UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Complications of laparoscopic surgery

Authors
Aurora Pryor, MD
William J Mann, Jr, MD
Gerald Gracia, MD
Section Editors
Jeffrey Marks, MD
Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

The rate of serious complications associated specifically with a laparoscopic approach is overall low. Up to half of complications occur at the time of abdominal access for camera or port placement [1]. Complications can also arise from abdominal insufflation, tissue dissection, and hemostasis [2]. Conversion to an open procedure may be needed to manage complications that have been identified intraoperatively, while others may not be recognized until the postoperative period. Severe complications such as vascular injury and bowel perforation can be catastrophic and are the main cause of procedure-specific morbidity and mortality related to laparoscopic surgery.

Much of the literature discussing the complications associated with laparoscopic surgery is drawn from the gynecologic literature, which has provided the most comprehensive study of these injuries [3]. It is presumed that results from these studies can be generalized to other abdominal and retroperitoneal surgeries, but wherever possible, outcomes of laparoscopic surgery in gynecology, general surgery, and urology are distinguished.

Surgical complications unique to a laparoscopic approach are discussed here. Surgical techniques and their specific complications are discussed in individual topic reviews. Other general issues relating to laparoscopic surgery, including abdominal access and instrumentation, are reviewed elsewhere. (See "Abdominal access techniques used in laparoscopic surgery" and "Instruments and devices used in laparoscopic surgery" and "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites" and "Overview of laparoscopy in children and adolescents".)

EPIDEMIOLOGY AND RISK FACTORS

The rate of complications associated specifically with a laparoscopic approach is overall low. Complications related to initial abdominal access occur in less than 1 percent of patients [4-7]. Once abdominal access is established, complications during the course of the procedure are similarly rare; however, late hernia at port sites can affect up to 6 percent of patients. The incidence of specific complications for specific laparoscopic procedures is discussed more fully in the sections below. The following studies illustrate typical findings:

One survey reported results of claims arising from abdominal access injuries between 1980 and 1999, and medical device reports to the United States Food and Drug Administration (FDA) [8]. The incidence of abdominal access injury was 5 to 30 per 10,000 procedures. Bowel and retroperitoneal vascular injuries comprised 76 percent of all injuries, and almost 50 percent of small and large bowel injuries were unrecognized for at least 24 hours. The type and proportion of organ injury during abdominal access were as follows:

                     

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Dec 10 00:00:00 GMT+00:00 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Magrina JF. Complications of laparoscopic surgery. Clin Obstet Gynecol 2002; 45:469.
  2. Trottier DC, Martel G, Boushey RP. Complications in laparoscopic intestinal surgery: prevention and management. Minerva Chir 2009; 64:339.
  3. Philips PA, Amaral JF. Abdominal access complications in laparoscopic surgery. J Am Coll Surg 2001; 192:525.
  4. Molloy D, Kaloo PD, Cooper M, Nguyen TV. Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry. Aust N Z J Obstet Gynaecol 2002; 42:246.
  5. Jiang X, Anderson C, Schnatz PF. The safety of direct trocar versus Veress needle for laparoscopic entry: a meta-analysis of randomized clinical trials. J Laparoendosc Adv Surg Tech A 2012; 22:362.
  6. Ahmad G, O'Flynn H, Duffy JM, et al. Laparoscopic entry techniques. Cochrane Database Syst Rev 2012; :CD006583.
  7. Kirchhoff P, Dincler S, Buchmann P. A multivariate analysis of potential risk factors for intra- and postoperative complications in 1316 elective laparoscopic colorectal procedures. Ann Surg 2008; 248:259.
  8. Chandler JG, Corson SL, Way LW. Three spectra of laparoscopic entry access injuries. J Am Coll Surg 2001; 192:478.
  9. Jansen FW, Kolkman W, Bakkum EA, et al. Complications of laparoscopy: an inquiry about closed- versus open-entry technique. Am J Obstet Gynecol 2004; 190:634.
