Prevention and Management of Intraabdominal and Pelvic Catastrophes - Society of Laparoscopic & Robotic Surgeons

Prevention and Management of Intraabdominal and Pelvic Catastrophes

Raymond J. Lanzafame, MD, MBA

The minimally invasive surgical (MIS) revolution opened new surgical vistas and ushered in an intense interest in rethinking much of conventional surgical dogma. Surgeons are more frequently using MIS techniques to solve an increasing array of clinical problems.1-3 Much development has occurred, and more options are available to the laparoscopic surgeon today relative to the timeframe of the first edition of this textbook.4-16

The problems of the learning curve have passed for laparoscopic cholecystectomy, but the rigors of mastering the techniques and technologies necessary for so-called “advanced” procedures remain for the majority of surgeons. The ability to intracorporeally suture and tie knots remains elusive for the greater majority of surgeons. We hope that these difficulties will become less severe as new generations of surgeons are trained and as they gain experience during residency training. However, new surgeons must be taught the appropriate steps by established surgeons who are familiar with these procedures. The development of appropriate measures of skills and competence with surgical tasks is gaining momentum but remains in its infancy at this time. Similarly, there is growing concern that residents see so few open procedures, particularly in the case of cholecystectomy, that they will be incapable of successful management should an open procedure or conversion be necessary.

The subject of this chapter is Herculean in scope. Entire texts have been devoted to this topic.17-22 This chapter will provide an overview of potential perioperative catastrophes and a philosophy for approaching minimally invasive surgical procedures and their complications. Few would argue the fact that complications can and do occur during surgery and that it is preferable to prevent them from occurring in so far as it is possible. However, the ability to recognize them and deal with them appropriately requires composure, thought, and skill.23-26 Let us begin our discussion by considering some of the general principles inherent to good surgical practice.

The surgeon must have a thorough understanding of regional anatomy for each procedure and a working knowledge of the endoscopic anatomy. This means that the surgeon understands the anatomy of the key steps of the procedure from a 3-dimensional perspective. Adequate visualization and illumination are imperative. Angled telescopes can do much to improve visualization. Unlike open procedures, the operating team can easily become disoriented if the camera and laparoscope are improperly aligned or rotated.

The surgeon should have an adequate skill level to undertake the proposed procedure and should have assistants familiar with laparoscopy. The surgical team should be consistent, having worked together frequently. This team concept simplifies the procedure as each member understands the nuances of laparoscopic procedure, has knowledge of the equipment used, and is able to anticipate the needs of the other team members.27-30

New procedures should not be the domain of the novice. The surgeon attempting a new procedure relative to his or her repertoire should proceed cautiously. Proper patient selection is critical. Appropriate informed consent should always provide clear and accurate information to the patient regarding risks and benefits of the procedure.

The surgeon should enlist the help of others experienced with the proposed procedure. Practicing the skills necessary to perform the procedure should be ongoing and should ideally occur in the skills or animal laboratory. It is inappropriate to subject a patient to surgery performed by a surgeon with inadequate training or skills. Individual surgeons must appraise their skills and limits honestly and should be willing to police colleagues in an even-handed fashion.

Surgeons should recognize that laparoscopic surgery, like all surgery, carries a risk of morbidity and mortality. Deziel et al31,32 reported an incidence of 0.04% postoperative mortality in a series of 77 604 laparoscopic cholecystectomies performed in 4292 hospitals. Of the 33 deaths reported, 19 resulted directly from operative injury with the balance being due to other “nontechnical” causes. These data underscore the fact that laparoscopic procedures can be performed with a low rate of mortality. Careful analysis and discussion of each mortality and/or significant morbidity is prudent to improve care and quality.

The surgeon should be intimately familiar with ALL of the equipment used for the procedure. Ideally, the surgeon should be able to troubleshoot the equipment that is to be used during the procedure. New devices may not be functioning properly, and other instruments may have been improperly assembled. This latter point is particularly true with new or inexperienced scrub personnel. The surgeon should never assume that others have an in-depth knowledge of the instruments. It is also prudent for one to be certain that all procedure-critical instrumentation and materials are on hand and in good working order before embarking on the procedure.29

The method of access to the abdomen should be selected carefully with particular attention to the avoidance of pervious surgical scars and the location of anticipated adhesions.33-38 Nezhat et al36 has analyzed all methods of initial access and has demonstrated no difference in the rate of complications regardless of the method chosen by the surgeon.37 It is incumbent on the surgeons to use those methods of access with which they are the most comfortable. The location and type of accessory ports must be well thought out and should be based on the habitus of the patient, the location of the target organ, and those positions that best facilitate retraction and dissection. The surgeon should be comfortable in placing additional ports as needed for retraction or dissection. A thorough laparoscopic review of the abdomen should be performed with every procedure.

