histopathological findings. Gross and microscopic pathological check-ups of the injury sites may distinguish between different mechanisms, and thus provide further clues postoperatively.

RESULTS

Several recommended practices are proposed to avoid electrosurgical injury laparoscopically. To achieve electrosurgical safety and to prevent electrosurgical injuries, the surgical team should have a good understanding of the biophysics of electrosurgery, the basis of equipment and general tissue effects, as well as the surgeon's spatial orientation and hand-eye coordination. Some intraoperative adjuvant procedures and newly developed safety devices have become available may aid to improve electrosurgical safety.

CONCLUSIONS

Knowledge of the biophysics of electrosurgery and the mechanisms of electrosurgical injury is important in recognizing potential complications of electrosurgery in laparoscopy. Procedures for prevention, intraoperative adjuvant maneuvers, early recognition of the injury with in-time salvage treatment, and alertness to postoperative warning signs can help reduce such complications.

High perimeter impedance defibrillation electrodes reduce skin burns in transthoracic cardioversion

During cardioversion, skin burns result from current preferentially flowing at the electrode edge. We tested new electrodes with high perimeter impedance to yield more uniform current distribution; these electrodes reduced histopathologic skin injury.

[Safety considerations to avoid current-induced skin burns in MRI procedures]

The safety aspects of radiological methods continue to evolve. In this paper we report on two cases of skin burns in MRI caused by induced electrical current. A second- and a third-degree skin burn occurred during imaging in a 1.5 T system. The electromagnetic radiofrequency field inadvertently led to electrical currents caused by a conducting loop through the extremities and trunk. Skin burns induced by electrical current may occur in extremely rare cases even with standard MR imaging protocols operating within all current safety guidelines by inadvertently forming a closed conducting loop. By avoiding focal skin to skin contact of the extremities, this extremely rare adverse event can be avoided.

Mechanisms of pediatric electrical injury. New implications for product safety and injury prevention

OBJECTIVES

To determine age-specific mechanisms of electrical injury in children, to examine product safety regulation of the major sources of electrical injury hazard, and to assess the adequacy of current prevention strategies.

DESIGN

Case series of 144 pediatric and adolescent electrical injuries in patients seen in the specialized burn center and tertiary care hospital between 1970 and 1995, examination of Consumer Product Safety Commission product recall reports for electrical injury hazards between 1973 and 1995, and review of the National Electric Code.

RESULTS

Eighty-six cases of electrical injuries resulted from low-voltage (< 1000-V) exposures, all occurring within the home. In children aged 12 years and younger, household appliance electrical cords and extension cords caused more than 64 (63%) of 102 injuries, whereas wall outlets were responsible for only 14 (15%) of injuries. Fifty-eight cases resulted from high-voltage exposures, accounting for 38 (90%) of 42 injuries in children older than 12 years. No federal safety regulations for electrical cords exist, although voluntary standards have been adopted by many manufacturers. Among 383 consumer products identified by the Consumer Product Safety Commission to be electrical injury hazards, 119 were appliance cords, extension cords, or holiday stringed light sets. Several products numbered more than 1.5 million units in US household distribution prior to the investigation by the Consumer Product Safety Commission.

CONCLUSIONS

Household electrical cords are the major electrocution hazard for children younger than 12 years, yet no federal safety mandates exist. Despite voluntary standards, noncompliant manufacturers can introduce vast numbers of unsafe cords onto the US household market every year. Conversion of existing voluntary safety guidelines into federally legislated standards may be the most effective intervention against pediatric electrocutions.

Complications in the use of diathermy

Electrical burns in diathermy rarely occur but are not always recognized as such or thoroughly investigated. The literature has proved to be very sparse in terms of reference to complications, although prolonged courses of treatment are required in individual cases. This paper analyses and discusses the problems of burns associated with diathermy that occurred in seven patients.

Industrial high-voltage electrical burn of the skull, a preventable injury

Deep burns of the scalp and skull are often caused by high-voltage electrical injuries. Patients with such injuries should be referred to regional burn centers that are prepared to excise necrotic burn tissue and cover the devitalized bone with a well-vascularized flap. Strategies for prevention of these electrical burns are discussed.

