Overcoming Technical Challenges: Prevention and Managing Complications

  • Bradley R. DavisEmail author


Laparoscopy for colorectal disease is complex and poses many new challenges for the minimally invasive surgeon. Knowledge of pitfalls and strategies to avoid and mitigate complications will improve outcomes for patients. Techniques for trocar insertion and vascular ligation and maneuvers to lengthen the conduit for an intestinal anastomosis are varied and not applicable to every situation or case. Establishment of pneumoperitoneum and adequate exposure are critical for the safe performance of laparoscopy and can be more difficult in obese patients.


Small Bowel Splenic Flexure Inferior Mesenteric Artery Veress Needle Ileorectal Anastomosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

Video 21.1

A bladeless trocar is used to bluntly dissect the layers of the abdominal wall. A zero-degree 5 mm laparoscope is inserted into the core of the trocar and focused just past the tip. Recognition of the peritoneal cavity is easy if a Veress needle has been used first to establish pneumoperitoneum. However, this is not necessary as seen in the latter part of the video (MOV 25112 kb)

Video 21.2

In this patient a previous laparotomy has resulted in the omentum adhering to the abdominal wall. Despite an optical view entry, the trocar is initially placed below the omentum, which can cause confusion upon camera insertion. Recognition of the malpositioned trocar and subsequent repositioning should be achieved quickly. An alternate trocar placed off midline under direct visualization can be used to reposition the camera and the adhesions to the abdominal wall can then be dissected free (MOV 171566 kb)

Video 21.3

When performing a laparoscopic adhesiolysis, judicious use of sharp dissection is encouraged to avoid thermal injury to the bowel. Thermal injury can be harder to recognize and occur remote to the site of dissection. Serosal injuries should be inspected to assess if repair is warranted (MOV 209264 kb)

Video 21.4

An enterotomy is inadvertently created during this re-operative right colon resection for Crohn’s disease. While the enterotomy would ultimately be part of the specimen, it is immediately closed to prevent contaminating the abdomen with enteric content (MOV 112286 kb)

Video 21.5

The mesentery of the left colon is being transected with a harmonic scalpel when too much traction is applied resulting in arterial bleeding. Initial attempts to control the bleeding with a 5 mm clip applier are not successful as proximal control and identification of the bleeding vessel are suboptimal. By transecting the tissue completely, the end vessel is identified and then ligated with an ENDOLOOP ® (MOV 223752 kb)

Video 21.6

Vaginal packing cut into short strips can be inserted through a 10 mm or larger trocar and used to absorb fluids and blood as well as provide pressure on a bleeding structure. It can also serve as a guard for the suction irrigator so that it will not be occluded with tissue. Once identified, the bleeding structure can then be ligated (MOV 99379 kb)

Video 21.7

Sacral bleeding is encountered following the placement of a stitch in the promontory during a laparoscopic rectopexy. This is particularly frustrating as the procedure is near completion. The bleeding is controlled with a clip applier (MOV 176648 kb)

Video 21.8

Following a stapled colorectal anastomosis, the serosa separates and is not incorporated into the staple line. This may result in an increased risk of leak and the staple line is oversewn with Vicryl™ sutures (MOV 144267 kb)