This diagnostic laparoscopy permits assessment for occult injuries that may possibly have been incurred during initial access, establishes the extent of disease, and permits a search for metastases or other significant pathology.

The dissection should proceed in a stepwise fashion and follow traditional anatomic planes. Strict adherence to basic surgical principles is as important as it is during open surgery. Structures are carefully dissected and clearly identified prior to division or ligation. It is always advisable to proceed from areas that are most clearly defined and are not involved with scarring or disease to safely trace and carefully dissect anatomic structures with reduced likelihood of causing iatrogenic injury. Ligating clips and sutures are placed deliberately but gently and with care not to injure adjacent structures. Vessels in the line of dissection are cleared and ligated with clips, sutures, or using Harmonic or plasma scalpel devices to facilitate their safe division. Surgical division and hemostasis are facilitated by the use of the Endo-GIA, Harmonic scalpel, or similar instrumentation. A clear view of instrument placement is mandatory. Care must be taken to avoid the inclusion of an excessive amount of tissue into jaws of the instrument. Division of the mesentery or bowel often requires multiple firings of the stapler, when these devices are used. It is imperative that each successive firing overlaps its predecessor. This overlap assures continuity of the staple line. The surgeon should always inspect the staple line after its completion to be certain of its continuity. Any questionable area should be oversewn or repaired with another firing of the stapler.39 A similar technique is suggested for Harmonic and plasma scalpel dissection.

Many different techniques are available for anastomosis. The surgeon should choose the method that best fits patient anatomy and location of the anastomosis. The surgeon must check the integrity of the anastomosis and should observe the same caution when creating an anastomosis intracorporeally as in “open” procedures. Several methods are available to assist in the proper alignment and orientation of the structures to be anastomosed.
These include the use of staples, stay sutures, or tattooing of the lesion area. The use of tattooing techniques with isosulfan blue, methylene blue, or other dyes is also helpful in performing sentinel lymph node localization procedures.40-42

When properly performed, laparoscopically assisted techniques enhance the surgical repertoire and offer many benefits to the patient. Extracorporeal anastomosis permits the surgeon the ability to create an anastomosis more easily with techniques that are familiar. Hand-assisted laparoscopic techniques have been used as a bridge between open and MIS procedures. These techniques are viewed as a logical extension of the older extracorporeal approaches. HALS sleeves are available from several manufacturers. The surgeon typically places the incision for the hand port at a predefined location based on the location of an anastomosis, stoma, or at a location that simplifies retrieval of the specimen. Usually, the surgeon inserts the nondominant hand in the port and uses laparoscopic instrumentation with the dominant hand. This allows the surgeon to use manual dissection techniques while visualizing the field with laparoscopic optics. The surgeon is able to use tactile feedback to locate lesions, verify the location of the vasculature, as well as to provide traction during the dissection. The length of the procedure is reduced and a much smaller incision is used with both HALS and extracorporeal anastomosis techniques. HALS techniques simplify specimen retrieval and can minimize the potential for spillage or wound contamination. The need for morcellators is minimized. These techniques have proven to be versatile, particularly in urologic procedures like donor and partial nephrectomy.

A minimally invasive approach results in reduced postoperative pain, less ileus, and a lower incidence of wound complications.39-49 However, the surgeon must be certain to maintain proper bowel orientation and gently manipulate the bowel so as to avoid misalignment or disruption of the anastomosis.

Considerable controversy exists in the literature as regards tumor implantation and wound-site recurrence following laparoscopic surgery. Tumor implantation at the trocar and incision site has been reported following cholecystectomy, colectomy, and oophorectomy. In these instances, tumor spillage or tumor disruption occurred during the course of the procedure. Experimental models for tumor implantation and growth enumerate conditions that are analogous to those responsible for septic wound complications. These conditions include “virulence” of the tumor (ie, the minimum number of cells necessary to overwhelm local host defenses), degree of local injury (ie, the amount of devitalized or impaired tissue, the presence of hematoma, or seroma), the mechanism of the wound’s creation (ie, scalpel, thermal, or electrosurgical), other factors, such as spillage of bile or intestinal content, and the timing of cellular implantation relative to initial wounding (surgery). Appropriate preventive precautions must be used during the conduct of MIS procedures and during specimen retrieval. Careful manipulation of the involved organ is necessary to prevent tumor disruption and spread during dissection. The specimen should be isolated and retrieved by using an endoscopic bag or pouch to protect the wound from tumor cell implantation as the specimen is removed from the abdomen. The use of HALS technology may simplify retrieval of the specimen and may reduce the potential for spillage or excess manipulation of the tissue.

