Hemorrhagic Complications in Laparoscopic Surgery
Hemorrhagic complications may occur as a consequence of entry into the peritoneal cavity or as a result of trauma incurred to blood vessels encountered during the course of the procedure.
Hemorrhage Associated with Access Technique
Great Vessel Injury
During access the most dangerous hemorrhagic complications of entry are to the great vessels, including the aorta and vena cava as well as the common iliac vessels and their branches, the internal and external iliac arteries and veins. The incidence of major vascular injury is probably under reported, but has been estimated to range widely from 0.93 to 9 per 10,000 cases. The trauma most often occurs secondary to insertion of an insufflation needle, but may be created by the tip of the trocar. However, not uncommonly, the injury is associated with the insertion of ancillary laparoscopic ports into the lower quadrants. The vessels most frequently damaged are the aorta and the right common iliac artery, which branches from the aorta in the midline. The anatomically more posterior location of the vena cava and the iliac veins provides relative protection, but not immunity, from injury. While most of these injuries are small amenable to repair with suture, some have been larger, requiring ligation with or without the insertion of a vascular graft. Not surprisingly, death has been reported in a number of instances.
Diagnosis
If great vessels are injured most often the problem presents as profound hypotension with or without the appearance of a significant volume of blood within the peritoneal cavity. In some instances, the surgeon aspirates blood via the insufflation needle, prior to introduction of distention gas. Frequently, the bleeding may be contained in the retroperitoneal space, a feature that usually delays the diagnosis. Consequently, the development of hypovolemic shock in the recovery room may well be secondary to otherwise unrecognized laceration to a great vessel. To avoid the late recognition, it is important to evaluate the course of each great vessel prior to completing the procedure.
Prevention
There are a number of ways by which the incidence of large vessel trauma can be minimized. Certainly it is essential that the positioning of ancillary or secondary trocar in the lower quadrants be performed under direct vision. This is more difficult for the primary cannula. It has been suggested that the use of “open laparoscopy” for the initial port entirely avoids the issue of great vessel injury secondary to insufflation needles and trocars. However, open laparoscopy has its own potential drawbacks such as increased operating time, the need for larger incisions, and a greater chance of wound infection, all without eliminating the incidence of bowel injury at entry.
The risk of large vessel injury should be reduced if careful attention is paid to access technique and equipments used. If used, both insufflation needles and the trocar should be kept sharp and surgeon should use same instrument each time. The safety sheath of the insufflation needle should be checked to ensure that both the spring and the sliding mechanism are functioning normally. Many disposable trocar-cannula systems are constructed with a safety mechanism that covers or retracts the trocar following passage through the fascia and peritoneum. However, there are currently no available data that demonstrate a reduction in the incidence of major vessel injury with the use of these devices.
The application of appropriate technique is based upon a sound understanding of the normal anatomic relationships between the commonly used entry points and the great vessels. A “safety zone” exists inferior to the sacral promontory in the area bounded superiorly by the bifurcation of the aorta, posteriorly by the sacral curve, and laterally by the iliac vessels. Safe insertion of the insufflation needle mandates that the instrument be maintained in a midline, sagittal plane while the operator directs the tip between the iliac vessels, anterior to the sacrum but inferior to the bifurcation of the aorta and the proximal aspect of the vena cava. Such positioning requires elevation of the abdominal wall while angling the insufflation needle about 45º to horizontal. The tactile and visual feedback created when the needle passes through the fascial and peritoneal layers of the abdominal wall, if recognized and heeded, may prevent overaggressive insertion attempts. Such proprioceptive feedback is diminished with disposable needles as compared to the classic Veress model. Instead, the surgeon must listen to the “clicks” as the needle obturator retracts when it passes through the rectus fascia and the peritoneum. The needle should never be forced.
It is critical to note that these anatomic relationships may vary with body type and with the orientation of the patient to the horizontal position. In women of normal weight and body habitus, in the horizontal recumbent position, the bifurcation of the aorta is located immediately beneath the umbilicus. However, in obese individuals the umbilicus may be positioned up to 2 or more cm below bifurcation. Fortunately, this circumstance allows the insufflation needle to be directed in a more vertical position-those between 160 to 200 pounds between 45° and 90°, while those women over 200 pounds at nearly 90°. Women placed in a head down position (Trendelenburg’s position); will shift their great vessel more superiorly and anteriorly in a fashion that may make them more vulnerable to an entry injury. Consequently, positioning of the insufflation needle, and at least the initial trocar and cannula, should be accomplished with the patient in a horizontal position. This approach additionally facilitates the evaluation of the upper abdomen, an exercise that is limited if the intraperitoneal content is shifted cephalad by the patient’s head down position.