  1. 1.
    Varma R, Gupta JK. Laparoscopic entry techniques: clinical guideline, national survey, and medicolegal ramifications. Surg Endosc. 2008;22(12):2686–97. Epub 2008/04/11.PubMedCrossRefGoogle Scholar
  2. 2.
    Ahmad G, O’Flynn H, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2012;2, CD006583. Epub 2012/02/18.PubMedGoogle Scholar
  3. 3.
    Deffieux X, Ballester M, Collinet P, Fauconnier A, Pierre F. Risks associated with laparoscopic entry: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol. 2011;158(2):159–66. Epub 2011/05/31.PubMedCrossRefGoogle Scholar
  4. 4.
    McKernan JB, Champion JK. Access techniques: Veress needle–initial blind trocar insertion versus open laparoscopy with the Hasson trocar. Endosc Surg Allied Technol. 1995;3(1):35–8. Epub 1995/02/01.PubMedGoogle Scholar
  5. 5.
    Moreaux G, Estrade-Huchon S, Bader G, Guyot B, Heitz D, Fauconnier A, et al. Five-millimeter trocar site small bowel eviscerations after gynecologic laparoscopic surgery. J Minim Invasive Gynecol. 2009;16(5):643–5. Epub 2009/10/20.PubMedCrossRefGoogle Scholar
  6. 6.
    Chiong E, Hegarty PK, Davis JW, Kamat AM, Pisters LL, Matin SF. Port-site hernias occurring after the use of bladeless radially expanding trocars. Urology. 2010;75(3):574–80. Epub 2009/10/27.PubMedCrossRefGoogle Scholar
  7. 7.
    Yamamoto M, Minikel L, Zaritsky E. Laparoscopic 5-mm trocar site herniation and literature review. JSLS. 2011;15(1):122–6. Epub 2011/09/10.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Vilos GA, Vilos AG, Abu-Rafea B, Hollett-Caines J, Nikkhah-Abyaneh Z, Edris F. Three simple steps during closed laparoscopic entry may minimize major injuries. Surg Endosc. 2009;23(4): 758–64. Epub 2008/07/16.PubMedCrossRefGoogle Scholar
  9. 9.
    Vilos GA, Ternamian A, Dempster J, Laberge PY. The Society of O, Gynaecologists of C. Laparoscopic entry: a review of techniques, technologies, and complications. J Obstet Gynaecol Can. 2007;29(5):433–65.PubMedGoogle Scholar
  10. 10.
    Agresta F, Mazzarolo G, Bedin N. Direct trocar insertion for laparoscopy. JSLS. 2012;16(2):255–9. Epub 2013/03/13.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Larobina M, Nottle P. Complete evidence regarding major vascular injuries during laparoscopic access. Surg Laparosc, Endosc Percutan Tech. 2005;15(3):119–23. Epub 2005/06/16.CrossRefGoogle Scholar
  12. 12.
    Ten Broek RP, Van Goor H. Laparoscopic reintervention in colorectal surgery. Minerva Chir. 2008;63(2):161–8. Epub 2008/04/23.PubMedGoogle Scholar
  13. 13.
    Yamamoto M, Okuda J, Tanaka K, Kondo K, Asai K, Kayano H, et al. Effect of previous abdominal surgery on outcomes following laparoscopic colorectal surgery. Dis Colon Rectum. 2013;56(3): 336–42. Epub 2013/02/09.PubMedCrossRefGoogle Scholar
  14. 14.
    Binnebosel M, Klink CD, Grommes J, Jansen M, Neumann UP, Junge K. Influence of small intestinal serosal defect closure on leakage rate and adhesion formation: a pilot study using rabbit models. Langenbeck’s Arch Surg. 2011;396(1):133–7. Epub 2010/07/09.CrossRefGoogle Scholar
  15. 15.
    Wu MP, Ou CS, Chen SL, Yen EY, Rowbotham R. Complications and recommended practices for electrosurgery in laparoscopy. Am J Surg. 2000;179(1):67–73. Epub 2000/03/29.PubMedCrossRefGoogle Scholar
  16. 16.
    Chino A, Karasawa T, Uragami N, Endo Y, Takahashi H, Fujita R. A comparison of depth of tissue injury caused by different modes of electrosurgical current in a pig colon model. Gastrointest Endosc. 2004;59(3):374–9. Epub 2004/03/05.PubMedCrossRefGoogle Scholar
  17. 17.
    Tou S, Malik AI, Wexner SD, Nelson RL. Energy source instruments for laparoscopic colectomy. Cochrane Database Syst Rev. 2011;5, CD007886. Epub 2011/05/13.PubMedGoogle Scholar
  18. 18.
    Di Lorenzo N, Franceschilli L, Allaix ME, Asimakopoulos AD, Sileri P, Gaspari AL. Radiofrequency versus ultrasonic energy in laparoscopic colorectal surgery: a metaanalysis of operative time and blood loss. Surg Endosc. 2012;26(10):2917–24. Epub 2012/05/15.PubMedCrossRefGoogle Scholar
