Gravity Line Strategy Can Reduce Risk of Intraoperative Injury during Laparoscopic Surgery

Anlong Zhu, PhD, Yanwei Xing, MS, Daxun Piao, PhD, Tao Jiang, MD, Hongchi Jiang, Prof

General Surgery, 1st Affiliated Hospital of Harbin Medical University

Background: Intraoperative injuries are the most common cause of morbidity and mortality after laparoscopic surgery. It is accepted that most injuries are the result of misidentification of anatomical structures, which may be due to the new visual pattern different from open surgery and the lack of experience in laparoscopic surgery, especially for surgeons with insufficient training. It is of great importance to build a correct concept for the perception and judgment of a relative position of visual field during the laparoscopic surgery. With the concept, Camera drivers and beginner surgeons would get a better learning curve and a low risk of intraoperative injuries during the later operations. In this study, we aimed to find new causes of complications related to the view shown on the monitor in laparoscopic operations and solution of safe laparoscopic procedure especially for inexperienced surgeons.

Method: A series of 425 consecutive patients from September 2006 to January 2012 who received laparoscopic LAR and APR for rectal cancer in our center were included. Among these patients, 398 medical videos of laparoscopy for sigmoid colon and rectal disease were reviewed. We established a method to measure rotation angle of the operating field on the monitor. The pictures at the time of injury creation in each video were reviewed and rotational angles were measured according to the reference line based on several anatomic landmarks. Statistical analysis was performed using chi-square, Fisher’s exact, and Mann-Whitney U tests, where appropriate.

Results: 398 medical videos of 425 patients for sigmoid colon and rectal disease were reviewed. The incidence of complications was 8.3% including ureter injury, bladder injury, vagina injury and hemorrhage. Rotation of the operation views,which were found at different degrees (as <15º, 15º-30º and >30º), shown on monitor was found in a relative high rate of the medical videos(31.4%), more frequently occurred in the first 100 cases . Compared with Uncomplication Group(UG), rotation angles in Complication Group(CG) were found in all operations (UG/CG: 100%/25.7%). In most injury cases (UG/CG: 91.9%/6.4%) the rotation angles were >15º (p<0.001), and in other cases(UG/CG: 9.1%/93.1%) were <15º(p<0.001).
We also noted that there was a high incidence of intraoperative complication (72.7%) and rotation angle >15 o (26%) in the first 100 cases and a steady low rate(complication:6.1-15.2%;rotation angle >15 o: 9-11%) in the second 100, third 100 and last 98 cases.

Conclusion: Rotation of the camera is not uncommon during laparoscopic procedures. Inexperienced camera drivers and surgeons often make such a mistake because of their ignorance and lose the critical vision of parts of an operation. The rotated views increased the risk of laparoscopic procedures in intraoperative injury. Therefore, keeping the camera in the right direction is recommended during laparoscopic procedures. We propose the "Gravity Line Strategy" principle as a basic operating criterion for laparoscopic operations. It is especially important for the inexperienced camera drivers and beginner surgeons.

Session: Podium Presentation

Program Number: S091

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