  10. Bhoyrul S, Vierra MA, Nezhat CR, et al. Trocar injuries in laparoscopic surgery. J Am Coll Surg 2001; 192:677.
  11. Mayol J, Garcia-Aguilar J, Ortiz-Oshiro E, et al. Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion. World J Surg 1997; 21:529.
  12. Amato L, Colais P, Davoli M, et al. [Volume and health outcomes: evidence from systematic reviews and from evaluation of Italian hospital data]. Epidemiol Prev 2013; 37:1.
  13. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349:2117.
  14. See WA, Cooper CS, Fisher RJ. Predictors of laparoscopic complications after formal training in laparoscopic surgery. JAMA 1993; 270:2689.
  15. Hyman N, Borrazzo E, Trevisani G, et al. Credentialing for laparoscopic bowel operation: there is no substitute for knowing the outcomes. J Am Coll Surg 2007; 205:576.
  16. Wright JD, Hershman DL, Burke WM, et al. Influence of surgical volume on outcome for laparoscopic hysterectomy for endometrial cancer. Ann Surg Oncol 2012; 19:948.
  17. Balik E, Asoglu O, Saglam S, et al. Effects of surgical laparoscopic experience on the short-term postoperative outcome of rectal cancer: results of a high volume single center institution. Surg Laparosc Endosc Percutan Tech 2010; 20:93.
  18. Csikesz NG, Singla A, Murphy MM, et al. Surgeon volume metrics in laparoscopic cholecystectomy. Dig Dis Sci 2010; 55:2398.
  19. Weber WP, Guller U, Jain NB, et al. Impact of surgeon and hospital caseload on the likelihood of performing laparoscopic vs open sigmoid resection for diverticular disease: a study based on 55,949 patients. Arch Surg 2007; 142:253.
  20. Fuller J, Ashar BS, Carey-Corrado J. Trocar-associated injuries and fatalities: an analysis of 1399 reports to the FDA. J Minim Invasive Gynecol 2005; 12:302.
  21. Ponsky JL. Complications of laparoscopic cholecystectomy. Am J Surg 1991; 161:393.
  22. Nuzzo G, Giuliante F, Tebala GD, et al. Routine use of open technique in laparoscopic operations. J Am Coll Surg 1997; 184:58.
  23. Deziel DJ, Millikan KW, Economou SG, et al. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 1993; 165:9.
  24. Ahmad, G, Duffy, JM, Phillips, K, Watson, A. Laparoscopic entry techniques. Cochrane Database Syst Rev 2008; CD006583.
  25. Sigman HH, Fried GM, Garzon J, et al. Risks of blind versus open approach to celiotomy for laparoscopic surgery. Surg Laparosc Endosc 1993; 3:296.
  26. Chapron CM, Pierre F, Lacroix S, et al. Major vascular injuries during gynecologic laparoscopy. J Am Coll Surg 1997; 185:461.
  27. Sandadi S, Johannigman JA, Wong VL, et al. Recognition and management of major vessel injury during laparoscopy. J Minim Invasive Gynecol 2010; 17:692.
  28. Abu-Amara M, Akle C, Adiseshiah M. Blind peritoneal access during laparoscopy: why is it still being used? Int Surg 2009; 94:201.
  29. Agresta F, Mazzarolo G, Bedin N. Direct trocar insertion for laparoscopy. JSLS 2012; 16:255.
  30. Jarrett JC 2nd. Laparoscopy: direct trocar insertion without pneumoperitoneum. Obstet Gynecol 1990; 75:725.
  31. Copeland C, Wing R, Hulka JF. Direct trocar insertion at laparoscopy: an evaluation. Obstet Gynecol 1983; 62:655.
  32. Borgatta L, Gruss L, Barad D, Kaali SG. Direct trocar insertion vs. Verres needle use for laparoscopic sterilization. J Reprod Med 1990; 35:891.
  33. Byron JW, Markenson G, Miyazawa K. A randomized comparison of Verres needle and direct trocar insertion for laparoscopy. Surg Gynecol Obstet 1993; 177:259.