The risk of great vessel injury is likely reduced by insufflating the peritoneal cavity to adequate pressure. An intraperitoneal pressure of 20 mm Hg, while not desirable for prolonged periods of time, can aid in separating the abdominal wall from the great vessels during the process of insertion of a sharp trocar.
Management
If blood is withdrawn from the insufflation needle, it should be left in place while immediate preparations are made to obtain blood products and perform laparotomy. If the diagnosis of hemoperitoneum is made upon initial visualization of the peritoneal cavity, a grasping instrument may be used, if possible, to temporarily occlude the vessel. While it is unlikely that significant injury can predictably be repaired by laparoscopically directed technique, if temporary hemostasis can be obtained, and the laceration visualized, selected, localized lesions can be repaired, with suture, under laparoscopic guidance. Such an attempt should not be made by any other than experienced and technically adept surgeons. Even if such an instance exists, fine judgment should be used so as not to delay the institution of life-saving, open surgical repair.
Most surgeons should gain immediate entry into the peritoneal cavity, and immediately compress the aorta and vena cava just below the level of the renal vessels, gaining at least temporary control of blood loss. At that juncture, the most appropriate course of action, including the need for vascular surgical consultation, will become more apparent.
Abdominal Wall Vessels
Most commonly injured abdominal wall vessels are the inferior epigastrics and superior epigastric vessel. They are invariably damaged by the initial passage of an ancillary trocar, or when a wider device is introduced later in the procedure. The problem may be recognized immediately by the observation of blood dripping along the cannula or out through the incision. However, it is not uncommon for the cannula itself to obstruct the bleeding until withdrawal at the end of the case.
More sinister, are injuries to the deep inferior epigastric vessels, branches of the external iliac artery and vein that also course cephalad but are deep to the rectus fascia and often deep to the muscles themselves. More laterally located are the deep circumflex iliac vessels that are uncommonly encountered in laparoscopic surgery. Laceration of these vessels may cause profound blood loss, particularly when the trauma is unrecognized and causes extraperitoneal bleeding.
Diagnosis
Diagnosis of abdominal wall vasculature injury is by visualization of the blood dripping down the cannula, or by the postoperative appearance of shock, abdominal wall discoloration, and/or a hematoma located near to the incision. In some instances, the blood may track to a more distant site, presenting as a pararectal or vulvar mass. Delayed diagnosis may be prevented at the end of the procedure by laparoscopically evaluating each peritoneal incision following removal of the cannula.
Prevention
With the help of telescope transillumination of the abdominal wall from within will, at least in most thin women, allow for identification of the superficial inferior epigastric vessels. However, the deep inferior epigastric vessels cannot be identified by this mechanism because of their location deep to the rectus sheath. Consequently, prevention of deep inferior epigastric vessel injury requires that the surgeon understand the anatomic course of these vessels.
The most consistent landmarks are the median umbilical ligaments (obliterated umbilical arteries) and the entry point of the round ligament into the inguinal canal. At the pubic crest, the deep inferior epigastric vessels begin their course cephalad between the medially located medial umbilical ligament and the laterally positioned exit point of the round ligament. The trocar should be inserted medial or lateral to the vessels, if they are visualized. If the vessels cannot be seen, and it is necessary to position the trocar laterally, it should be positioned 3 to 4 cm lateral to the median umbilical ligament, or lateral to the lateral margin of the rectus abdominis muscle. Too lateral an insertion will endanger the deep circumflex epigastric artery. The operator may further limit risk of injury by placing a No: 22 spinal needle though the skin at the desired location, directly observing the entry via the laparoscope. This not only provides more reassurance that a safe location has been identified, but the easily visualized peritoneal needle hole gives the surgeon a target for inserting the trocar with greater precision.
A common mistake is to fashion the incision appropriately, only to direct the trocar medially in its course through the abdominal wall, thereby injuring the vessels. Another factor that may contribute to the risk of injury is the use of large diameter trocar. Consequently, for this and other reasons, the surgeon should use the smallest trocar necessary for performance of the procedure.
Management
Superficial inferior epigastric artery lacerations usually respond to expectant management. Rotation of the cannula to a position where compression is possible is also helpful. Rarely is a suture necessary.
