Costas D. Lallas, MD, FACS
Leonard G. Gomella, MD, FACS
BASICS
DESCRIPTION
• Vascular or visceral injury during placement of trocars in laparoscopic surgery commonly referred to as “access injuries.”
• Initial trocar placement is generally considered the most hazardous portion of minimally invasive surgery.
• Hemorrhage due to vessel injury and infection secondary to bowel injury, especially when diagnosis is delayed, are the most serious complications and the most likely to result in death.
EPIDEMIOLOGY
Incidence
• Vascular injury: 0.04–0.5%
• Visceral: 0.06%
Prevalence
N/A
RISK FACTORS
• Blind port placement
• Dilated viscus
• Inexperienced surgeon
• Prior intra-abdominal surgery
• Thin patient
Genetics
N/A
PATHOPHYSIOLOGY (1,2,3)
• During transperitoneal laparoscopy at risk structures are in proximity to port:
– Umbilicus: Right common iliac artery
– Upper midline: Aorta or vena cava
– Right upper quadrant: Liver or gall bladder
– Left upper quadrant (LUQ): Spleen or stomach
– Pelvis: Bladder
– Right and left lower quadrant: Epigastric vessels
• Bifurcation of the aorta and vena cava is generally at the level of the umbilicus or at the level of the anterior-superior iliac spine.
– Direct perpendicular trocar or Veress needle entry created a situation whereby a great vessel (aorta, vena cava, common iliac artery, and vein) can be injured.
• Life-threatening gas embolism is rare and most often caused by direct insufflation of CO2 gas into a vessel by the Veress needle.
– The 1st sign of intravascular insufflation is acute cardiovascular collapse. The diagnosis is usually made by the anesthesiologist based on an abrupt increase of end-tidal CO2 accompanied by a sudden decline in oxygen saturation and then a marked decrease in end-tidal CO2
• The bladder is most likely injured during initial trocar placement.
• Extraperitoneal laparoscopy decreases the risk of visceral and vascular injury.
ASSOCIATED CONDITIONS
• For urologic laparoscopy the underlying indication for the laparoscopy:
– Malignancy (kidney, prostate, testicular, ureteral, bladder)
– Obstruction: Ureteropelvic junction obstruction
– Masses: Adrenal, retroperitoneal
– Others: Lymphocele, hernia
GENERAL PREVENTION
• Hasson technique (“cut down,” or “open trocar placement”) for initial access; allows direct visualization of peritoneum.
• Use of visual obturator trocar for primary port placement.
• Use of a nonbladed port for all ports.
• Utilization of confirmatory testing to insure proper placement of initial Veress needle before full insufflation (4):
– Aspiration of colored (red, yellow, green, brown) or malodorous fluid suggests improper placement.
– Drop test: Apply a drop of saline inside the hub of the needle and lift the abdominal wall. If in proper position, the drop will enter the abdomen due to the negative intraperitoneal pressure.
– Advancement test: If the needle has truly just entered the peritoneal cavity, then the surgeon ought to be able to advance the needle 1 cm deeper without the tip meeting any resistance.
– Modified Palmer test: Inject 10 mL of saline into the needle and attempt to aspirate. Inability to aspirate the fluid suggests that the fluid has dispersed into the abdomen and the needle is in correct position.
– Initial pressure reading <8 mm Hg. The insufflator is turned on with no flow to obtain a pressure reading.
A decrease in pressure with elevation of the abdominal wall.
– If perforation of a viscus occurs, the needle should be removed and discarded. A new needle may then be inserted at another location or the surgeon may choose to obtain open access using the Hasson technique. The injury should be observed laparoscopically or through open intervention if there is any concern over the degree of injury
• Utilizing a LUQ insertion site (Palmer point), located 3 cm below the middle of the left costal margin, for primary port
– Patients with a history of prior abdominal surgery should be a 1st-line option to eliminate major vessel injury and entry injuries into the bowel which might adhere to a previously made lower abdominal incision
• Angle ports at insertion to 45° into the pelvis; critically important in very thin patients
• Increase pneumoperitoneum to 20–25 mm Hg during port placement to increase tension of abdominal wall and decrease posterior displacement during trocar insertion
• Ensure adequate skin incision for trocar size to avoid excess insertion pressure
• Stabilize abdominal wall when inserting trocar
• Direct vision of secondary port placement and transillumination of abdominal wall to avoid more superficial vessels.
• Bladder catheter placement
• Nasogastric tube placement
• Surgeons should completely familiarize themselves with a new trocar device or design before 1st-time use.
• Visualization of port removal can help identify unrecognized anterior abdominal wall vascular injury.
