Laparoscopic Vascular Complications Case File
Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG
Case 12
A 28-year-old thin and nulliparous woman with a history of progressive dysmenorrhea not responding to medical therapy is taken to surgery for laparoscopy and possible excision of endometriosis. The Veress needle is introduced through an infraumbilical incision and the abdomen filled with 2 L of CO2 gas. A 10/11-mm trocar is introduced into the abdominal cavity without much effort. Upon inserting the laparoscope, large amount of blood is visualized. The anesthesiologist alerts you that the patient is currently hypotensive.
➤ What is the most likely diagnosis?
➤ What is your next step?
ANSWERS TO CASE 12:
Laparoscopic Vascular Complications
Summary: This is a 28-year-old woman who, during a laparoscopy, developed hypotension and intra-abdominal bleeding.
➤ Most likely diagnosis: Major vascular injury.
➤ Next step: Proceed with a laparotomy and obtain the assistance of a vascular surgeon.
ANALYSIS
Objectives
- Be familiar with the definition and consequences of major vascular injury.
- Learn the differences between closed versus open technique in laparoscopy.
- Learn strategies to minimize the incidence of major vascular injury.
- Be familiar with the management of major vascular injury.
Considerations
This is a 28-year-old thin woman who suffered a major vascular injury during laparoscopic surgery. Sometimes surprising to the surgeon, it is the thin patient who is at greatest risk for vascular injuries, because of the decreased distance from the skin to the retroperitoneal space. This patient had a
hypotensive episode immediately upon injury to her major vessels. It is unclear at this point whether it is the aorta or vena cava that is injured. The surgeon should immediately perform a laparotomy via vertical incision to put pressure on the vascular injury. Large bore IVs should be placed, and crystalloid resuscitation should be initiated. Blood should be immediately ordered, and likely, the patient will need uncross-matched O negative blood. A vascular surgeon should be immediately summoned. Time is of the essence, and may mean survival or death for this patient. Major vascular injury is defined as one that threatens the patient’s life almost immediately upon its occurrence.
APPROACH TO
Laparoscopic Vascular Injury
Vascular injury associated with laparoscopy has an incidence of less than 1 per 1000 cases (0.1%). Despite its low incidence, it remains one of the most feared complications in laparoscopic procedures. It is a complication that can occur even to the most experienced laparoscopic surgeon. However, timely diagnosis and proper management are paramount for a good outcome. Laparoscopy is particularly associated with vascular injury due to the blind introduction of either the Veress needle to produce the pneumoperitoneum or the trocar to introduce the initial laparoscope.1
Perhaps counterintuitive, it is the thin patient rather than the obese patient who is at greater risk for these injuries, especially in those patients with welldeveloped abdominal walls. In the thin athletic patients, the distance from the abdominal wall to the retroperitoneal structures is less than that in obese patients. Certain anatomical considerations and surgical techniques can minimize vascular injuries. An intraumbilical incision at the deepest point represents the shorter distance to the abdominal cavity. In a retrospective review by Hurd and associates,2 the vertical distance from the base of the umbilicus to the peritoneum remained very constant despite an increase in the BMI of the subjects. It was a distance of 6 cm or less in nearly all subjects. In contrast, the distance at 45 degrees from the lower margin and base of the umbilicus to the peritoneum increased to a much larger degree with an increase in the BMI. The introduction of the initial umbilical trocar remains a blind entry. Despite the utilization of an open technique, major vascular complications can occur.3-5 Thus, even with open trocar introduction, the surgeon should be vigilant and should exercise careful technique.
Clinical trials comparing closed versus open entry technique have not demonstrated a superiority of one over the other. A study by the American Association of Gynecologic Laparoscopists showed more visceral lesions with open laparoscopy entry but not significantly fewer vascular lesions.3 It is important to note that visceral lesions are potentially more life threatening since they are commonly missed during laparoscopy and only recognized when the patient is admitted with peritonitis and sepsis. I prefer the closed technique. In the establishment of pneumoperitoneum, filling the abdomen to a specific pressure rather than a set volume allows for different intra-abdominal distensibility and volume capacity. In our setting, I typically insufflate the abdomen to a pressure of 20 mm Hg. This offers a tight abdomen which allows for an easier insertion of the trocar. The patient should be kept in a completely horizontal position. Premature Trendelenburg position such as by the anesthesiologist or even the surgeon direction can alter the anatomy, bringing the major vessels into closer proximity to the site of the trocar insertion. In this case the insufflation of the abdominal cavity with 2 L was inadequate and may have been the contributing factor to the major vascular injury. The utilization of sharp/disposable trocars allows for an easier and controlled insertion.