We have found that the use of a straight suture passer, is most useful for the ligation of lacerated deep inferior epigastric vessels. A number of other devices and techniques have been introduced that facilitate the accomplishment of this task. To summarize, the trocar and cannula are removed. Then, under laparoscopic visualization, and using a ligature carrier, a ligature is placed through the incision and directed laterally and inferiorly, where it is held by a grasping forceps. The ligature carrier is removed and subsequently passed through the incision again, without a suture, but this time medial and inferior to the lacerated vessels. The suture is threaded into the carrier from within the peritoneal cavity, and is then externalized and tied. For small incisions, narrower than the diameter of the surgeon’s finger, the knot may be tightened with a knot manipulator.
There are other, less uniformly successful methods for attaining hemostasis from a lacerated deep inferior epigastric vessel. The most obvious is the placement of large, through- and-through mattress sutures. These are usually removed about 48 hours later. Electrodesiccation may be successful. Either a unipolar or bipolar grasping forceps is passed through another ancillary cannula taking care to identify, grasp, and adequately desiccate the vessel. Either continuous or “blended” current is used at appropriate power outputs for the machine and the electrode. Another method that has enjoyed some success is temporary compression with the balloon of a Foley’s catheter, passed through the incision into the peritoneal cavity, then secured and tightened externally with a clamp. While some suggest that the balloon should be left in place for 24 hours, the delicate channel may be damaged by the clamp, making it impossible to deflate the balloon. For this reason, we not recommend this option.
Intraperitoneal Vessel Injury
The bleeding may result from inadvertent entry into a vessel failure of a specific occlusive technique, or human error in the application of the selected technique. Furthermore, in addition to the problem of delayed hemorrhage inherent in transection of arteries, there may be further delay in diagnosis at laparoscopy because of the restricted visual field and the temporary occlusive pressure exerted by the CO2 within the peritoneal cavity.
Diagnosis
During laparoscopy inadvertent division of an artery or vein will usually become immediately self-evident. However, in some instances, transected arteries will go into spasm only to begin bleeding minutes to hours later, an event that may temporarily go unnoticed due to the limited field of view presented by the laparoscope. Consequently, at the end of the procedure, all areas of dissection should be carefully examined. In addition, the CO2 should be vented, decreasing the intraperitoneal pressure to about 5 mm Hg, allowing recognition of vessels occluded by the higher pressure.
Prevention
Attention to meticulous technique is at least as important in laparoscopically directed surgery as it is for open or vaginal cases. During dissection, vessels should be identified and occluded prior to division, a task made simpler by the magnification afforded by the laparoscope. If suture is used to occlude a vessel it must be, of the appropriate caliber, positioned with an adequate pedicle, and tied snugly with a secure knot. Electrosurgery if used should be applied in the appropriate waveform and power density and for a time adequate to allow for sufficient tissue desiccation. Clips should be of a size appropriate for the vessel and they must be applied in a secure fashion, also with an adequate pedicle of tissue. Care should be exercised to avoid manipulation of pedicles secured with clips or suture; as such trauma could adversely affect the security of the closure. When linear stapling devices are employed, the appropriate staple size should be selected and the tissue encompassed in the staple line should be of uniform thickness. Failure to maintain relatively uniform tissue thickness may result in inadequate compression of blood vessels that course through the thinner areas of the pedicle.
Management
Transected vessels should be secured immediately. If electrosurgical desiccation is used to maintain or achieve hemostasis, the use of a serial ammeter is useful to demonstrate the endpoint of energy application. There is evidence that artery larger in diameter than 3 mm are less reliably occluded with desiccation than are those 3 mm or less. Care must be exerted to avoid blind clamping and electrosurgical desiccation, even with bipolar instruments, especially when less than 1 cm from ureter or bowel. When a vessel is in such a location, it is usually preferable to secure it with a clip.
Identification of small vessel bleeding and ooze is often facilitated by the use of copious irrigation and even underwater examination. Capillary ooze may be managed with higher voltage fulguration currents using electrodes with a bulbous tip. When using electrosurgery for this purpose, the use of electrolyte- containing solutions should be avoided, as they disperse current, rendering the technique ineffective. Instead the low viscosity fluids like glycine are recommended as, in addition to being nonconductive, they may facilitate localization of the vessels.
Gastrointestinal Complications
Following laparoscopy, it is not uncommon for the patient to experience nausea. However, in some instances the problem becomes severe. Gastrointestinal viscera potentially injured during the performance of gynecologic laparoscopy include the stomach, the small bowel, and the colon.
Insufflation Needle Injuries
Needle entry into the stomach almost invariably happens in the presence of gastric distention. While this may occur secondary to aerophagia, the complication is frequently related to difficult or improper intubation or to the use of mask induction with an inhalation anesthetic. Mechanical entry into large or small bowel may occur in any instance, but is up to 10 times more common when laparoscopy is performed on patients with previous intraperitoneal inflammation or abdominal surgery. In such instances, loops of intestine can adhere to the abdominal wall under the insertion site. Perforation may also occur following an overly aggressive attempt to insert the insufflation needle.