DIAGNOSIS
HISTORY
Prior abdominal surgery records should be reviewed if appropriate
PHYSICAL EXAM
• Intraoperative findings that suggest trocar injury:
– Blood in the port after initial placement
– Bile in the port after initial placement
– Retroperitoneal hematoma on initial abdominal inspection
– Air in the bladder catheter bag after initial trocar
– Drip of blood form trocar
Visualization of port removal can help identify unrecognized anterior abdominal wall vascular injury
– Drop pneumoperitoneum to 5 mm Hg at the end of the case to uncover possible significant small vessel or venous bleeding.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Sudden unexplained drop in blood pressure at the beginning of the case consistent with unrecognized major vascular injury
– Need to differentiate from insufflation causing compromised blood pressure
Imaging
Not usually used acutely
Diagnostic Procedures/Surgery
N/A
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
Serosal tear in viscera without mucosal violation
TREATMENT
GENERAL MEASURES
• In general Veress needle injuries often heal with conservative management whereas trocar injuries or gross spillage of bowel contents require formal repair
• Direct injury may be observed laparoscopically or during conversion laparotomy
• Abdominal wall/epigastric vessel bleeding may be recognized after ports are removed under direct visualization
• If a port is placed into a major vessel, do not remove but keep in place during laparotomy
– During an emergent open conversion, use anteriorly deflected port or laparoscope to cut down into abdomen (unless in major vessel)
MEDICATION
First Line
N/A
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Laparoscopic or open repair of injury
– Always have open tray available for each case
• If the Veress needle aspiration returns frank blood or other fluid (5)
– Consider leaving the needle in place to help tamponade and identify the injury site
– If the patient is unstable due to a presumed major vascular injury, immediate laparotomy is indicated
– If the patient is stable, consider an alternate access site and laparoscopically evaluate the site.
• For abdominal wall bleeding:
– Clip or electrocautery
– Intra-abdominal suture placement under laparoscopic guidance.
– Transcutaneous suture placement using Endo Close or other technique used to close the fascia.
– Acute placement of Foley inflated to tamponade bleeding.
• For gas embolism (4):
– Immediate cessation of insufflation and prompt desufflation of the peritoneal cavity.
– The patient is turned into a left lateral decubitus position and hyperventilated with 100% oxygen.
– Advancement of a central venous line into the right heart with subsequent attempts to aspirate gas may sometimes be helpful.
• Bladder injury:
– Veress needle injury can usually be managed by bladder catheter for 7–10 days.
– More significant injury requires 2-layer closure with absorbable suture and catheter drainage.
• Bowel injury:
– Requires further inspection and repair either laparoscopically or via laparotomy.
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Correction of any coagulopathy
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Excellent if injury is recognized and managed quickly.
• Delayed or unrecognized visceral injury can lead to significant morbidity or mortality.
– Many bowel injuries are not recognized initially and typically present with peritonitis.
COMPLICATIONS
Unrecognized injury can lead to ongoing hemorrhage, infection
FOLLOW-UP
Patient Monitoring
Dependent on injury and management.
Patient Resources
MedlinePlus: Diagnostic laparoscopy. http://www.nlm.nih.gov/medlineplus/ency/article/003918.htm
REFERENCES
1. Ghavamian R, ed. Complications of Laparoscopic and Robotic Urologic Surgery. New York, NY: Springer. 2010. ISBN 978-1-60761-675-7
2. Ahmad G, O’Flynn H, Duffy JM, et al. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2012;2:CD006583.
3. Pickett SD, Rodewald KJ, Billow MR, et al. Avoiding major vessel injury during laparoscopic instrument insertion. Obstet Gynecol Clin North Am. 2010;37(3):387–397.
4. Bandi G, Gomella LG. Basic Laparoscopy In: Graham S, ed. Glenn’s Operative Urology. 7th ed. Philadelphia, PA: LWW; 2010.
5. Ponsky L, Matin SF. Chapter 28. Special considerations in laparoscopy. In: Taneja SS, ed. Complications of Urologic Surgery. 4th ed. Philadelpia, PA: Saunders; 2010.
ADDITIONAL READING
Chandler JG, Corson SL, Way LW, et al. Three spectra of laparoscopic entry access injuries. J Am Coll Surg. 2001;192(4):478–490.
See Also (Topic, Algorithm, Media)
• Hypercarbia During Laparoscopy
• Rectal Injury During Radical Prostatectomy or Radical Cystectomy
• Trocar Injury During Laparoscopy Image
CODES
ICD9
• 868.19 Injury to other and multiple intra-abdominal organs, with open wound into cavity
• 902.9 Injury to unspecified blood vessel of abdomen and pelvis
• 998.2 Accidental puncture or laceration during a procedure, not elsewhere classified
ICD10
• K91.72 Acc pnctr & lac of a dgstv sys org during oth procedure
• S35.91XA Laceration of unspecified blood vessel at abdomen, lower back and pelvis level, initial encounter
• S36.90XA Unspecified injury of unspecified intra-abdominal organ, initial encounter
CLINICAL/SURGICAL PEARLS
• Drop pneumoperitoneum to 5 mm Hg at the end of the case to uncover possible significant small vessel or venous bleeding.
• Remove ports under direct visualization to detect latent abdominal wall/epigastric vessel bleeding.
• During an emergent open conversion, use anteriorly deflected port to cut down into abdomen (unless port in major vessel).
• Have open tray available for each laparoscopy case.