Avoidance of Injury
The abdominal and pelvic examinations should be performed preoperatively not only to assess for disease but also to assess the distance between the abdominal wall and the retroperitoneal vessels. A very easily palpable abdominal aortic pulse, a sharply inclined sacral promontory, or pronounced lumbar lordosis can all be hints of bony variations that push the aorta or vena cava toward the abdominal wall, putting the patient at risk for vascular injury. Additionally, patients who have had abdominal surgery or pelvic adhesive disease may also be at risk due to a “solid interface” between the anterior abdominal wall and the retroperitoneum. This lack of space does not allow the trocar sheath guard to engage, and, thus, the surgeon may make multiple attempts to push the trocar deeper and deeper trying to get the trocar sleeve to activate. Furthermore, if the surgeon deviates off the midline even slightly upon introducing the trocar, the iliac vessels can be injured. Thus, the laparoscopic surgeon must be much disciplined to place the trocar in the midline. During the surgical aspect of laparoscopy, injury to vascular structures can occur due to dissection near the retroperitoneal vessels. Ablation of endometriosis for instance can lead to vascular injury due to the distorted anatomy from the endometriotic implants.6 The surgeon should ensure that the patient is horizontal and not in Tredelenburg position (Figure 12-1 A and B) since the change in position can lead to inadvertent directing of the trocar into the retroperitoneal vessels.
Recognition of Vascular Injury
At times, the vascular injury is obvious with bright red blood filling the abdominal cavity. Sometimes, though, the findings are more subtle. For instance, vena cava laceration may be associated with a “hematoma” in the retroperitoneal space that can deceptively “appear stable.” As a rule of thumb, any hematoma in the retroperitoneal area should be fully investigated and should be considered a major vascular injury until proven otherwise. A common scenario is that a venous injury may appear stable in the operating room, only to lead to further hemorrhage postoperatively, and even exsanguination. Abdominal wall vessels can also be injured such as the inferior epigastric artery. Visualization with the laparoscope of these vessels as they course between the rectus muscle and the parietal peritoneum can direct lateral ports away from these vessels (Figure 12–1A and B).
Treatment
As soon as a major vascular injury is recognized, the surgeon should proceed with an immediate laparotomy through a midline incision, while anesthesia secures additional IV lines, experienced cardiovascular surgeon is summoned, and arrangements are being made in making blood available for transfusion. Once laparotomy has begun, the first priority is to compress the aorta to prevent exsanguination. This is accomplished by placing hand compression over the aorta or a vascular clamp. If the compression lasts for over 15 minutes, systemic anticoagulation with heparin should be considered once the repair is complete and the patient is stable. Injury to the vena cava is generally more difficult to repair due to the thin wall and friable tissue. Gentle constant pressure to help decrease blood loss, while awaiting a vacular surgeon, is the most prudent action. Because the vena cava can tear more easily, the pressure
Figure 12–1. Placement of laparoscope with care to stay in the midline directed into the hollow of the sacrum (A), whereas incorrect positioning deviating from the midline can cause inadvertent injury to the retroperitoneal vessels (B).
should be directed downward without excessive movement that may cause further vessel laceration. A number of techniques are used to address injury to the inferior epigastric artery, including bipolar cautery via laparoscopy, the use of a Foley bulb placed into the trocar site into the abdominal cavity with traction and held in place such as with a small clamp on Foley catheter against the anterior abdominal wall. Various needles have been designed to allow for deep surgical ligatures, and finally enlarging the surgical incision to isolate and ligate the vessel may be employed.7-10
Comprehension Questions
12.1 A 43-year-old woman is undergoing laparoscopy for chronic pelvic pain. Upon placement of the umbilical trocar, there is a large amount of blood noted. Which of the following is the best next step for this patient?
