Intraoperative Complications of Anesthesia

Managing Director

Success is the capacity to endure successive setbacks without losing enthusiasm.

-William Winston Churchill

As we saw in the previous chapter, despite the impressive success of the AGB in reducing or eliminating chronic health problems, any surgical procedure carries with it the possibility of problems or complications. Despite the fact that the benefits of the AGB generally outweigh the frequency of these issues, they must be recognized as genuine possibilities. This is the topic covered in this chapter.

Introduction

In dramatic operating room scenes, we have all witnessed actors clad in surgical attracts portraying surgeons, assistants, anesthesiologists, and nurses. While some of the information presented is reasonably accurate, the majority of what you see and hear is designed primarily for entertainment. Some of the more recent health documentaries are more realistic and frequently depict an entire operation from beginning to end. However, these procedures and patients are frequently selected in advance for demonstration purposes, so you are unlikely to observe any significant complications or problems.

Surgical complications and undesirable outcomes can and do occur on occasion. A common saying in the surgical community is, "The only surgeon who has never encountered a complication has never performed surgery." This does not imply that every patient, or even the preponderance of patients, will experience difficulties. Minimally invasive, modern surgery and

Anesthesia are generally much safer than they were a generation ago, but there are still hazards that depend heavily on the individual patient. Obese patients with diabetes, high blood pressure, or cardiac issues are obviously at a greater risk, but it is precisely these conditions that necessitate bariatric surgery.

Although it is essential for patients to be aware of the potential risks of surgery, it is impossible to discuss every possible risk and situation with each patient. In the remainder of this chapter, you will find a brief explanation of some of the most prevalent risks associated with the AGB. These complications can arise during surgery, postoperatively, and even years later.

Intraoperative Complications

When most people consider surgical risks, they automatically think of catastrophic outcomes such as uncontrolled bleeding or a heart attack. However, the majority of intraoperative complications are manageable by the surgeon without incident. The key to minimizing surgical problems is identifying them before they become complications.

Laparoscopic surgery has a number of well-known advantages, including less discomfort, a quicker recovery, and smaller scars, but it also has some limitations. Given that the surgeon must rely solely on what he or she can see on the video monitor, it can be more challenging to identify certain unforeseen injuries. However, experienced laparoscopic surgeons can identify and manage intraoperative complications with nearly the same proficiency as during open surgery.

Certain injuries are exclusive to laparoscopic procedures. When the surgeon inserts the laparoscopic canulas, there is a possibility that blood vessels within the abdominal wall or one or more organs within the abdomen will be damaged. Typically, injury to minor blood vessels is not a major concern, but it can result in significant bruising around the incision site. Intestinal injuries are uncommon, but are somewhat more prevalent in patients who have undergone abdominal surgery previously. Adhesions, or internal fibrosis, may cause the intestine to adhere to the interior of the abdominal cavity. This not only increases the likelihood of intestinal injury, but also makes it more difficult to detect such an injury. Such an injury could result in a severe infection, but the symptoms may not manifest for several days.

Electrocautery is a common method for controlling surgical hemorrhage. When electrocautery is used during laparoscopic surgery, the risk of unseen electrical injury to internal organs increases slightly. These injuries are particularly difficult to identify because they can occur far from the area the physician is examining, and the damage may be nearly imperceptible. Again, such an injury may not manifest its effects for several days. In recent years, the mechanism underlying

Injuries caused by electrocution are now better understood, and their incidence has decreased.

The surgeon is required to conduct a dissection around the upper stomach and lower esophagus when performing the AGB procedure. It is possible to injure either of these structures during this procedure. The prevalence of an undiagnosed hole in either the stomach or the esophagus is likely to become a severe issue. If the injury occurs on the back, it is extremely difficult to detect. Within approximately twenty-four hours, the patient will develop an accelerated heart rate, fever, and abdominal or chest pain. If such symptoms occur following surgery, one or more tests can determine whether the esophagus or stomach has actually been perforated. The sooner a confirmed injury can be surgically repaired, the better. The longer it goes untreated, the greater the risk of a life-threatening infection developing.

In addition to the esophagus and stomach, other organs and structures in the same general region can be damaged during surgery. The spleen is particularly vulnerable due to its proximity to the upper portion of the stomach, its susceptibility to injury, and its potential to cause severe hemorrhage. Additionally, there are numerous significant blood vessels in the region. Fortunately, this type of injury is exceedingly uncommon during AGB surgery. But if significant hemorrhaging were to occur, the surgeon would likely need to open the abdomen to control it.

Post-Surgical Complications

Pain in the chest after surgery, especially when accompanied by shortness of breath, may indicate a severe heart condition. The effects of anesthesia on the heart can be substantial, particularly in patients with a history of cardiac disease. This is one of the many reasons why I believe hospital observation for the first night is a smart idea.

Following general anesthesia, a variety of respiratory issues may develop. Atelectasis is the most prevalent form of respiratory complication. This occurs when you do not breathe thoroughly enough to completely fill your lungs. In the lower regions of the lungs, small airways tend to collapse, trapping mucus and bacteria in these microscopic areas. This issue can typically be avoided if the patient takes long breaths and coughs frequently. If not treated, atelectasis can develop into pneumonia. Patients who smoke or have preexisting pulmonary conditions such as asthma, emphysema, and chronic obstructive pulmonary disease are more likely to develop respiratory complications.

Pulmonary embolism is one of the most feared postoperative complications. This condition occurs when a blood clot forms in the capillaries of the legs or pelvis, breaks off, and travels rapidly through the heart and into the arteries of the lungs. If the embolism is small, only temporary shortness of breath and minor chest discomfort may result. However, a large clot can obstruct one of the main pulmonary arteries. This not only prevents blood from passing through the lungs, where it should be taking up oxygen and releasing carbon dioxide, but it also places an enormous amount of strain on the heart. Pulmonary embolus can result in abrupt death days, weeks, or even months after surgery. The majority of blood clots begin while the patient is entirely immobile on the operating table or in the initial hours following surgery.

Typically, the frequent contraction of the leg muscles functions as a pump, forcing blood through the veins. As long as blood is in motion, clotting is unlikely. During the complete inactivity of anesthesia, additionally

Blood has a tendency to collect in the large veins of your legs and pelvis during the initial postoperative period due to the limited muscle movement. If blood lodges within these veins, it may remain there until it dissolves or become permanently attached to the vein wall. This blood coagulation is referred to as deep vein thrombosis (DVT). However, if the thrombus breaks loose, it can cause pulmonary embolism.

The most effective method for treating DVT and PE is to prevent thrombus formation in the first place. This is especially true regarding bariatric surgery. Obese patients are at a higher risk than the majority of normal-weight patients for developing DVT during surgery. Patients are administered heparin, a blood thinner, prior to surgery and typically for 12 to 24 hours afterward to reduce risk. This reduces the likelihood of blood clotting within the vessels. In addition, the patient's legs are enveloped in sequential compression devices (SCDs), which are specially designed leggings. These devices simulate the pulsing action of active leg muscles by periodically squeezing the legs during surgery and in the postoperative period. The combination of heparin and SCDs substantially reduces the risk of DVT. In addition, the quicker the patient is able to stand and walk, the sooner blood flow returns to normal.