Recognition
Recognition of gastric entry by the insufflation needle may follow identification of any or all of the signs of extraperitoneal entry, including increased filling pressure, asymmetric distension of the peritoneal cavity, or the aspiration of gastric particulate matter through the lumen of the needle. However, the hollow, capacious nature of the stomach may allow the initial insufflation pressure to remain normal. Unfortunately, in some instances, the problem is not identified until the trocar is inserted and the gastric mucosa identified by direct vision. Recognition of bowel entry usually follows observation of the signs described above for gastric injury, with the addition of feculent odor to the list of findings. Prevention of insufflation needle injury to the gastrointestinal tract is important because such measures largely eliminate the risk of more sinister trocar trauma. Gastric perforation can largely be eliminated with the selective use of preoperative oral or nasogastric suction. The surgeon should request that this be performed if there has been difficulty with intubation or when the needle is intentionally inserted near to the stomach in the left upper quadrant.
Many have suggested that open laparoscopy is the most appropriate and effective way to reduce the incidence of intestinal injury in a patient at risk because of previous lower abdominal surgery. However, there are no studies that prove this to be the case. Indeed, there exists evidence that open laparoscopy is itself associated with intestinal injury. Consequently, many surgeons have suggested the use of left upper quadrant insertion with a properly decompressed stomach.
Although not strictly a prophylactic measure, the routine use of preoperative mechanical bowel preparation, at least in selected, high-risk cases, will diminish the need for laparotomy and/ or colostomy if large bowel entry occurs.
Management
The management of any trauma to the gastrointestinal tract depends in part upon the nature of the injury and in part upon the organ(s) involved. In general, insufflation needle punctures that have not resulted in a defect significantly larger than their diameter may be handled expectantly. Larger defects should be repaired or resected, by laparoscopic or a laparotomy based technique, depending upon extent of the lesion.
If, following insertion of an insufflation needle, particulate debris are identified, the needle should be left in place and an alternate insertion site identified, such as the left upper quadrant. If the insufflation needle possesses a removable obturator, a narrow caliber optical fiber or laparoscope may be passed to evaluate the location of the tip and to aid in later identification of the puncture site. Immediately following successful entry into the peritoneal cavity, the site of injury is identified. Unless significant injury or bleeding is identified, the situation may be handled expectantly. If there is unexpected extension of the laceration, it should be managed similarly to a trocar injury.
Trocar Injuries
During access technique damage caused by sharp trocar penetration is usually more serious than when needle injury occurs. Most often, the injury is created by the primary trocar because of its blind insertion. However, inadequate attention paid to the insertion of ancillary cannulas may also result in visceral injury.
Diagnosis
If a primary trocar penetrates bowel, the diagnosis is usually made when the surgeon visualizes the mucosal lining of the gastrointestinal structure following insertion of the laparoscope. If large bowel is entered, feculent odor may be noted. However, in some instances, the injury may not immediately be recognized as the cannula may not stay within, or it may pass through, the lumen and out the other side of the viscus. Such injuries usually occur when a single loop of bowel is adhered to the anterior abdominal wall near to the entry point. Consequently, it is important at the end of the procedure to directly view the removal of the primary cannula, either through the cannula itself or via an ancillary port. Routine direct visualization of primary port incisional closure will facilitate the accomplishment of this task. Unfortunately, the injury may go unrecognized until it presents postoperatively as peritonitis, abscess, enterocutaneous fistula, or death.
Prevention
The following measures were reported to reduce the incidence of trocar injuries:
• Disposable laparoscopes are usually sharper. They require less force to insert and thus there is less chance of compressing the trocar against the bowel or blood vessels.
• Some manufacturers provide a plastic sheath which springs and cover the sharp edge of the trocar after insertion. Safety shields will not prevent injury, however, in case of bowel adhesions.
• The use of ultrasound to “map” the abdominal wall for safe entry area is recommended especially when adhesions are present.
• The smaller 5 mm cannula is safer as it requires less pressure to insert. Equipped with a camera it allows safe placement of the larger cannula under vision.
• Hasson described an open surgical approach to placement of the cannula thus reducing the risk of perforation by the blind closed technique.
• Before the conclusion of surgery, a thorough search for bowel injuries must be performed as delay in recognition of such injury can be catastrophic. Thus review of the video tapes can ascertain if safety measures were taken during this critical part of the procedure.