  34. Kaali SG, Bartfai G. Direct insertion of the laparoscopic trocar after an earlier laparotomy. J Reprod Med 1988; 33:739.
  35. Shea JA, Healey MJ, Berlin JA, et al. Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. Ann Surg 1996; 224:609.
  36. Nordestgaard AG, Bodily KC, Osborne RW Jr, Buttorff JD. Major vascular injuries during laparoscopic procedures. Am J Surg 1995; 169:543.
  37. Larson GM, Vitale GC, Casey J, et al. Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients. Am J Surg 1992; 163:221.
  38. Leibl BJ, Schmedt CG, Schwarz J, et al. A single institution's experience with transperitoneal laparoscopic hernia repair. Am J Surg 1998; 175:446.
  39. McDonald PT, Rich NM, Collins GJ Jr, et al. Vascular trauma secondary to diagnostic and therapeutic procedures: laparoscopy. Am J Surg 1978; 135:651.
  40. Mintz M. Risks and prophylaxis in laparoscopy: a survey of 100,000 cases. J Reprod Med 1977; 18:269.
  41. Peterson HB, Hulka JF, Phillips JM. American Association of Gynecologic Laparoscopists' 1988 membership survey on operative laparoscopy. J Reprod Med 1990; 35:587.
  42. Phillips JM, Hulka JF, Peterson HB. American Association of Gynecologic Laparoscopists' 1982 membership survey. J Reprod Med 1984; 29:592.
  43. Phillips J, Keith D, Hulka J, et al. Gynecologic laparoscopy in 1975. J Reprod Med 1976; 16:105.
  44. Riedel HH, Lehmann-Willenbrock E, Conrad P, Semm K. German pelviscopic statistics for the years 1978-1982. Endoscopy 1986; 18:219.
  45. Yuzpe AA. Pneumoperitoneum needle and trocar injuries in laparoscopy. A survey on possible contributing factors and prevention. J Reprod Med 1990; 35:485.
  46. Baadsgaard SE, Bille S, Egeblad K. Major vascular injury during gynecologic laparoscopy. Report of a case and review of published cases. Acta Obstet Gynecol Scand 1989; 68:283.
  47. Chapron C, Pierre F, Harchaoui Y, et al. Gastrointestinal injuries during gynaecological laparoscopy. Hum Reprod 1999; 14:333.
  48. Shirk GJ, Johns A, Redwine DB. Complications of laparoscopic surgery: How to avoid them and how to repair them. J Minim Invasive Gynecol 2006; 13:352.
  49. Quilici PJ, Greaney EM, Quilici J, Anderson S. Transabdominal preperitoneal laparoscopic inguinal herniorrhaphy: results of 509 repairs. Am Surg 1996; 62:849.
  50. Tews G, Arzt W, Bohaumilitzky T, et al. Significant reduction of operational risk in laparoscopy through the use of a new blunt trocar. Surg Gynecol Obstet 1991; 173:67.
  51. Fernández EM, Malagón AM, Arteaga I, et al. Conservative treatment of a huge abdominal wall hematoma after laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A 2005; 15:634.
  52. Phillips EH, Arregui M, Carroll BJ, et al. Incidence of complications following laparoscopic hernioplasty. Surg Endosc 1995; 9:16.
  53. Levinson CJ. Laparoscopy is easy--except for the complications: a review with suggestions. J Reprod Med 1974; 13:187.
  54. Sharp HT, Dodson MK, Draper ML, et al. Complications associated with optical-access laparoscopic trocars. Obstet Gynecol 2002; 99:553.
  55. Kuster GG, Fischer B. Pharmacologic hemostasis in laparoscopy: topical epinephrine facilitates cholecystectomy. Am Surg 1993; 59:281.
  56. Kuster GG. Local epinephrine facilitates laparoscopic Heller myotomy. Surg Endosc 1998; 12:79.
  57. Saxena AK, van Tuil C. Advantages of fibrin glue spray in laparoscopic liver biopsies. Surg Laparosc Endosc Percutan Tech 2007; 17:545.
