The Clinical Manifestations of Complications of Laparoscopic Surgery, as produced by The Association of Laparoscopic Surgeons of Great Britain and Ireland

‘Most patients who developed peritonitis or bleeding after traditional surgery display florid signs of circulatory instability and peritonitis. After laparoscopic surgery, the signs are characteristically much more subtle and are often overlooked until precipitous deterioration of the patient's condition occurs, usually several days later.

The majority of patients who undergo a laparoscopic operation have relatively little pain and are eager to mobilise soon after the completion of the operation. Appetite is often hardly depressed at all, and it is commonplace for patients to eat a relatively full meal within a few hours of a laparoscopic procedure. Clearly, the rapidity with which normal activity is resumed is dependent upon factors such as the magnitude and type of operation. Postoperative pain is more likely to be a feature if there has been an extensive division of adhesions, or if it has been necessary to extend a laparoscopic incision in order to remove a large specimen or to introduce the surgeons and into the abdominal cavity.

If the following symptoms and signs are present during the second 12 hour period after the conclusion of a laparoscopic operation, the presence of an abdominal complication should be suspected:-

• Abdominal pain needing opiate analgesia
• Anorexia or reluctance to drink
• Reluctance to mobilise
• Nausea
• Vomiting
• Tachycardia (>100)
• Abdominal tenderness
• Abdominal distension
• Poor urine output

Pyrexia and tachycardia frequently absent at this early stage, and abdominal tenderness may be of relatively minor degree. The classic signs of tenderness, guarding and rebound tenderness are usually absent. The patient may well be able to get out of bed, and to take small amounts of food and drink, but will not have the normal vitality, mobility and appetite characteristically displayed by patients who have undergone an uncomplicated laparoscopic procedure.

In patients who have developed leakage of bile into the peritoneal cavity, liver function is usually abnormal. If there is associated obstruction of the bile duct, bilirubin, transaminase and alkaline phosphatase are all likely to be raised. If there is no obstruction, simply leakage of bile into the peritoneal cavity, bilirubin is characteristically the only abnormality, transaminase and alkaline phosphatase being normal or only mildly abnormal.

Intra-abdominal bleeding may be revealed by the drainage of blood through an abdominal drain. Whilst this may be helpful, the absence of significant bloodstained drainage cannot be used as a reliable guide that bleeding has not occurred. If significant intra-abdominal bleeding has occurred it is important to evacuate the blood and if necessary stop further bleeding. Clinical signs of bleeding are paramount, and should not be overlooked because little in the way of blood has emerged through a drain. Tachycardia and abdominal pain may be the only clinical manifestations of bleeding often a laparoscopic operation despite significant blood loss.

As time passes it will become more apparent that the patient's recovery is far from routine. Abdominal pain and distension are likely to persist, the patient will characteristically want to lie in bed and be reluctant to mobilise, and food and drink will be accepted only in small amounts. Urine output will continue to decline, even if intravenous fluid is provided, and urea and creatinine characteristically show further rises. If no action is taken, it is likely that precipitous circulatory collapse combined with organ failure will eventually occur. It is essential that appropriate management is undertaken before such a late stage occurs.

Particularly careful attention should be paid to any patient who has a pulse rate of 100 or greater 6 hours after a laparoscopic procedure.’

The Association of Laparoscopic Surgeons of Great Britain and Ireland

1. ALS Clinical Guidelines on the Recognition, Management and Prevention of Abdominal Complications of Laparoscopic Surgery 

A complication may not be negligent in itself but a failure to act on warning signs, providing insufficient information to the patient and not ensuring that there are systems in place for the patient/relatives to seek clinical advice about a potential complication may be grounds for a successful claim.