Good surgical technique is necessary during any procedure. However, oncologic procedures demand careful staging and adherence to accepted surgical practice regarding the extent of resection required for disease control. Similarly, the prudent surgeon proceeds in a fashion that avoids spillage of bowel content or bile while maintaining a clean, dry operative field, regardless of the indication or procedure being conducted.48

Analogs of the Miculicz pads used for packing of an open procedure (wound) are available for laparoscopic use. Inflatable dams and retractors are available, but these devices do not have the same absorptive or isolation capacity, as do sponges. It is therefore incumbent upon the surgeon to aspirate leakage immediately and thoroughly irrigate and aspirate the operative field when the procedure has been completed.
Materials like vaginal packing, Kerlix, and Ray-tex sponges have been used for packing during classical laparoscopic procedures. These materials can be inserted through the trocars and be used intraabdominally. Using sutures or other methods to assure retrieval of these materials before case completion is suggested. HALS techniques do permit the use of standard packing and sponges, because they can be easily introduced through the hand port. It is incumbent upon the surgeon to verify that all packing material and sponges are retrieved prior to the conclusion of the procedure.

Although the use of drains remains controversial, laparoscopic techniques do not obviate their use. Therefore, the surgeon should continue to use drains when indicated. Similarly, attention to antibiotic prophylaxis and bowel preparation should not deviate from accepted guidelines for surgery.

Because surgical procedures are often required to treat acute pelvic or abdominal conditions, and because the operative findings in elective procedures may disclose more severe disease than was anticipated, the surgeon must realistically assess the degree of progress being made during a case and determine whether the dissection is proceeding safely within a reasonable length of time. These variables will assist the surgeon in making the decision to convert a laparoscopic procedure to an open one. The conversion of a laparoscopic procedure to an open operation or the use of a hand-assisted laparoscopic technique should be considered to be an exercise of sound surgical judgment rather than a complication of laparoscopy.

Although the best method for managing complications is to avoid them, the surgeon must remain vigilant during laparoscopy to recognize and address complications immediately. As minimally invasive surgical techniques continue to develop, it is likely that specialty boundaries will continue to blur. That is not to say that there is no need for the specialist or consultant. The surgical laparoscopist should have a range of skills that permits safe handling of common complications encountered during the course of surgery regardless of the organs involved. For example, the gynecologist or urologist should have the basic skills needed to repair or resect bowel injured during the course of pelvic surgery or involved with tumor. Similarly, the general surgeon should be able to resect an ovary or perform hysterectomy when these are demanded by the treatment of disease in contiguous organs. By the same token, the surgical laparoscopist should recognize his or her limitations and request a consultation or the assistance of a colleague when necessary. This latter point should not be underestimated. Assistance or consultation can be as informal as asking a colleague already in the department to look at the monitor and verify what the surgical team is “seeing,” or to serve as a “reality check” for a proposed course of action during a difficult procedure. It is also helpful to adopt a multidisciplinary approach when attempting to tackle a complex or unusual case.50 Good judgment should prevail as regards the appropriateness of formal consultation in the event of a suspected or already recognized complication.

The occurrence of a serious complication can be devastating to both the patient and the surgeon. This can certainly impair one’s ability to assess and address the complication appropriately, particularly if one’s composure is lost. It may be preferable for the surgeon to consider the possibility of transferring the care of the patient to another surgeon in such cases, rather than risking the potential worsening of the problem.

Trocar-related complications generally involve inadvertent laceration or perforation of intraabdominal organs or vascular structures during initial access. The method of gaining access is an independent variable regarding the incidence of these problems. The surgeon should choose the method of access with which she or he is most comfortable and insert all secondary trocars under direct vision. The abdomen should be carefully inspected for serosal injuries or tears due to adhesiolysis or traction. Using alternative puncture sites in patients with abdominal incisions (including previous laparoscopies) will reduce the possibility of bowel injury during initial puncture.35,37,51-55 A secondary advantage of these techniques is the ability to perform careful adhesiolysis under direct vision.