  19. 19.
    Targarona EM, Balague C, Marin J, Neto RB, Martinez C, Garriga J, et al. Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis. Surg Innov. 2005;12(4): 339–44. Epub 2006/01/21.PubMedCrossRefGoogle Scholar
  20. 20.
    Campagnacci R, de Sanctis A, Baldarelli M, Rimini M, Lezoche G, Guerrieri M. Electrothermal bipolar vessel sealing device vs ultrasonic coagulating shears in laparoscopic colectomies: a comparative study. Surg Endosc. 2007;21(9):1526–31. Epub 2007/02/09.PubMedCrossRefGoogle Scholar
  21. 21.
    Hubner M, Demartines N, Muller S, Dindo D, Clavien PA, Hahnloser D. Prospective randomized study of monopolar scissors, bipolar vessel sealer and ultrasonic shears in laparoscopic colorectal surgery. Br J Surg. 2008;95(9):1098–104. Epub 2008/08/12.PubMedCrossRefGoogle Scholar
  22. 22.
    Marcello PW, Roberts PL, Rusin LC, Holubkov R, Schoetz DJ. Vascular pedicle ligation techniques during laparoscopic colectomy. A prospective randomized trial. Surg Endosc. 2006;20(2): 263–9. Epub 2005/12/20.PubMedCrossRefGoogle Scholar
  23. 23.
    Abarca F, Saclarides TJ, Brand MI. Laparoscopic colectomy: complications causing reoperation or emergency room/hospital readmissions. Am Surg. 2011;77(1):65–9. Epub 2011/03/15.PubMedGoogle Scholar
  24. 24.
    D’Ambra L, Berti S, Bonfante P, Bianchi C, Gianquinto D, Falco E. Hemostatic step-by-step procedure to control presacral bleeding during laparoscopic total mesorectal excision. World J Surg. 2009;33(4):812–5. Epub 2008/12/19.PubMedCrossRefGoogle Scholar
  25. 25.
    Rutegard M, Hemmingsson O, Matthiessen P, Rutegard J. High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage. Br J Surg. 2012;99(1):127–32. Epub 2011/11/01.PubMedCrossRefGoogle Scholar
  26. 26.
    Karanjia ND, Corder AP, Bearn P, Heald RJ. Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum. Br J Surg. 1994;81(8):1224–6. Epub 1994/08/01.PubMedCrossRefGoogle Scholar
  27. 27.
    Lange MM, Buunen M, van de Velde CJ, Lange JF. Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review. Dis Colon Rectum. 2008;51(7):1139–45. Epub 2008/05/17.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Buunen M, Lange MM, Ditzel M, Kleinrensink GJ, van de Velde CJ, Lange JF. Level of arterial ligation in total mesorectal excision (TME): an anatomical study. Int J Color Dis. 2009;24(11):1317–20. Epub 2009/07/18.CrossRefGoogle Scholar
  29. 29.
    Deloyers L. Suspension of the right colon permits without exception preservation of the anal sphincter after extensive colectomy of the transverse and left colon (including rectum). technic -indications- immediate and late results. Lyon Chir. 1964;60:404–13. Epub 1964/05/01. La bascule du c olon droit permet sans exception de conserver le sphincter anal apr’es les colectomies etendues du transverse et du c olon gauche (rectum y compris). technique -indications- r’esultats imm’ediats et tardifs.PubMedGoogle Scholar
  30. 30.
    Manceau G, Karoui M, Breton S, Blanchet AS, Rousseau G, Savier E, et al. Right colon to rectal anastomosis (Deloyers procedure) as a salvage technique for low colorectal or coloanal anastomosis: postoperative and long-term outcomes. Dis Colon Rectum. 2012; 55(3):363–8. Epub 2012/04/04.PubMedCrossRefGoogle Scholar
  31. 31.
    Beard JD, Nicholson ML, Sayers RD, Lloyd D, Everson NW. Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial. Br J Surg. 1990;77(10):1095–7. Epub 1990/10/01.PubMedCrossRefGoogle Scholar
  32. 32.
    Yalin R, Aktan AO, Yegen C, Dosluoglu H, Okboy N. Importance of testing stapled rectal anastomoses with air. Eur J Surg. 1993; 159(1):49–51.PubMedGoogle Scholar
  33. 33.
    Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz DJ. Anastomotic leak testing after colorectal resection: what are the data? Arch Surg. 2009;144(5):407–11. discussion 11-2. Epub 2009/05/20.PubMedCrossRefGoogle Scholar
  34. 34.
