Anterior Abdominal Wall Injury

This has been attributed to the more lateral course of the inferior epigastrics along the rectus muscles compared to the more medial distribution for the superior epigastrics. The inferior epigastric artery is also larger than the superior epigastric. It has been reported that injuries to the superior epigastric artery are more likely to stop on its own than the inferior epigastric. Multiple techniques have been described for controlling bleeding from these sites. Resectoscopes have been placed via the trocar site and fulguration of the bleeding point has been described. This is difficult if the bleeding is significant or if a large amount of adipose tissue is present. Medial or lateral displacement of the trocar may temporize hemorrhage by pressure tamponade. A Foley catheter has successfully been placed via the trocar, insufflated with 30 cm3 of saline, the upward traction utilized to tamponade the bleeding. Percutaneous sutures placed via a Stamey needle have also successfully ligated abdominal wall bleeding (75). Because the epigastrics are anatomically located in predictable patterns, just medial to the lateral border of the rectus abdominus these injuries should be avoidable. But as pointed out previously, the more complex the operation, the more likely that staying within the safe boundaries of known drainage patterns can be compromised. It is best to identify the anterior abdominal wall vasculature by transillumination with the laparoscope prior to placing any trocars near the vicinity of these vessels. By using the smallest trocar necessary, the risk of a major injury to the epigastric vessels is also reduced. Some have suggested not angling the trocar radically towards the midline from lateral locations to avoid shear that could damage vascular tributaries. Use of cone-shaped blunt-tip trocar or a radially dilating "step trocar" can minimize chances of injury to the inferior epigastrics. Finally, it is critically important to inspect all trocar sites both at the beginning of the laparoscopic case and at its conclusion. Trocars have been known to damage a blood vessel but not result in serious bleeding until it has been removed. This is thought to occur secondary to tamponade of the vessel by the trocar and pneu-moperitoneum.

Liebl et al. (28) investigated the risk of abdominal wall injuries by evaluating bleeding from access sites in complex general surgical cases. They noted that the risk of injury of a blood vessel in the anterior abdominal wall was not only associated with the type of surgery being performed but also the type of trocar utilized. The trocar's tip design is itself a significant factor in causing bleeding from access via the abdominal wall. They reviewed the surgical literature and found very rare accounts of this problem in laparoscopic hernia surgery (0.8%), in laparoscopic Nissen fundoplication (3%), and in laparoscopic colon surgery (3.4%). In evaluating various trocar tip designs, they noted that the rate of anterior abdominal wall bleeding was reduced from sharp-cutting tipped trocars (0.83% to 0.33%) to 0 when cone-shaped trocars were used.

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Unlike major vascular injury, many bowel injuries go unrecognized at the time of the laparoscopic procedure. This is because they have a tendency to be small and often out of the line of sight during the laparoscopic procedure. That is to say, they occur off camera and are thus easily overlooked.

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