A. Await 2 U of packed red blood cells before proceeding further.
B. Attempt to repair the vascular injury laparoscopically in conjunction with a fluid evacuator.
C. Normal saline infusion and await vacular surgeon.
D. Immediate laparotomy to compress vacular injury and aorta.
12.2 The surgeon is discussing with a patient who is being scheduled for a laparoscopic myomectomy. Injury to vessels and bleeding is discussed. Which of the following blood vessels is most likely to be injured?
A. Inferior epigastric artery
B. Common iliac artery
C. Internal iliac artery
D. Ovarian artery
12.3 Which of the following situations places patients at increased risk of vascular injury during laparoscopy?
A. Obese patients at greater risk rather than thin patients
B. Closed versus open laparoscopic trocar placement
C. Trocar deviated to the right side rather than the midline
D. Use of disposable trocar instruments versus reusable instruments
ANSWERS
12.1 D. Upon discovery of a major vascular injury, the surgeon should perform an immediate laparotomy via a vertical skin incision. Pressure should be applied at the vascular injury site, and also the aorta should be compressed. The anesthesiologist should place two large bore IVs and normal saline should be infused, while blood be cross-matched.
12.2 A. The inferior epigastric artery is the most commonly injured vessel causing major hemorrhage. The inferior epigastric artery is located between the rectus muscle and the peritoneum, and at the medial aspect of the rectus muscle. Injury can be avoided by transilluminating through the intra-abdominal region, to try to locate the vessels prior to placement of the lateral ports.
12.3 C. Vascular injuries are more common with thin patients rather than obese ones. The best technique is to aim at the hollow of the sacrum in the midline to avoid injury of the common iliac vessels. Because thin patients have less distance from the skin to the retroperitoneal space, the retroperitoneal vessels are more often injured.
Clinical Pearls
(See Table 1-2 for definition of level of evidence and strength of recommendation)
➤ The most common vessel injured during laparoscopy is the inferior epigastric artery (Level B).
➤ The most commonly injured retroperitoneal vessel is the common iliac artery or vein (Level B).
➤ In a hypotensive patient when a major artery is lacerated, pressure at the vessel injury site and compression of the aorta are paramount (Level B).
➤ A closed versus open technique for laparoscopic trocar entry has not been shown to affect the incidence of vascular injury (Level A).
REFERENCES
1. Loffer F, Pent D. Indications, contraindications and complications of laparoscopy. Obstet Gynecol Surv. 1975;30:407-427.
2. Hurd WW, Bude RO, Delancey JOH, Gauvin JM, Aisen AM. Abdominal wall characteristics by MRI and CT imaging: the effect of obesity on laparoscopic approach. J Reprod Med. 1992;36:473-476.
3. Phillips JM, Hulka JF, Peterson HB. American Association of Gynecologic Laparoscopists’ 1982 membership survey. J Reprod Med. 1984;29:592-594.
4. Frenkel Y, Oelsner G, Ben-Baruch G, Menczer J. Major surgical complications of laparoscopy. Eur J Obstet Gynecol Reprod Biol. 1981;12:107-111.
5. Chamberlain G, Brown JC, eds. Gynecological laparoscopy: the report of the confidential inquiry into gynaecological laparoscopy. London: Royal College of Obstetricians and Gynaecologists. 1978:114.
6. Mintz M. Risks and prophylaxis in laparoscopy: a survey of 100,000 cases. J Reprod Med. 1977;18:269.
7. Jansen FW, Kolkman W, Bakkum E, de Kroon C, Trimbos-Kemper TC, Trimbos JB. Complications of laparoscopy: an inquiry about closed-versus open-entry technique. Am J Obstet Gynecol. 2004;190:634-638.
8. Reich H. New techniques in advanced laparoscopic surgery. Baillieres Clin Obstet Gynaecol. 1989;3:655-681.
9. Pring CM. Aortic injury using the Hasson trocar: a case report and review of the literature. Ann R Coll Surg Engl. 2007 Mar;89(2):W3-W5. Review.
10. Nezhat C, Childers J, Nezhat F, Nezhat CH, Seidman DS. Major retroperitoneal vascular injury during laparoscopic surgery. Hum Reprod. 1997 Mar;12(3):480-483.
0 comments:
Post a Comment
Note: Only a member of this blog may post a comment.