  58. Olmi S, Scaini A, Erba L, et al. Use of fibrin glue (Tissucol) as a hemostatic in laparoscopic conservative treatment of spleen trauma. Surg Endosc 2007; 21:2051.
  59. van Dijk JH, Pes PL. Haemostasis in laparoscopic partial nephrectomy: current status. Minim Invasive Ther Allied Technol 2007; 16:31.
  60. Lee MG, Provost DA, Jones DB. Use of fibrin sealant in laparoscopic gastric bypass for the morbidly obese. Obes Surg 2004; 14:1321.
  61. Bak JB, Singh A, Shekarriz B. Use of gelatin matrix thrombin tissue sealant as an effective hemostatic agent during laparoscopic partial nephrectomy. J Urol 2004; 171:780.
  62. Callery MP. Avoiding biliary injury during laparoscopic cholecystectomy: technical considerations. Surg Endosc 2006; 20:1654.
  63. Bingener-Casey J, Richards ML, Strodel WE, et al. Reasons for conversion from laparoscopic to open cholecystectomy: a 10-year review. J Gastrointest Surg 2002; 6:800.
  64. Levy BS, Soderstrom RM, Dail DH. Bowel injuries during laparoscopy. Gross anatomy and histology. J Reprod Med 1985; 30:168.
  65. Chapron C, Querleu D, Bruhat MA, et al. Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 29,966 cases. Hum Reprod 1998; 13:867.
  66. Jansen FW, Kapiteyn K, Trimbos-Kemper T, et al. Complications of laparoscopy: a prospective multicentre observational study. Br J Obstet Gynaecol 1997; 104:595.
  67. Härkki-Sirén P, Kurki T. A nationwide analysis of laparoscopic complications. Obstet Gynecol 1997; 89:108.
  68. Härkki-Siren P, Sjöberg J, Kurki T. Major complications of laparoscopy: a follow-up Finnish study. Obstet Gynecol 1999; 94:94.
  69. Philosophe R. Avoiding complications of laparoscopic surgery. Fertil Steril 2003; 80 Suppl 4:30.
  70. A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club. N Engl J Med 1991; 324:1073.
  71. Baird DR, Wilson JP, Mason EM, et al. An early review of 800 laparoscopic cholecystectomies at a university-affiliated community teaching hospital. Am Surg 1992; 58:206.
  72. Collet D, Cadière GB. Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease. Formation for the Development of Laparoscopic Surgery for Gastroesophageal Reflux Disease Group. Am J Surg 1995; 169:622.
  73. Soderstrom RM. Bowel injury litigation after laparoscopy. J Am Assoc Gynecol Laparosc 1993; 1:74.
  74. Schwartz MJ, Faiena I, Cinman N, et al. Laparoscopic bowel injury in retroperitoneal surgery: current incidence and outcomes. J Urol 2010; 184:589.
  75. Georgy FM, Fetterman HH, Chefetz MD. Complication of laparoscopy: two cases of perforated urinary bladder. Am J Obstet Gynecol 1974; 120:1121.
  76. Sia-Kho E, Kelly RE. Urinary drainage bag distention: an indication of bladder injury during laparoscopy. J Clin Anesth 1992; 4:346.
  77. Poffenberger RJ. Laparoscopic repair of intraperitoneal bladder injury: a simple new technique. Urology 1996; 47:248.
  78. Swank HA, Mulder IM, la Chapelle CF, et al. Systematic review of trocar-site hernia. Br J Surg 2012; 99:315.
  79. Azurin DJ, Go LS, Arroyo LR, Kirkland ML. Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia. Am Surg 1995; 61:718.
  80. George JP. Presentation and Management of Laparoscopic Incisional Hernias. J Am Assoc Gynecol Laparosc 1994; 1:S12.
  81. Felix EL, Harbertson N, Vartanian S. Laparoscopic hernioplasty: significant complications. Surg Endosc 1999; 13:328.
  82. Fitzgibbons RJ Jr, Camps J, Cornet DA, et al. Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial. Ann Surg 1995; 221:3.
