Introduction

Along with the ever-changing times, experts have developed various modern technologies, especially in the health sector. With the slogan "Dangerous Disease Requires Treatment That Is Not Too Harmful" surgeons have been using minimally invasive technology in their daily practice, one of which is the use of laparoscopy^1-3.

Laparoscopy is a diagnostic and therapeutic surgical tool used to view intra-abdominal organs. Various studies have begun to assess the effectiveness and efficiency of laparoscopy when compared with conventional surgery. The results suggest that laparoscopy has the same effectiveness with an acceptable efficiency value when compared to conventional surgery. Laparoscopy shows clear advantages, namely reduced postoperative pain, better cosmetic aspects, faster recovery, shorter length of stay, and lower costs. Based on these various studies, laparoscopy is used throughout various surgeries, especially in various urological cases^4-6.

Laparoscopic surgery does have many advantages, but that just like any other surgical intervention, laparoscopy also comes with a few complications. Significant complications of laparoscopy include vascular, visceral, intestinal, and urological injuries. Operational complications are classified into 2 groups based on the Satava hierarchy system, namely error 1. where there are no harmful consequences or errors that can be ignored, and error 2. where the error must be immediately identified and corrected (serious complications). Based on the European Scoring System (ESS) laparoscopic urological surgery is divided into 3 groups based on the complexity of the operation, namely: easy, difficult, and very difficult^7-10.

Patients and Methods

Research Methods

The research design used in this study is a retrospective study of patient medical record data starting from surgery until patients were allowed to be treated as outpatients. The sampling technique used was Non-Probability Sampling using convenience sampling (accidental sampling). The reason for using this method is due to the unknown population of patients undergoing urologic laparoscopy at Dr. Sardjito Hospital.

Patient Study

The operating protocol at Dr. Sardjito Hospital was that all patients had been described and had signed informed consent beforehand. Samples taken in this study were urology patients who were performed laparoscopic measures at Dr. Sardjito Hospital from January 2017 to January 2020. The inclusion criteria of the sample in this study were urology patients who have performed a laparoscopy with pre-operative albumin, hemoglobin, and electrolyte values within normal limits. Meanwhile, exclusion criteria were patients who have had previous operations and patients with other comorbid diseases.

Statistics

In this study, the analysis was performed using SPSS statistical software ver. 22. The p-value was calculated using Chi-Square, and a value of p<0.05 was considered statistically significant.

Results

In this study, it was found that the characteristics of respondents were divided into gender, age, postoperative hospital stay, intraoperative bleeding, and duration of surgery. Based on the gender of the respondent, consisting of men and women. As for the characteristics of other respondents, it was averaged based on available data.

The general characteristics of patients from a total of 82 cases and 9 cases with complications are shown in Table 1. Various actions were taken to deal with the complications that arise so that no further morbidity and mortality occur. The incidence of complications in this study was around 11%. Gender in total cases was known to be higher in males than females, whereas in cases with complications the incidence of females was higher than males. On the other hand, the results of this study indicate that complications clearly occur in older patients. For the length of stay, it is known that in cases with complications it took 2 times longer than the time needed in total cases. In addition, as is well known, that the bleeding volume of surgery and the duration of surgery clearly increase in patients who have complications.

Complications Occurring in Laparoscopic Urology

Laparoscopic urology is divided into 3 groups, namely easy, difficult, and very difficult. The incidence of complications in all three groups is shown in figure 1. It is known that the more difficult the surgery performed, the incidence of complications will also increase significantly (p < 0.05).

The types of complications that occur are shown in figure 2, which consists of venous injuries, arterial injuries, and organ injuries. The incidence of vascular injury and organ injury is almost the same, namely, in this study, there were found 4 vascular injuries including inferior vena cava injury (2 cases), iliac artery injury (1 case), abdominal aortic injury (1 case), and organ injury (5 cases) including 1 case of pleural injury, 1 case of ileal injury, and 3 cases of rectal injury.

Convert Durante Operations to Open Operations

As shown in Table 2, cases of conversion to open surgery were 5 cases including 0 cases in the easy group, 1 case of the difficult group, and 4 cases in the very difficult group. Of the various cases, it is known that conversion to open surgery is carried out due to complications. It can be seen in Table 2 that the percentage of conversion to open operations is 6.1% of the total cases. With statistical analysis, there was no significant difference in the incidence rate of conversion from surgery to open surgery between easy, difficult, and very difficult groups (p > 0.05).

Figure 1.
Graph of the types of complications in urologic laparoscopy (p < 0.05)

Figure 2.
Complications in the action group

Discussions

Complication incidence increases with an increase in the difficulty of urologic laparoscopy surgery. Based on ESS, laparoscopy surgery is divided into 3 difficulty groups, easy, difficult, and very difficult. This research found that very difficult surgeries showed complications with the highest incidence, followed by the other groups. This occurs because of complex anatomy and higher difficulty level. It is known that patients with complications must immediately receive treatment to correct the condition for a preferable prognosis and may undergo outpatient care^11,12.

This research found the main complication was vascular injury. In the beginning, the nescience of anatomy and surgery technique caused bleeding, requiring immediate treatment or conversion of a method to open surgery. However, after laparoscopy was popularized, complications originating from adhesion, majorly being vascularization at tumor surfaces, and difficult surgery positions. During kidney and adrenal laparoscopy in difficult groups, is known in two vena cava inferior injuries^13,14.

Vascular vena cava inferior wall avulsion mainly happens from surgery errors. Furthermore, there are two arterial injury cases (1 case Aorta abdominalis injury and 1 case of Iliaca artery injury) in this research. Injury in the big artery might be an iatrogenic vascular injury, the worst vascular injury. The aorta is very susceptible to retroperitoneal dissection, like in nephrectomy or retroperitoneal lymph gland dissection. In many cases, injuries happen because of organs reached close to the adventitia aorta, making imaging pre-surgery mandatory to guide intra-operative management¹³.

The data show that open surgery conversions in complication cases were done. There are many reasons for injuries in big blood vessels during laparoscopy, such as the lack of understanding of laparoscopic anatomy, an overwhelming amount of force, or surgery errors that can cause unpredicted situations, anatomical variations, or local dysplasia, and adhesions leading to increasing surgery difficulty. Laparoscopic treatment recommendations for major blood vessel injuries are as following; hemostasis by clamping or pressing, exact dissociation of perivascular tissue to clog blood vessel, sewing with 4-0 atraumatic stitches, and clamping blood vessel with a vascular clamp. However, if bleeding occurs and it is impossible to create a clear surgical environment, the operation method has to be conversed to open surgery. Furthermore, if bleeding cannot be stopped effectively in a short time, the patient also has to undergo open surgery^13,14.

This study found that pleural injury is a secondary condition from diaphragmatic injury. This usually happens in upper surgical areas like kidney and adrenal surgeries. This research had 1 hemothorax case that happened during nephrectomy kidney donor surgery. Hemothorax is a complication seldomly reported. A previous study reported one case (0.08%) from 1129 patients that underwent urological laparoscopy surgeries. It is known that the intercostal artery ruptured, causing blood accumulation in the pleura after urological surgery. Conditions like this need thoracotomy treatment to correct patients' condition. Other reports have shown the existence of hemothorax after pyeloplasty laparoscopy, kidney mass cryoablation, and percutaneous nephrolithotomy¹⁵.

Every procedure inside or near the stomach have the risk of accidental intestine injury for example cystectomy, laparoscopy, percutaneous nephrolithotomy, cystostomy, depending on size and location of the injury and whether injury involves electrocautery¹⁶.

If the injury is caused by electrocautery, segmental resection must be done. The small intestine can usually be reconnected safely. The big intestine is normally also reconnected if the fecal spillage is minimal. Delayed identification of intestine injury is usually accompanied by prolonged ileus, abscess, and intraperitoneal sepsis. Early symptoms after laparoscopy do not imply intestinal injury. The patient may only show pain in one trocar wound, bloated stomach, diarrhea, and leucopenia. Surgical exploration and washing are indicated in patients with uncontrollable leakage to obtain or identify a leak source. Controlled leakage (abscess) or retroperitoneal intestine injury in patients is declared stable if percutaneous drainage management has succeeded^17,18.

Rectal injury is an interesting intestinal injury case in urology. Not more than 1% of cases of complications in prostatectomy nor cystectomy have been reported. Computed tomography (CT) images of a previous study showed air in the urinary bladder and rectum in patients with rectum injuries that were not identified in surgical treatment that needed proximal intestine diversion. Cystogram examination showed fistula between the urethra and rectum¹⁹.

Developments in surgical technique have decreased surgery duration and complication incidences, being that various unpredictable complications are still present in urological laparoscopy. Indication in urological laparoscopy must closely be controlled and must be accompanied by a thorough understanding of micrological structure during surgery to prevent accidental injuries. Complications can be minimalized by improving surgical technique, substantiate anatomy knowledge, and increased experience. This through this surgeon can benefit from minimally invasive surgeries, without causing complications²⁰.

Conclusion

In this research, a relation between difficulty level of surgery and intraoperative complication incidences in urological laparoscopy has been established in RSUP Dr. Sardjito (a public hospital). The more difficult the urological laparoscopy the higher the level of incidences of complications occurred. Complications that were discovered in the study included vascular and organ injuries, which needed corrections with laparoscopy or open surgeries, depending on objective condition. This is related to the anatomy understanding and difficulty of surgery.

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