Major Complications of Laparoscopy: A Follow-Up Finnish Study

Abstract

The increase in the number of laparoscopic procedures and the increasing complexity of operations using laparoscopy has led to an increase in the number of complications arising from such procedures. This article presents findings from a recent study of major complications associated with laparoscopic procedures in Finland. Using information obtained from the Finnish Hospital Discharge Register, which contains information on each inpatient, and the National Patient Insurance Association, which has data on all major complications, the investigators reviewed records of all gynecologic laparoscopies and all complications associated with these procedures during 1995 and 1996. The findings were compared with results from 1990 through 1994. During the 2 years of the study, 32,205 gynecologic laparoscopies were performed in Finland, and 130 major complications associated with these procedures were reported (Table 1). Complications occurred in 4 of 6680 diagnostic laparoscopies, 8 of 16,188 sterilization laparoscopies, and 118 of 9337 operative laparoscopies. There were 0.6 major complications per 1000 sterilization procedures and 12.6 complications per 1000 operative laparoscopies. Forty-two percent of the operative laparoscopies were hysterectomies; 88 of the 118 major complications (75 percent) arising from operative laparoscopy occurred during hysterectomy.TABLE 1: Major complications in gynecologic laparoscopies, 1995-1996 Of the 24 bowel injuries, 13 (54 percent) were to the small intestine, 7 (29 percent) were to the large intestine, and 4 (17 percent) were to the rectum. Bowel injuries were caused by either electrocoagulation (54 percent), trocar or Veress needle (42 percent), or grasping forceps (4 percent). Two bowel injuries occurred during diagnostic laparoscopy (2 per 1000 of 6680, 0.3 percent), 7 occurred during sterilization procedures (7 per 1000 of 16,188, 0.4 percent), and 15 occurred during operative laparoscopy (15 per 1000 of 9337, 1.6 percent). All eight incisional hernias occurred as a result of operative procedures and were diagnosed within 2 weeks. Three patients required small-bowel resection to repair injury. No urinary tract injuries were reported during diagnostic or sterilization procedures. Seventy-nine of the women undergoing operative laparoscopy had injury to either the bladder (N = 22) or ureter (N = 57). There were 12 simple bladder injuries; these were sutured laparoscopically in two women and vaginally in one, but laparotomy was required in nine women. The other 10 bladder injuries were vesicovaginal fistulas, and all occurred during operative laparoscopy. All 10 patients required another procedure for repair, and 3 women needed a third procedure for adequate repair. Fifty-one of the 57 ureteral injuries occurred during laparoscopic hysterectomy. Three of these were bilateral. Several different procedures were performed to repair ureteral injury; the most common was ureteroneocystostomy (32 of 59, 54 percent). Four vascular injuries occurred, one during diagnostic laparoscopy and three during operative procedures other than hysterectomy. All were successfully repaired by laparotomy. Fifteen other major complications were reported; the majority required laparotomy for repair. One patient died of a massive pulmonary embolism. From 1990 through 1996, the rate of complications from laparoscopic procedures for diagnostic and sterilization procedures remained below 1 per 1000. During this same period, the rate of major complications for operative hysterectomies increased from 0 per 1000 in 1990 to 13 per 1000 in 1996 (P < .001). Intestinal injuries were the most frequent complication from 1990 through 1994, but since 1995, ureteral injuries have been the most common. When complications from laparoscopic hysterectomy were removed from analyses, the annual rates of ureteral and bladder injuries after operative laparoscopy remained below 1.4 per 1000 for the entire study period. Intestinal injury was greatest during 1994 (3.5 per 1000) and has been declining since then. The overall incidence of major complications during laparoscopic hysterectomy had decreased significantly from 1993 through 1996 despite the fact that the incidence of ureteral injuries remained at about 10 per 1000. Complications were studied according to the type of hospital in which the procedure was performed (i. e., university, central, or local hospital). The incidence of ureteral injury after laparoscopic hysterectomy was twice as great in local hospitals as in central hospitals and in central hospitals as in university hospitals (university hospitals, 0.6 percent; central hospitals, 1.1 percent; local hospitals, 2.2 percent). Local hospitals had a significant decrease in ureteral complications during the study period.