Laparoscopic surgery is no different from open surgery in that significant serosal injuries should be repaired. Full-thickness injuries of the small bowel can be oversewn with different endoscopic techniques. Repair of small defects can be accomplished with the use of suture, linear GIA staplers, or with the use of certain versions of endoscopic hernia staples. Serosal tears or simple lacerations are easily repaired with seromuscular sutures of 3-0 polyglycolic acid or polydioxanone. Extracorporeal or intracorporeal knots can be used depending on intraoperative findings. Wedge resections of the bowel can be accomplished and subsequently repaired with interrupted suture of 3-0 polyglycolic acid or polydioxanone. The Endo-GIA can be used with the triangulation technique to affect an anastomosis and can be applied perpendicularly to the long axis of the bowel to resect and repair segmental injuries without compromising the diameter of the bowel lumen.
Small defects can also be repaired by careful approximation of the wound by using Ethicon Endo-hernia staples to close the seromuscular layer.

Repair of colorectal injuries remains more controversial.39,40,56-60 However, the trauma literature would argue strongly for primary closures of minor injuries or lacerations, particularly in instances where minimal soiling of the peritoneum has occurred. Any questionable large bowel injury should be exteriorized or resected, and sound clinical judgment should prevail as to whether these injuries should be handled with open repair or the creation of a proximal colostomy, or both. Appropriate antibiotic coverage for gram-negative organisms and anaerobic bacteria should be administered.

Injuries to the genitourinary system frequently involve the bladder or ureters.6,20,60-63 Bladder lacerations may occur with the initial puncture or pelvic dissection, particularly in cases complicated by dense adhesions or previous radiation therapy. Bladder injuries related to the initial puncture can be prevented or minimized by routinely using Foley catheterization or ensuring that the patient has voided immediately prior to surgery. The bladder can be instilled with methylene blue or indigo carmine before the initial dissection as a means of distinguishing it during a complicated pelvic dissection. Bladder instillation can also be used after or during the dissection to visualize any evidence of leak or injury to the bladder as a result of surgical trauma. Minor injuries to the bladder can be handled with catheterization or with bladder closure and drainage. Simple lacerations should be closed with a single or double layer by using a full-thickness suture technique. Most urologists recommend that chromic suture or Monocryl (poliglecaprone) be used for urinary bladder repair, because polyglycolic acid and other materials may act as a nidus for stone formation. Bladder injuries can be devastating if they are through and through or involve the trigone area. Cystoscopy may be necessary and should be considered if any question of such an injury exists.

Ureteral injuries are best avoided by locating the ureters before division of pelvic vessels or before mesenteric division during colectomy. The use of fiberoptic or other stents has been advocated by some surgeons in both open and laparoscopic procedures. Careful placement of surgical clips and suture ligatures will diminish the risk of injury. Simple lacerations of the ureter may be successfully managed with ureteral stenting. Segmental defects require urologic consultation and may require ureteroureterostomy or renal autotransplantation.

Vascular complications can be the most devastating and potentially fatal complications of laparoscopy. The key to successful resolution of vascular injuries is prompt recognition and treatment. Nordestgaard and colleagues64 found that vascular injuries were a rarely reported complication. Three cases proved fatal due to the failure to recognize the injury in a series of 11 vascular injury cases. Indeed, 2 fatalities reported during the early experience with laparoscopic cholecystectomy in New York State resulted from iatrogenic injury to the aortic bifurcation and to the portal vein. Major vascular injuries continue to be a source of major morbidity and mortality today. Preoperative evaluation of specific anatomy and other strategies are often helpful in preventing these potentially fatal events.65

The principles of proximal and distal control and rapid application of pressure to control hemorrhage apply for both laparoscopic and open procedures. The surgeon and team must remain calm and avoid panic. Blind clamping and suturing must be avoided.
Control of hemorrhage by direct pressure will allow time for conversion to an open procedure if necessary and permit methodical assessment and possible laparoscopic control in small injuries. Vaginal packing or gauze sponges can be inserted to assist in the application of pressure to the point of bleeding and reducing the possibility of further damage by the use of metallic instruments alone. The surgeon must be certain to retrieve any such materials before the completion of the procedure. Direct suture or ligation of vessels is best accomplished with the use of double-armed polypropylene suture. As in open surgery, proximal and distal control is essential to successfully visualizing and dealing with vascular problems. The use of an endo-Allis or Babcock clamp will often control venous injury and permit closure without further danger to the vessel wall. Early consultation with the vascular team should be obtained if a severe injury occurs or if there is a question concerning the management of an injury.

