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Urologic Laparoscopic Complications
Deep Venous Thrombosis (DVT)


Semir A. S. Al Samarrai

 

Incidence:

The actual incidence of deep vein thrombosis and pulmonary embolus due to Laparoscopic surgery is poorly defined ranging from 0.2-1.5 % (1, 2).

Risk Factors:

Urologic patients are often older, have decreased mobility, have baseline vascular disease or venous stasis and have a concurrent malignancy that results in a hypercoagulable state and are mostly obese.

In addition, the majorities of the Laparoscopic Procedures are lengthy and involve extensive pelvic dissections (Radical Prostatectomy, Pelvic Lympadenoectomy, Cystectomy) that may precipitate pelvic vein clot formation.

Patient positioning and pneumoperitonium also contribute to decreased venous return and peripheral venous stasis. Thus patients, undergoing urologic laparoscopic major surgery (Prostatectomy, Cystectomy) may have all the risk factors described by Professor Virehow in the Nineteenths century, that predispose to Deep Vein Thrombosis (DVT): Venous Stasis, Endothelial Injury and a Hypercoagulable state. (3)

Additionally, patients who are at higher risk for Deep Vein Thrombosis (DVT) include those patients who have a prior history of thromboembolic phenomena or phlebitis and those patients who have a history of lower extremity venous stasis. 

Diagnosis 

The clinical diagnosis of DVT is difficult and indeed, unreliable. DVT is frequently present with symptoms like pain, heat and swelling of the legs. The gold standard is ascending contrast venography. The application of this test is often limited.

Among available non-invasive techniques, two have been well-validated against venography.

1.) Impedance Plethysmograpgy (IPG), which detects venous outflow obstruction, is highly sensitive to acute above-knee thrombosis, but fails to detect many below-knee thrombi.
2.) The Radio Fibrinogen Method, which is very sensitive to thrombus formation in calf in the upper thigh or above.

The Doppler Ultrasound (“doppler”) are widely used. However, the driteria employed to interpret this test have not been standardized, the sensitivity and specificity of the technique have been poorly validated against venography and the test is quite operator-dependent.

The diagnosis of Deep Vein Thrombosis (DVT) has to be done by impedance plethysmography, this can detect in the most case the Deep Vein Thrombosis (DVT). The definitive diagnosis can be made through vascular contrast studies. The risk of performing angiography and venography must be weighed against the probability of positive results. (4)

Treatment

Patients who are at high risk for DVT as mentioned above, in those patients the prevention of deep vein thrombosis involves the use of aggressive prophylaxis, including Sequential Compression Stocking Devise (SCD), low-dose heparin administration and early postoperative ambulation. 

Most of post-operative deep vein thrombosis have subclinical course. The most common clinical scenario is detection of a Deep Vein Thrombosis (DVT) only after a patient has developed a pulmonary embolism.

The problem can be avoided to some extent through the use of pneumatic sequential compression devices or early post-operative ambulation of the patient. For all major Laparoscopic Surgery is enough to use the Pneumatic Sequential Compression Devices or Pneumatic Compression Stockings (SCD) and only for 48-72 hr post-operative, but for all minor laparoscopic surgery as varicoceletomy and herniotomy, it is enough to ambulate the patient early postoperatively.

This morbidity is common by obese patients or in individual of high risk for thrombosis but not by patients who are or has normal weight. The use of Fractional Heparin (FH) as DVT prophylaxis is only indicated by major complicated operation which taking more than two hours in time to be performed, but this treatment with FH may increase the incidence of hemorrhagic complications, without reduction in thrombotic complication compared with sequential compression device (Montgomery and Wolf 2005).

Bibliography

1. Kozminski M, Gimella L, Stone NN, et al: Laparoscopic Urologic Surgery: Outcome assessment. J Urol 1992; 147:245A.
2. Capeluto CC, Kavoussi LR: Complications of Laparoscopic surgery Urology 1993; 42:2.
3. Borten M: Postoperative complications. In Friedman EA (ed): Laparoscopic Complications, Prevention and Management, p 405. Toronto, BC Decker, 1986. 
4. John Naitoh, Steven J. Shichman: Urologic Laparoscopic Complications: p 555-556.

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae