Venous Thrombosis

As demonstrated by Doppler flow studies, the increased intra-abdominal pressure of pneumoperitoneum diverts blood from the splanchnic circulation into the lower extremities (155), with subsequent lower-extremity venous engorgement and stasis during transperitoneal laparoscopy (Fig. 7) (156-158).

Femoral vein pressure generally parallels intra-abdominal pressure. Comparing intraperitoneal and preperitoneal gas insufflation in the same patients, one study demonstrated that femoral vein flow decreased with the former but not the latter (159). In two studies comprising 133 patients, no cases of deep venous thrombosis were detected with lower limb venous duplex scans following low-risk laparoscopic surgery (157,160). Larger series using clinical rather than routine imaging assessment have described a 0% to 1% incidence of deep venous thrombosis after laparoscopy (161-164). Pulmonary emboli following laparoscopy have also been reported (161,164-167).

The relative risk of thrombotic complications following laparoscopic surgery compared to open surgery is unknown. Until certain laparoscopic procedures have been determined to be at very low risk, prophylaxis against venous thrombosis is recommended.

Use of sequential compression devices during laparoscopy reverses the pneu-moperitoneum-induced reduction of femoral vein flow (168). In a study at the author's institution, of 354 consecutive urologic patients, 189 received subcutaneous fractionated heparin for venous thrombosis prophylaxis, and 165 were managed with sequential compression devices (164). Thrombotic complications in the heparin group included two deep venous thromboses without pulmonary emboli (1.0%). In the sequential compression devices group, there were two pulmonary emboli and one thrombosis of a dialysis fistula (1.8%) (p = 0.03). The rates of hemorrhagic complication were 18/189 (9.5%) and 6/165 (3.6%), respectively (p > 0.05). For urologic laparoscopic patients, these data suggest that fractionated subcutaneous heparin is associated with increased hemorrhagic complications without an apparent reduction in thrombotic complications as compared to sequential compression devices.

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