  83. Ramshaw BJ, Tucker JG, Conner T, et al. A comparison of the approaches to laparoscopic herniorrhaphy. Surg Endosc 1996; 10:29.
  84. Bensley RP, Schermerhorn ML, Hurks R, et al. Risk of late-onset adhesions and incisional hernia repairs after surgery. J Am Coll Surg 2013; 216:1159.
  85. Montz FJ, Holschneider CH, Munro MG. Incisional hernia following laparoscopy: a survey of the American Association of Gynecologic Laparoscopists. Obstet Gynecol 1994; 84:881.
  86. Boike GM, Miller CE, Spirtos NM, et al. Incisional bowel herniations after operative laparoscopy: a series of nineteen cases and review of the literature. Am J Obstet Gynecol 1995; 172:1726.
  87. Kadar N, Reich H, Liu CY, et al. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol 1993; 168:1493.
  88. Bunting DM. Port-site hernia following laparoscopic cholecystectomy. JSLS 2010; 14:490.
  89. Alptekin H, Yilmaz H, Acar F, et al. Incisional hernia rate may increase after single-port cholecystectomy. J Laparoendosc Adv Surg Tech A 2012; 22:731.
  90. Yi F, Jin WS, Xiang DB, et al. Complications of laparoscopic cholecystectomy and its prevention: a review and experience of 400 cases. Hepatogastroenterology 2012; 59:47.
  91. Johnson WH, Fecher AM, McMahon RL, et al. VersaStep trocar hernia rate in unclosed fascial defects in bariatric patients. Surg Endosc 2006; 20:1584.
  92. Marks JM, Phillips MS, Tacchino R, et al. Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg 2013; 216:1037.
  93. Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004; 139:1248.
  94. Liu CD, McFadden DW. Laparoscopic port sites do not require fascial closure when nonbladed trocars are used. Am Surg 2000; 66:853.
  95. Bhoyrul S, Payne J, Steffes B, et al. A randomized prospective study of radially expanding trocars in laparoscopic surgery. J Gastrointest Surg 2000; 4:392.
  96. Bruyère F, Sun J, Cosson JP, Kouri G. Incarceration of bowel through opening of a 5-mm port. J Endourol 2004; 18:675.
  97. Chen LF, Anderson DJ, Hartwig MG, et al. Surgical site infections after laparoscopic and open cholecystectomies in community hospitals . Infect Control Hosp Epidemiol 2008; 29:92.
  98. Tan LG, See JY, Wong KS. Necrotizing fasciitis after laparoscopic colonic surgery: case report and review of the literature. Surg Laparosc Endosc Percutan Tech 2007; 17:551.
  99. Losanoff JE, Richman BW, Jones JW. Trocar-site hernia complicated by necrotizing fasciitis--case report and review of the literature. Hernia 2003; 7:220.
  100. Bharathan R, Hanson M. Diagnostic laparoscopy complicated by group A streptococcal necrotizing fasciitis. J Minim Invasive Gynecol 2010; 17:121.
  101. Voitk AJ, Tsao SG. The umbilicus in laparoscopic surgery. Surg Endosc 2001; 15:878.
  102. Coelho JC, Wiederkehr JC, Campos AC, Andrigueto PC. Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease. J Am Coll Surg 1999; 189:356.
  103. Laine S, Rantala A, Gullichsen R, Ovaska J. Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study. Surg Endosc 1997; 11:441.
  104. Goldberg JM, Chen CCG, Falcone T. Complication of laparoscopic surgery. In: Basic, Advanced, and Robotic Laparoscopic Surgery, Falcone T, Goldberg JM. (Eds), Saunders Elsevier, Philadelphia 2010. p.221.
  105. Farooqui MO, Bazzoli JM. Significance of radiologic evidence of free air following laparoscopy. J Reprod Med 1976; 16:119.
  106. Roopnarinesingh S, Raj-Kumar G, Woo J. Laparoscopic trocar point perforation of the small bowel. Int Surg 1977; 62:76.