Despite the widespread use of retractable trocars or safety sheaths, injury to bowel or other structures may occur. As stated above, many employ, routinely or selectively, the concept of “open” laparoscopy, where the peritoneal cavity is entered directly via an infra-or intraumbilical incision. Despite the apparent virtues of this approach, bowel entry may still occur. An alternative approach, especially when entering an abdomen with previous laparotomy scars, is the insertion of a narrow caliber cannula in the left upper quadrant following decompression of the stomach. It is unusual for a patient to have had previous surgery in this location. Following placement of the cannula, usually just below the costal margin in the midclavicular line, a narrow diameter laparoscope may be passed, allowing a direct view of the abdominal wall under the umbilicus or other planned site of insertion. If necessary, the small laparoscope may be used to direct the dissection of intestine from under the insertion site. This approach gains additional value with the introduction of a fiber laparoscope small enough to fit through the lumen of an insufflation needle.
Stomach injuries most frequently occur when there has been difficulty in intubation, and may be more common following left upper quadrant insertion if the stomach has not previously been decompressed. Consequently, liberal use of oral or nasogastric decompression will likely reduce the incidence of trocar injury to the stomach.
The most common cause of bowel injuries usually is when the intestine is adherent to the abdominal wall under the site of trocar insertion. Adherence is usually secondary to previous surgery. Consequently, in such patients open laparoscopy or left upper quadrant entry may be used. Preoperative mechanical bowel preparation should be employed in high-risk patients to facilitate repair of colonic defects without the need to perform a laparotomy.
Management
Trocar injuries to small bowels require repair. If it can be ascertained that the injury is isolated, and if the operator is capable, the lesion may be sutured under laparoscopic guidance with a double layer of running 2-0 or 3-0 synthetic absorbable suture. Extensive lesions may require resection and reanastomosis. In well trained and experienced hand, this may be performed under laparoscopic direction. However, in most instances, laparotomy will be required. Regardless of the method of repair, copious irrigation should be employed and the patient admitted for postoperative observation. The patient is kept without oral intake and nasogastric decompression should be liberally used at the discretion of the surgeon.
If the injury is to the sigmoid colon, primary repair may be attempted if the bowel has been mechanically prepared preoperatively. Otherwise, colostomy should be considered, with the possible exception of ascending colon lesions. If uncertainty exists regarding the extent of injury, laparotomy is always indicated.
Hemorrhagic complications may occur as a consequence of entry into the peritoneal cavity or as a result of trauma incurred to blood vessels encountered during the course of the procedure.
Hemorrhage Associated with Access Technique
Great Vessel Injury
During access the most dangerous hemorrhagic complications of entry are to the great vessels, including the aorta and vena cava as well as the common iliac vessels and their branches, the internal and external iliac arteries and veins. The incidence of major vascular injury is probably under reported, but has been estimated to range widely from 0.93 to 9 per 10,000 cases. The trauma most often occurs secondary to insertion of an insufflation needle, but may be created by the tip of the trocar. However, not uncommonly, the injury is associated with the insertion of ancillary laparoscopic ports into the lower quadrants. The vessels most frequently damaged are the aorta and the right common iliac artery, which branches from the aorta in the midline. The anatomically more posterior location of the vena cava and the iliac veins provides relative protection, but not immunity, from injury. While most of these injuries are small amenable to repair with suture, some have been larger, requiring ligation with or without the insertion of a vascular graft. Not surprisingly, death has been reported in a number of instances.
Diagnosis
If great vessels are injured most often the problem presents as profound hypotension with or without the appearance of a significant volume of blood within the peritoneal cavity. In some instances, the surgeon aspirates blood via the insufflation needle, prior to introduction of distention gas. Frequently, the bleeding may be contained in the retroperitoneal space, a feature that usually delays the diagnosis. Consequently, the development of hypovolemic shock in the recovery room may well be secondary to otherwise unrecognized laceration to a great vessel. To avoid the late recognition, it is important to evaluate the course of each great vessel prior to completing the procedure.
Prevention
There are a number of ways by which the incidence of large vessel trauma can be minimized. Certainly it is essential that the positioning of ancillary or secondary trocar in the lower quadrants be performed under direct vision. This is more difficult for the primary cannula. It has been suggested that the use of “open laparoscopy” for the initial port entirely avoids the issue of great vessel injury secondary to insufflation needles and trocars. However, open laparoscopy has its own potential drawbacks such as increased operating time, the need for larger incisions, and a greater chance of wound infection, all without eliminating the incidence of bowel injury at entry.
