© Springer International Publishing AG 2018Chad G. Ball and Elijah Dixon (eds.)Treatment of Ongoing Hemorrhagedoi.org/10.1007/978-3-319-63495-1_19
19. Laparoscopic Hemorrhage: Do We Have to Open?
General/Bariatric Surgery, St. Joseph’s Healthcare, Mcmaster University, Hamilton, ON, Canada
KeywordsLaparoscopyHemorrhageMinimally invasive surgeryBleeding
You’re performing a laparoscopic extended right hemicolectomy on a 72 year-old female for cancer when a little too much traction results in torrential venous haemorrhage from the right upper quadrant. The field turns red…
Many surgeons have found themselves trapped in this so-called laparoscopic snowball. It is a nightmare situation, the surgical equivalent of quicksand: the more you panic, the quicker you sink. Unless you have a clear plan of action in place before the case even begins, rest assured, you’ll undoubtedly find yourself stuck in one of these snowballs at some point in your career. This chapter gives you a practical strategy for dealing with hemorrhage during laparoscopic cases.
Laparoscopy Is a Different Animal
Laparoscopy has clearly revolutionized the way we perform surgery. There’s certainly been no shortage of papers regaling the virtues of minimally invasive surgery: everything from decreasing the length of hospital stays to reducing surgical site infections and postoperative pain.
The advent of specialized staplers, energy devices, and laparoscopic suturing techniques has allowed surgeons to push the surgical envelope further and further. Complex procedures that once seemed impossible to perform laparoscopically have become commonplace in the laparoscopic arena. Gastric bypass ? Whipple procedure ? AAA repair ? Done, done, and done.
With these advances, however, comes the realization that major surgical bleeding remains the great equalizer. If having to deal with serious bleeding during open surgery isn’t harrowing enough, laparoscopic surgery serves to introduce a whole new level of pain to the game .
Developing Your Strategy Beforehand
The key to dealing with laparoscopic bleeding (or any bleeding, for that matter) is putting a well-developed strategy in place before you ever find yourself needing one in the first place.
Step 1: Initial Temporary Control
When you encounter a big (or potentially big) bleeder, your first move should almost always be to obtain initial temporary control . You have at your disposal a few precious seconds to see where the bleeding is coming from and to grasp or compress the vessel or surrounding tissue. If you miss this window, you’ll quickly find that the accumulated blood has completely obscured the bleeding vessel—along with much of your visual field.
When faced with bleeding, I commonly see trainees of all levels frantically reach for their suction device or ask for a clip applier. You need to resist this urge. Often, by the time you’ve successfully introduced either of these instruments into the abdomen, your visual field will already have been lost, making it much more difficult to recover.1
If you can see the bleeding vessel, gently grasp it with an instrument in your nondominant hand. A word of caution: when grasping tissue, you always run the risk of turning a small side hole in a vessel into a major bleeder. If you can’t see the vessel or feel it isn’t safe to grasp (e.g., retracted vessel in the splenic hilum), you should instead consider compression with some radiopaque surgical gauze (e.g., Ray-Tec©).
Have you successfully brought the bleeding to a stop or at least to a slow trickle? If so, proceed immediately to Step 2. Do not readjust your hand to get a better grasp of the tissue. Don’t start suctioning, and definitely don’t start throwing clips everywhere. You have control; it’s time to take a deep breath and regroup.
If you’re unable to gain control of the bleeding, this is the point at which you’ll need to start thinking about the possibility of having to convert to open. A good surgeon will appreciate the gravity of the situation and will make the decision to open before the necessity of doing so becomes apparent to everyone around him or her. Don’t wait for the patient to become hemodynamically unstable before making this decision. For a surgeon, there can be no greater tragedy than failing to convert to an open procedure as their patient exsanguinates right in front of them.
As soon as you become aware of the severity of the current situation, inform the scrub nurse that you may need to open, and ask him or her to prepare a 10 blade in the event that you do. There’s nothing worse than trying to perform an emergent laparotomy with a tiny 15 blade normally used for trocar incisions.
Step 2: Stop What You’re Doing!!!!!
This step is, without question, the most critical—and it’s the key to dealing with any serious bleed you may encounter during laparoscopic surgery. What you do next will represent the difference between a small fender bender and ten-car pileup . Now that you have control, stop and regroup.
I realize that the worst thing you can tell someone who is panicking is to “calm down.” The fact remains, though—in a situation as urgent as this—you do need to calm down. Your team is looking to you for leadership, your patient is relying upon you to save his or her life, and you’re of no use to anyone if you can’t first regain control of yourself.
Here are two of the best techniques I know for quickly snapping yourself out of a panic state:
Consciously slow down your breathing . Tons of research has been done in professional sports around the use of deep, diaphragmatic breathing as a tool to slow down one’s heart rate and regain self-control. Once you have regained temporary control of the vessel, your next step should be to take a deep breath. You’ll be amazed at how quickly this can bring you out of panic mode .2
The “ Mister Rogers Technique .” Ever notice that people who are panicking tend to raise their voices and speak really, really fast? Another great trick for quickly neutralizing panic is to deliberately lower the volume of your voice and speak more slowly—hence, the “Mister Rogers Technique.” Consciously forcing yourself to speak like Mister Rogers (“Okay, boys and girls…”) will instantaneously calm your mind and lower the chaos level in the room .
The next time you find that you have just ripped a hole in a major vessel, try simply grabbing the vessel, taking a deep breath, and, in your calmest voice, saying, “Hmmm…interesting.” You’ll look like a seasoned pro .
Step 3: Plan of Attack
Remember the laparoscopic snowball we discussed at the beginning of the chapter? This is where we do everything in our power to prevent it from ever launching down the mountain. As Benjamin Franklin famously said, “By failing to prepare, you are preparing to fail.” This situation has now morphed into a game of simple strategy, and you should be thinking at least three moves ahead. The best way to ensure that your plan is smoothly executed is to run through a mental checklist prior to moving forward.
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You’ll need at least one 12 mm (or larger) trocar in place (preferably for your dominant hand working port). If you don’t have any in place, strongly consider upsizing one of the 5 mm ports now.
If the first rule of bleeding control in open surgery is to extend the incision, then the equivalent in laparoscopy is to add more trocars. Make sure there are extra trocars available and positioned close by, if needed (two 5 mm and one 12 mm trocar should suffice).
Ask the scrub nurse to open a package of 4 × 4-inch Ray-Tec© sponges (or any x-ray-detectable sponge).
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