  107. Milliken, RA, Milliken, GM. Gastric perforation: rare complications of laparoscopy. NY State J Med 1975; Jan:77.
  108. Endler GC, Moghissi KS. Gastric perforation during pelvic laparoscopy. Obstet Gynecol 1976; 47:40S.
  109. Esposito JM. Hematoma of the sigmoid colon as a complication of laparoscopy. Am J Obstet Gynecol 1973; 117:581.
  110. Birns MT. Inadvertent instrumental perforation of the colon during laparoscopy: nonsurgical repair. Gastrointest Endosc 1989; 35:54.
  111. Thompson BH, Wheeless CR Jr. Gastrointestinal complications of laparoscopy sterilization. Obstet Gynecol 1973; 41:669.
  112. Shell JH Jr, Myers RC Jr. Small bowel injury after laparoscopic sterilization. Am J Obstet Gynecol 1973; 115:285.
  113. Homburg R, Segal T. Perforation of the urinary bladder by the laparoscope. Am J Obstet Gynecol 1978; 130:597.
  114. Deshmukh AS. Laparoscopic bladder injury. Urology 1982; 19:306.
  115. Sherer DM. Inadvertent transvaginal cystotomy during laparoscopy. Int J Gynaecol Obstet 1990; 32:77.
  116. Levy BF, De Guara J, Willson PD, et al. Bladder injuries in emergency/expedited laparoscopic surgery in the absence of previous surgery: a case series. Ann R Coll Surg Engl 2012; 94:e118.
  117. Sandbichler P, Draxl H, Gstir H, et al. Laparoscopic repair of recurrent inguinal hernias. Am J Surg 1996; 171:366.
  118. Wheeler KH. Laparoscopic inguinal herniorrhaphy with mesh: an 18-month experience. J Laparoendosc Surg 1993; 3:345.
  119. Grainger DA, Soderstrom RM, Schiff SF, et al. Ureteral injuries at laparoscopy: insights into diagnosis, management, and prevention. Obstet Gynecol 1990; 75:839.
  120. Gomel V, James C. Intraoperative management of ureteral injury during operative laparoscopy. Fertil Steril 1991; 55:416.
  121. Woodland MB. Ureter injury during laparoscopy-assisted vaginal hysterectomy with the endoscopic linear stapler. Am J Obstet Gynecol 1992; 167:756.
  122. Kadar N, Lemmerling L. Urinary tract injuries during laparoscopically assisted hysterectomy: causes and prevention. Am J Obstet Gynecol 1994; 170:47.
  123. Tamussino KF, Lang PF, Breinl E. Ureteral complications with operative gynecologic laparoscopy. Am J Obstet Gynecol 1998; 178:967.
  124. Saidi MH, Sadler RK, Vancaillie TG, et al. Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 1996; 87:272.
  125. Gao JS, Leng JH, Liu ZF, et al. Ureteral injury during gynecological laparoscopic surgeries: report of twelve cases. Chin Med Sci J 2007; 22:13.
  126. Abu-Rustum NR, Rhee EH, Chi DS, et al. Subcutaneous tumor implantation after laparoscopic procedures in women with malignant disease. Obstet Gynecol 2004; 103:480.
  127. Ramirez PT, Wolf JK, Levenback C. Laparoscopic port-site metastases: etiology and prevention. Gynecol Oncol 2003; 91:179.
  128. Ost MC, Tan BJ, Lee BR. Urological laparoscopy: basic physiological considerations and immunological consequences. J Urol 2005; 174:1183.
  129. Pados G, Vavilis D, Pantazis K, et al. Unilateral vulvar edema after operative laparoscopy: a case report and literature review. Fertil Steril 2005; 83:471.
  130. Guven S, Guven ES, Ayhan A. Vulvar edema as a rare complication of laparoscopy. J Am Assoc Gynecol Laparosc 2004; 11:429.
  131. Marcovici I, Shadigian E. Operative laparoscopy and vulvar hematoma: an unusual association. JSLS 2001; 5:87.