Vascular Injury

Major vascular injury during access for laparoscopic surgery is a well-described and much-feared complication (65). This probably is because of its dramatic presentations such as near instantaneous instability of the patient's hemodynamic state or sudden large volume blood from the Veress needle or trocar and also because of the high rate of mortality.

Major vascular injury as the cause of death following a laparoscopic surgery is second only to anesthesia complications, at 15%. Pneumoperitoneum needle injuries account for the vast majority of major vascular injuries reported.

In reviewing the gynecologic literature, 11 of 15 such injuries were noted from needle placement and only two out of fifteen from trocar placement (66). The distal aorta and right common iliac artery are not surprisingly the most prone to injury. This is because the distance from the anterior abdominal wall to the retroperitoneal vascula-ture may be as little as 2 cm in thin people. Injuries to the inferior vena cava, the left hepatic vein, the abdominal aorta, and the inferior phrenic vessels have all been reported as well. These injuries are most often the result of the laparoscopic dissection, and not from laparoscopic access methods. Hallmark features of these injuries include immediate bloody return from the needle and/or rapid deterioration of the hemodynamic status of the patient (67). Once a major vascular injury is suspected, the Veress needle or trocar should not be moved medially or laterally. The offending access portal should be left in place and open exploration should be performed. At exploration, bleeding is typically confined to the retroperitoneum even with extensive vascular lacerations. Most arterial injuries can be oversewn with simple, nonabsorbable sutures after obtaining proximal and distal control of the injured vessel. Rarely, the iliac vein has been lacerated along with the iliac artery. More extensive injuries have required prosthetic replacement of the injured blood vessel (68,69). These vascular injuries are the reason why open surgical instruments should be immediately available during all laparoscopic cases. At least two reported deaths are attributed to laparoscopic vascular injuries, and sequelae resulting from peripheral ischemia have resulted in successful litigations in the United States (70,71).

Although best avoided by careful instrument placement, and thorough understanding of anatomy and procedures it is equally important to be prepared for a major vascular catastrophe. An adequate response in a controlled yet rapid fashion can spare further morbid sequelae.

Early involvement by skilled vascular surgeons is associated with less permanent disability. Anticipation of this injury is essential. An open set of operative instruments should be available. If injury occurs during pneumoperitoneum insertion, avoid lateral displacement of the needle and remove it. Observe the patient's vital signs and draw a stat baseline hemoglobin and hematocrit. If vitals and serum parameters remain stable, open laparoscopic access should be accomplished or the procedure should be terminated and rescheduled another day. If vital signs indicate instability or serum parameters indicate continued hemorrhage, immediate laparotomy is indicated. Trocar injuries are usually more severe. The first indication may not be blood in the trocar but hemodynamic instability of the patient. If vascular injury is suspected do not remove the trocar or desufflate the abdomen but turn off the insufflator to avoid massive CO2 embolization. A midline celiotomy is performed and the trocar is used to guide the exploration. The trocar should not be touched until proximal and distal vascular control is obtained. Vascular injuries can also be encountered during dissection. These are usually smaller vessels or branches and rarely laceration of larger veins (femoral vein). Pressure is usually sufficient to tamponade the bladder until the field can be cleared and carefully explored to attempt laparoscopic salvage. During pelvic lymph adenectomy

It is advisable that inspection of the operative site at the conclusion of the procedure be accomplished with minimal abdominal pressures, 2-4 mmHg, prior to removal of any trocars.

The vasculature of the anterior abdominal wall can also be injured during laparoscopy, most often secondary to trocar injuries to the inferior or superior epigastric artery or vein. The inferior epigastric vessels are much more commonly injured than the superior epigastric vessles.

bleeding from an accessory obturator vein or artery can be very difficult to control laparoscopically. Despite the greatest care, these vascular structures can be inadvertantly torn or cut. Electrocautery or argon beam coagulation is not advisable choices in this scenario because of the risk of thermal injury to the obturator nerve (72). All alternatives to augmenting hemostasis should be considered. Chemical augmentation of hemostasis is possible with microfibrillar collagen (Endo-AviteneTMb) or fibrin glue (73). Occasionally the bleeding is severe and significant, warranting immediate exploration. Again, leave the trocars and pneumoperitoneum intact so that celiotomy can be performed quickly. The laparoscope can be placed in the midline to aid in countertrac-tion for the knife during this maneuver.

Finally, major lacerations to large veins can go unnoticed during laparoscopic procedures because of the pressure of pneumoperitoneum.

It is advisable that inspection of the operative site at the conclusion of the procedure be accomplished with minimal abdominal pressures, 2-4 mmHg, prior to removal of any trocars.

In addition, a good rule of thumb for all laparoscopic surgery is that the first instrument active on the table is the laparoscopic suction/irrigation unit, and that it is the last off the table for the conclusion.

The vasculature of the anterior abdominal wall can also be injured during laparoscopy (74), most often secondary to trocar injuries to the inferior or superior epigastric artery or vein. The inferior epigastric vessels are much more commonly injured than the superior epigastric vessles.

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