Significant bleeding can occur from vessels that are intentionally divided as a part of the procedure. This can occur intraoperatively or during the postoperative period.41 The majority of these problems can be prevented through verification of the appropriate placement and use of ligatures, clips, and staples during the course of the operation, and careful inspection for hemostasis and appropriate clip positioning prior to closure.66-72 The use of endoscopic locking type hemoclips can be helpful in assuring closure of large vascular pedicles, such as those encountered in splenic, hepatic, and renal surgery.

Injury to the retroperitoneum and its structures can result in significant morbidity or mortality, particularly if injury to these structures is unrecognized and not properly addressed. Many retroperitoneal injuries occur due to trocar insertion or traumatic insertion of other instrumentation.46,73-75 The careful placement of trocars and instruments in a controlled fashion and under direct vision will prevent the vast majority of these potentially lethal complications. As with open surgery, a suspected injury requires careful and meticulous control. The decision for conversion to an open procedure should be based on the type and location of the injury. A pelvic hematoma can be managed initially by packing or pressure application with fan-type retractors or the use of vaginal packing or gauze sponges. An expanding hematoma will require exploration. An apparently stable hematoma should be observed carefully as the abdomen is desufflated. Exploration, endoscopic ultrasonography, or angiography is warranted if the hematoma expands as the abdominal pressure returns to baseline. A similar strategy is useful for the management of hematomas at the root of the mesentery and in other areas. Blind suturing and mass ligature techniques should not be used under any circumstance. Injuries to the retroperitoneum in the area of the duodenum or pancreas deserve particular attention and should always be explored due to the significant mortality associated with untreated injuries to the duodenum and adjacent structures.

Injuries may occur from the use of electrosurgical or laser devices during minimally invasive surgical procedures.76 Many of these injuries can be prevented by meticulous technique and the careful application of these devices. The minimum amount of energy necessary to coagulate or cut should be used irrespective of the source of that energy. The entire active portion of the electrode or delivery instrument should be in clear view before the use of an electrosurgical or laser device. The instrument should not be in contact with any other structure than the desired target. Electrosurgical device injuries may occur as a result of insulation breakage and current leakage, direct coupling as current travels to or from the electrode to the laparoscope or other instruments, or capacitance coupling as the endo instrument and metallic cannula stores energy and functions as a capacitor.
Electrical energy may cause isolated tissues or tissues placed under tension to overheat and secondarily injure adjacent structures as electrical energy heats tissue with the greatest resistance to the flow of current to the grounding electrode. The instrument itself may remain hot for a brief time after current application, particularly after protracted use. Contact of adjacent tissues can produce a thermal burn under these circumstances.
Bipolar instruments and the Harmonic scalpel are also capable of inflicting contact thermal burns to adjacent structures, because these devices also become heated during prolonged use.

Laser devices of various types have been used for minimally invasive surgical procedures.77-81 These tools can be a valuable addition to the surgeon’s armamentarium when plied by a skilled laparoscopist conversant with laser technology and its limitations. Both free-beam and fiberoptic applications are possible. For most surgeons, fiberoptic lasers are the simplest to master and apply. The surgeon should have a thorough understanding of the particular laser’s wavelength and delivery system and carefully consider the depth of penetration, tissue effects, and visual appearance of the tissue after laser energy has been applied. Selection of the appropriate wavelength and delivery system is necessary for the safe and successful use of these technologies. The same basic care as is described for electrosurgical devices should be observed when using lasers. The surgeon should prevent inadvertent injury due to reflected or stray laser energy. This is accomplished by proper orientation of the device relative to the target, the use of optical backstops during dissection and careful retraction and displacement of adjacent structures. Contact laser devices convert light energy to heat and as such can cause thermal injury to adjacent tissues after the laser has beendisengaged.

Injuries due to the use of electrosurgical devices, the Harmonic scalpel, or lasers should be treated aggressively if noted at the time of surgery.76,77,80 This is particularly important as the visible appearance of the lesion may grossly underestimate the full extent of injury and subsequent tissue necrosis. Serosal injuries should be oversewn. Unfortunately, injuries may only be recognized after tissue necrosis and perforation occur. A high index of suspicion should be raised in the postoperative patient who presents with severe or increasing discomfort, fever, or “ileus” after surgery. Prompt assessment and management of these complications are required to avert significant morbidity or mortality.