The risk of large vessel injury should be reduced if careful attention is paid to access technique and equipments used. If used, both insufflation needles and the trocar should be kept sharp and surgeon should use same instrument each time. The safety sheath of the insufflation needle should be checked to ensure that both the spring and the sliding mechanism are functioning normally. Many disposable trocar-cannula systems are constructed with a safety mechanism that covers or retracts the trocar following passage through the fascia and peritoneum. However, there are currently no available data that demonstrate a reduction in the incidence of major vessel injury with the use of these devices.
The application of appropriate technique is based upon a sound understanding of the normal anatomic relationships between the commonly used entry points and the great vessels. A “safety zone” exists inferior to the sacral promontory in the area bounded superiorly by the bifurcation of the aorta, posteriorly by the sacral curve, and laterally by the iliac vessels. Safe insertion of the insufflation needle mandates that the instrument be maintained in a midline, sagittal plane while the operator directs the tip between the iliac vessels, anterior to the sacrum but inferior to the bifurcation of the aorta and the proximal aspect of the vena cava. Such positioning requires elevation of the abdominal wall while angling the insufflation needle about 45º to horizontal. The tactile and visual feedback created when the needle passes through the fascial and peritoneal layers of the abdominal wall, if recognized and heeded, may prevent overaggressive insertion attempts. Such proprioceptive feedback is diminished with disposable needles as compared to the classic Veress model. Instead, the surgeon must listen to the “clicks” as the needle obturator retracts when it passes through the rectus fascia and the peritoneum. The needle should never be forced.
It is critical to note that these anatomic relationships may vary with body type and with the orientation of the patient to the horizontal position. In women of normal weight and body habitus, in the horizontal recumbent position, the bifurcation of the aorta is located immediately beneath the umbilicus. However, in obese individuals the umbilicus may be positioned up to 2 or more cm below bifurcation. Fortunately, this circumstance allows the insufflation needle to be directed in a more vertical position-those between 160 to 200 pounds between 45° and 90°, while those women over 200 pounds at nearly 90°. Women placed in a head down position (Trendelenburg’s position); will shift their great vessel more superiorly and anteriorly in a fashion that may make them more vulnerable to an entry injury. Consequently, positioning of the insufflation needle, and at least the initial trocar and cannula, should be accomplished with the patient in a horizontal position. This approach additionally facilitates the evaluation of the upper abdomen, an exercise that is limited if the intraperitoneal content is shifted cephalad by the patient’s head down position.
The risk of great vessel injury is likely reduced by insufflating the peritoneal cavity to adequate pressure. An intraperitoneal pressure of 20 mm Hg, while not desirable for prolonged periods of time, can aid in separating the abdominal wall from the great vessels during the process of insertion of a sharp trocar.
Management
If blood is withdrawn from the insufflation needle, it should be left in place while immediate preparations are made to obtain blood products and perform laparotomy. If the diagnosis of hemoperitoneum is made upon initial visualization of the peritoneal cavity, a grasping instrument may be used, if possible, to temporarily occlude the vessel. While it is unlikely that significant injury can predictably be repaired by laparoscopically directed technique, if temporary hemostasis can be obtained, and the laceration visualized, selected, localized lesions can be repaired, with suture, under laparoscopic guidance. Such an attempt should not be made by any other than experienced and technically adept surgeons. Even if such an instance exists, fine judgment should be used so as not to delay the institution of life-saving, open surgical repair.
Most surgeons should gain immediate entry into the peritoneal cavity, and immediately compress the aorta and vena cava just below the level of the renal vessels, gaining at least temporary control of blood loss. At that juncture, the most appropriate course of action, including the need for vascular surgical consultation, will become more apparent.
Abdominal Wall Vessels
Most commonly injured abdominal wall vessels are the inferior epigastrics and superior epigastric vessel. They are invariably damaged by the initial passage of an ancillary trocar, or when a wider device is introduced later in the procedure. The problem may be recognized immediately by the observation of blood dripping along the cannula or out through the incision. However, it is not uncommon for the cannula itself to obstruct the bleeding until withdrawal at the end of the case.
More sinister, are injuries to the deep inferior epigastric vessels, branches of the external iliac artery and vein that also course cephalad but are deep to the rectus fascia and often deep to the muscles themselves. More laterally located are the deep circumflex iliac vessels that are uncommonly encountered in laparoscopic surgery. Laceration of these vessels may cause profound blood loss, particularly when the trauma is unrecognized and causes extraperitoneal bleeding.
Diagnosis
Diagnosis of abdominal wall vasculature injury is by visualization of the blood dripping down the cannula, or by the postoperative appearance of shock, abdominal wall discoloration, and/or a hematoma located near to the incision. In some instances, the blood may track to a more distant site, presenting as a pararectal or vulvar mass. Delayed diagnosis may be prevented at the end of the procedure by laparoscopically evaluating each peritoneal incision following removal of the cannula.