    Li VK, Wexner SD, Pulido N, Wang H, Jin HY, Weiss EG, et al. Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc. 2009;23(11):2459–65. Epub 2009/03/21.PubMedCrossRefGoogle Scholar
  35. 35.
    Shamiyeh A, Szabo K, Ulf Wayand W, Zehetner J. Intraoperative endoscopy for the assessment of circular-stapled anastomosis in laparoscopic colon surgery. Surg Laparosc, Endosc Percutan Tech. 2012;22(1):65–7. Epub 2012/02/10.CrossRefGoogle Scholar
  36. 36.
    Marderstein E TJ, Stulberg J, Champagne B, Reynolds H, Delaney CP. Analysis of stapler misfire during colorectal surgical procedures using a national event report database. 2007; Available from: Scholar
  37. 37.
    Pandya S, Murray JJ, Coller JA, Rusin LC. Laparoscopic colectomy: indications for conversion to laparotomy. Arch Surg. 1999;134(5):471–5. Epub 1999/05/14.PubMedCrossRefGoogle Scholar
  38. 38.
    Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane database Syst Rev (Online). 2012;2:CD003144. Epub 2012/02/18.Google Scholar
  39. 39.
    Kirat HT, Kiran RP, Lian L, Remzi FH, Fazio VW. Influence of stapler size used at ileal pouch-anal anastomosis on anastomotic leak, stricture, long-term functional outcomes, and quality of life. Am J Surg. 2010;200(1):68–72. Epub 2010/07/20.PubMedCrossRefGoogle Scholar
  40. 40.
    Polese L, Vecchiato M, Frigo AC, Sarzo G, Cadrobbi R, Rizzato R, et al. Risk factors for colorectal anastomotic stenoses and their impact on quality of life: what are the lessons to learn? Colorectal Dis. 2012;14(3):e124–8. Epub 2011/09/14.PubMedCrossRefGoogle Scholar
  41. 41.
    Kyzer S, Gordon PH. Experience with the use of the circular stapler in rectal surgery. Dis Colon Rectum. 1992;35(7):696–706. Epub 1992/07/01.PubMedCrossRefGoogle Scholar
  42. 42.
    Detry RJ, Kartheuser A, Delriviere L, Saba J, Kestens PJ. Use of the circular stapler in 1000 consecutive colorectal anastomoses: experience of one surgical team. Surgery. 1995;117(2):140–5. Epub 1995/02/01.PubMedCrossRefGoogle Scholar
  43. 43.
    Tekkis PP, Senagore AJ, Delaney CP. Conversion rates in laparoscopic colorectal surgery: a predictive model with, 1253 patients. Surg Endosc. 2005;19(1):47–54. Epub 2004/11/19.PubMedCrossRefGoogle Scholar
  44. 44.
    Casillas S, Delaney CP, Senagore AJ, Brady K, Fazio VW. Does conversion of a laparoscopic colectomy adversely affect patient outcome? Dis Colon Rectum. 2004;47(10):1680–5. Epub 2004/11/13.PubMedCrossRefGoogle Scholar
  45. 45.
    Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005; 365(9472):1718–26. Epub 2005/05/17.PubMedCrossRefGoogle Scholar
  46. 46.
    Read TE, Salgado J, Ferraro D, Fortunato R, Caushaj PF. "Peek port": a novel approach for avoiding conversion in laparoscopic colectomy. Surg Endosc. 2009;23(3):477–81. Epub 2008/07/16.PubMedCrossRefGoogle Scholar
  47. 47.
    Ngu SF, Cheung VY, Pun TC. Left upper quadrant approach in gynecologic laparoscopic surgery. Acta Obstet Gynecol Scand. 2011;90(12):1406–9. Epub 2011/08/23.PubMedCrossRefGoogle Scholar
  48. 48.
    Levrant SG, Bieber E, Barnes R. Risk of anterior abdominal wall adhesions increases with number and type of previous laparotomy. J Am Assoc Gynecol Laparosc. 1994;1 (4, Part 2)(4):S19. Epub 1994/08/01.CrossRefGoogle Scholar
  49. 49.
    Kadono Y, Yaegashi H, Machioka K, Ueno S, Miwa S, Maeda Y, et al. Cardiovascular and respiratory effects of the degree of head-down angle during robot-assisted laparoscopic radical prostatectomy. Int J Med Robotics. 2013;9(1):17–22. Epub 2013/01/26.CrossRefGoogle Scholar
  50. 50.
    Meininger D, Westphal K, Bremerich DH, Runkel H, Probst M, Zwissler B, et al. Effects of posture and prolonged pneumoperitoneum on hemodynamic parameters during laparoscopy. World J Surg. 2008;32(7):1400–5. Epub 2008/01/29.PubMedCrossRefGoogle Scholar
  51. 51.
    Nguyen NT, Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg. 2005;241(2):219–26. Epub 2005/01/15.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Cincinnati Medical CenterCincinnatiUSA

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