Laparoscopic cholecystectomy brought with it an increased incidence of injuries to the extrahepatic biliary tree, including segmental defects considered to be unique to laparoscopic cholecystectomy.32,46,82-84 Although many of these complications were thought to occur only during the “learning curve,” any patient who presents with severe postoperative pain, ileus, or increased discomfort should be considered to have a bile duct injury or leak until proven otherwise. DISIDA (diisopropyl iminodiacetic acid) scanning and ERCP (endoscopic retrograde cholangiopancreatography) can elucidate the presence of an injury or leak. Minor injuries or leaks can be managed with nasobiliary drainage.
However, major injuries require operative repair. Definitive repair should be taken early. The surgeon should seek the assistance of surgeons conversant with biliary reconstruction techniques if he or she is not experienced in these techniques. The development of multidisciplinary teams to manage these problems has been shown to be advantageous and is generally more practical in larger and academic institutions.50

Way and colleagues82 analyzed the causes and prevention of laparoscopic bile duct injuries based on their review of 252 cases. They noted that the primary cause of error was visual perceptual error in 97% of the cases, with faulty technical skills accounting for the remaining 3% of injuries. These authors also found that only 25% of the injuries were recognized at the initial operation. More sobering was the fact that only 6% of the injuries were recognized early enough to limit further iatrogenic injury. A rather comprehensive list of rules of thumb is enumerated to help prevent these injuries from occurring.

Liver lacerations can often be controlled with gentle pressure and patience.17,22,46 A fan retractor may be used to compress the parenchyma against the abdominal wall or back muscles. Hemostatic agents, such as Surgicel or Avitene, may be quite useful. Bleeding that persists following 5 minutes to 10 minutes of compressions should be reassessed.44,52,75,85 Any specific bleeding point should be dealt with cautery, argon beam coagulator, laser, hemoclips, or suture ligation. Packing major injuries with omentum and drainage of the subhepatic and subphrenic spaces may be used to control major problems. However, major injuries should not be oversewn. The use of vaginal packing or Kerlix for temporary control of persistent bleeding from a large injury has its place when bleeding isongoing.

Management of disease or injury to the fallopian tubes or ovaries should be assessed as to its severity and the likelihood of salvageability. Severe disease or injury will often require resection.49,71,81 The Endo GIA and similar devices have made resection quite simple.
Alternatively, the surgeon can use Endo loops or hemoclips for serial ligation of the vascular pedicle and control the fallopian tube at the level of the infundibulum.86-88 Great care must be taken to avoid iatrogenic injury to the ureters during dissection.86 Identification of the ureters prior to ligation or stapling is important.89 Minor injury or bleeding from the ovary can generally be controlled with compression, cautery, laser photocoagulation, or suture ligation. Simple perforation of the uterus can generally be managed conservatively as has been demonstrated in the literature on dilatation and curettage. Contiguous involvement of the uterus with tumor or disease may require hysterectomy. A variety of techniques for LAVH have been described.9,30,49,55,90 The use of staplers has facilitated these procedures. Management of the vaginal cuff will depend on the clinical circumstances. However, the cuff may be oversewn with polyglycolic acid or polydioxanone sutures or stapled with titanium or absorbable staples. To facilitate removal, the large uterus can be sectioned or morcellated and delivered vaginally or through a mini-laparotomy incision.

An outline of the philosophy for the prevention and management of catastrophic complications during minimally invasive surgery of the abdomen and pelvis has been presented. Knowledge of anatomy and strict attention to detail will prevent many complications. However, it must be recognized that anatomic conditions in vivo are rarely as depicted in textbooks. Human factors, including visual perceptual illusions can also play a role in the etiology of a surgical complication. The fact that one can fall prey to misperception should provide an even stronger impetus to verify and reconfirm anatomy before making a potentially irreversible maneuver, or when the anatomy is perceived to be anomalous. It is preferable to assume that the anatomy is really normal but confusing, rather than assuming that an anatomic anomaly exists. This requires constant vigilance and discipline on the part of the surgeon.

The keys to management of catastrophic or minor complications are careful, methodical assessment and appropriate action without panic. The surgeon should feel comfortable in converting an MIS procedure to an open one when necessary and should endeavor to cooperate with colleagues in the best interest of the patient. It is likely that future developments in technology and clinical experience will improve outcomes and reduce the incidence of complications. However, no technology will replace constant vigilance, cooperation, and sound clinical judgment.


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