Prevention
With the help of telescope transillumination of the abdominal wall from within will, at least in most thin women, allow for identification of the superficial inferior epigastric vessels. However, the deep inferior epigastric vessels cannot be identified by this mechanism because of their location deep to the rectus sheath. Consequently, prevention of deep inferior epigastric vessel injury requires that the surgeon understand the anatomic course of these vessels.
The most consistent landmarks are the median umbilical ligaments (obliterated umbilical arteries) and the entry point of the round ligament into the inguinal canal. At the pubic crest, the deep inferior epigastric vessels begin their course cephalad between the medially located medial umbilical ligament and the laterally positioned exit point of the round ligament. The trocar should be inserted medial or lateral to the vessels, if they are visualized. If the vessels cannot be seen, and it is necessary to position the trocar laterally, it should be positioned 3 to 4 cm lateral to the median umbilical ligament, or lateral to the lateral margin of the rectus abdominis muscle. Too lateral an insertion will endanger the deep circumflex epigastric artery. The operator may further limit risk of injury by placing a No: 22 spinal needle though the skin at the desired location, directly observing the entry via the laparoscope. This not only provides more reassurance that a safe location has been identified, but the easily visualized peritoneal needle hole gives the surgeon a target for inserting the trocar with greater precision.
A common mistake is to fashion the incision appropriately, only to direct the trocar medially in its course through the abdominal wall, thereby injuring the vessels. Another factor that may contribute to the risk of injury is the use of large diameter trocar. Consequently, for this and other reasons, the surgeon should use the smallest trocar necessary for performance of the procedure.
Management
Superficial inferior epigastric artery lacerations usually respond to expectant management. Rotation of the cannula to a position where compression is possible is also helpful. Rarely is a suture necessary.
We have found that the use of a straight suture passer, is most useful for the ligation of lacerated deep inferior epigastric vessels. A number of other devices and techniques have been introduced that facilitate the accomplishment of this task. To summarize, the trocar and cannula are removed. Then, under laparoscopic visualization, and using a ligature carrier, a ligature is placed through the incision and directed laterally and inferiorly, where it is held by a grasping forceps. The ligature carrier is removed and subsequently passed through the incision again, without a suture, but this time medial and inferior to the lacerated vessels. The suture is threaded into the carrier from within the peritoneal cavity, and is then externalized and tied. For small incisions, narrower than the diameter of the surgeon’s finger, the knot may be tightened with a knot manipulator.
There are other, less uniformly successful methods for attaining hemostasis from a lacerated deep inferior epigastric vessel. The most obvious is the placement of large, through- and-through mattress sutures. These are usually removed about 48 hours later. Electrodesiccation may be successful. Either a unipolar or bipolar grasping forceps is passed through another ancillary cannula taking care to identify, grasp, and adequately desiccate the vessel. Either continuous or “blended” current is used at appropriate power outputs for the machine and the electrode. Another method that has enjoyed some success is temporary compression with the balloon of a Foley’s catheter, passed through the incision into the peritoneal cavity, then secured and tightened externally with a clamp. While some suggest that the balloon should be left in place for 24 hours, the delicate channel may be damaged by the clamp, making it impossible to deflate the balloon. For this reason, we not recommend this option.
Intraperitoneal Vessel Injury
The bleeding may result from inadvertent entry into a vessel failure of a specific occlusive technique, or human error in the application of the selected technique. Furthermore, in addition to the problem of delayed hemorrhage inherent in transection of arteries, there may be further delay in diagnosis at laparoscopy because of the restricted visual field and the temporary occlusive pressure exerted by the CO2 within the peritoneal cavity.
Diagnosis
During laparoscopy inadvertent division of an artery or vein will usually become immediately self-evident. However, in some instances, transected arteries will go into spasm only to begin bleeding minutes to hours later, an event that may temporarily go unnoticed due to the limited field of view presented by the laparoscope. Consequently, at the end of the procedure, all areas of dissection should be carefully examined. In addition, the CO2 should be vented, decreasing the intraperitoneal pressure to about 5 mm Hg, allowing recognition of vessels occluded by the higher pressure.