Risk perception following exposure to a job-related electrocution accident: the mediating role of perceived control

Perceived control was proposed to be a significant mediator for the relation often observed between mental simulation (simulation heuristic) and perceived personal risk for future lethal events. Baron and Kenny's (1986) procedure for testing a mediational hypothesis was used to evaluate this hypothesis. Employees of a recreational facility where a lifeguard was accidently electrocuted and a matched control group (N = 32) estimated their perceived risk for future electrocution events, how much personal control they believed they had over preventing future events, and the degree of clarity for mentally simulating future events. Although perceived control was not found to be a significant mediator for the relation between mental simulation and perceived risk as hypothesized, both mental simulation and perceived control accounted for a significant proportion of the variance in perceived risk for future electrocution events. The trauma group reported significantly higher ratings for perceived risk and mental simulation of future events. However, the trauma group did not differ from the non-trauma group on perceived control over future events. Possible explanations for the relatively high degree of perceived control over future electrocution events within the trauma group, in spite of their experience with a near-fatal electrocution event, are discussed.

Lesions and shocks during iontophoresis

Although a generally safe procedure, iontophoresis has recognized adverse side effects, including first-degree burns-and in fact, any low-voltage direct-current device has the potential to cause such injuries through electrolysis. In addition, as the reported problems indicate, shocks are possible under certain circumstances. Proper device operation and staff understanding of the causes of skin injuries associated with iontophoresis are essential to minimize the occurrence of these problems. It is also important to instruct the patient to inform the operator of any discomfort experienced during the treatment.

Electrical injuries from graphite fishing rods

High tension electrical injuries have a high morbidity and mortality. Carbon fibre and graphite used in the manufacture of fishing rods gives them superconductor qualities. The resistance of a fishing rod with a carbon content of more than 70 per cent is very low, ranging from 0.9 to 10.5 k omega. Nine cases are reported, which teach an important lesson not only in the management of those severe injuries, but also in their prevention.

Electrical burn caused by contact of radio receiver antenna with overhead cables

Two soldiers suffering from electrical burns due to contact of radio receiver antenna with overhead cables are presented. The necessary preventive measures for such injuries are discussed.

Laparoscopic electrosurgical injuries: survey results and their implications

This article provides the results of a survey on electrosurgical complications and surgical techniques during laparoscopy from the American College of Surgeons. Of the respondents, 18% stated that they had personally experienced an electrosurgical burn to their patient during laparoscopy. The survey shows that the majority of surgeons, 74%, employ coagulation mode most commonly during surgery. Of the surgeons, more than one third routinely employ high-voltage coagulation and blend mode operation at power settings > 40 W. We discuss the possible complications that may occur from high-voltage-high-power settings, such as direct coupling, insulation failure, and capacitive coupling of unintended current into internal tissue such as bowel. We further describe techniques that may be employed to minimize the likelihood of unintended electrosurgical burns as well as technologies that can eliminate or greatly decrease the likelihood of electrosurgical complications.

Cause and prevention of electrosurgical injuries in laparoscopy

BACKGROUND

Electrosurgical injuries occur during laparoscopic operations and are potentially serious. The overall incidence of recognized injuries is between one and two patients per 1,000 operations. The majority go unrecognized at the time of the electrical insult and commonly present three to seven days afterward with fever and pain in the abdomen. Since these injuries appear late the pathophysiology remains speculative.

STUDY DESIGN

This article reviewed the physics of electrosurgery and provides the surgeon with an insight to the mechanisms responsible in each type of injury. In addition, a comprehensive search of the world literature has reviewed all articles on the topic.

RESULTS

The main causes of electrosurgical injuries are: inadvertent touching or grasping of tissue during current application, direct coupling between a portion of intestine and a metal probe that is touching the activated probe, insulation breaks in the electrodes, direct sparking to the intestine from the diathermy probe, and current passage to the intestine from recently coagulated, electrically isolated tissue. The majority of injuries, not surprisingly, are caused by monopolar diathermy. Bipolar diathermy is safer and should be used in preference to monopolar diathermy, especially in anatomically crowded areas.

CONCLUSIONS

An awareness of the hazards of diathermy together with an understanding of the mechanisms of injury should enable the surgeon to dissect tissue and to achieve hemostasis, while at the same time decreasing the risk of serious complications to the patient.

AANA Journal course: update for nurse anesthetists--an overview of electrical safety

A major part of anesthesia care involves ensuring the safety of the patient. Electrical hazards in the operating room abound. Knowledge of the principles of electricity is an important foundation for promoting a safe and hazard-free environment. This installment of the AANA Journal course deals with issues that have an impact on electrical safety.

Burns from electric fire-guards

Nine children with burns caused by contact with electric fire-guards are presented. A method of preventing such injuries is recommended.