Prevention
Attention to meticulous technique is at least as important in laparoscopically directed surgery as it is for open or vaginal cases. During dissection, vessels should be identified and occluded prior to division, a task made simpler by the magnification afforded by the laparoscope. If suture is used to occlude a vessel it must be, of the appropriate caliber, positioned with an adequate pedicle, and tied snugly with a secure knot. Electrosurgery if used should be applied in the appropriate waveform and power density and for a time adequate to allow for sufficient tissue desiccation. Clips should be of a size appropriate for the vessel and they must be applied in a secure fashion, also with an adequate pedicle of tissue. Care should be exercised to avoid manipulation of pedicles secured with clips or suture; as such trauma could adversely affect the security of the closure. When linear stapling devices are employed, the appropriate staple size should be selected and the tissue encompassed in the staple line should be of uniform thickness. Failure to maintain relatively uniform tissue thickness may result in inadequate compression of blood vessels that course through the thinner areas of the pedicle.
Management
Transected vessels should be secured immediately. If electrosurgical desiccation is used to maintain or achieve hemostasis, the use of a serial ammeter is useful to demonstrate the endpoint of energy application. There is evidence that artery larger in diameter than 3 mm are less reliably occluded with desiccation than are those 3 mm or less. Care must be exerted to avoid blind clamping and electrosurgical desiccation, even with bipolar instruments, especially when less than 1 cm from ureter or bowel. When a vessel is in such a location, it is usually preferable to secure it with a clip.
Identification of small vessel bleeding and ooze is often facilitated by the use of copious irrigation and even underwater examination. Capillary ooze may be managed with higher voltage fulguration currents using electrodes with a bulbous tip. When using electrosurgery for this purpose, the use of electrolyte- containing solutions should be avoided, as they disperse current, rendering the technique ineffective. Instead the low viscosity fluids like glycine are recommended as, in addition to being nonconductive, they may facilitate localization of the vessels.
Gastrointestinal Complications
Following laparoscopy, it is not uncommon for the patient to experience nausea. However, in some instances the problem becomes severe. Gastrointestinal viscera potentially injured during the performance of gynecologic laparoscopy include the stomach, the small bowel, and the colon.
Insufflation Needle Injuries
Needle entry into the stomach almost invariably happens in the presence of gastric distention. While this may occur secondary to aerophagia, the complication is frequently related to difficult or improper intubation or to the use of mask induction with an inhalation anesthetic. Mechanical entry into large or small bowel may occur in any instance, but is up to 10 times more common when laparoscopy is performed on patients with previous intraperitoneal inflammation or abdominal surgery. In such instances, loops of intestine can adhere to the abdominal wall under the insertion site. Perforation may also occur following an overly aggressive attempt to insert the insufflation needle.
Recognition
Recognition of gastric entry by the insufflation needle may follow identification of any or all of the signs of extraperitoneal entry, including increased filling pressure, asymmetric distension of the peritoneal cavity, or the aspiration of gastric particulate matter through the lumen of the needle. However, the hollow, capacious nature of the stomach may allow the initial insufflation pressure to remain normal. Unfortunately, in some instances, the problem is not identified until the trocar is inserted and the gastric mucosa identified by direct vision. Recognition of bowel entry usually follows observation of the signs described above for gastric injury, with the addition of feculent odor to the list of findings. Prevention of insufflation needle injury to the gastrointestinal tract is important because such measures largely eliminate the risk of more sinister trocar trauma. Gastric perforation can largely be eliminated with the selective use of preoperative oral or nasogastric suction. The surgeon should request that this be performed if there has been difficulty with intubation or when the needle is intentionally inserted near to the stomach in the left upper quadrant.
Many have suggested that open laparoscopy is the most appropriate and effective way to reduce the incidence of intestinal injury in a patient at risk because of previous lower abdominal surgery. However, there are no studies that prove this to be the case. Indeed, there exists evidence that open laparoscopy is itself associated with intestinal injury. Consequently, many surgeons have suggested the use of left upper quadrant insertion with a properly decompressed stomach.
Although not strictly a prophylactic measure, the routine use of preoperative mechanical bowel preparation, at least in selected, high-risk cases, will diminish the need for laparotomy and/ or colostomy if large bowel entry occurs.
Management
The management of any trauma to the gastrointestinal tract depends in part upon the nature of the injury and in part upon the organ(s) involved. In general, insufflation needle punctures that have not resulted in a defect significantly larger than their diameter may be handled expectantly. Larger defects should be repaired or resected, by laparoscopic or a laparotomy based technique, depending upon extent of the lesion.
If, following insertion of an insufflation needle, particulate debris are identified, the needle should be left in place and an alternate insertion site identified, such as the left upper quadrant. If the insufflation needle possesses a removable obturator, a narrow caliber optical fiber or laparoscope may be passed to evaluate the location of the tip and to aid in later identification of the puncture site. Immediately following successful entry into the peritoneal cavity, the site of injury is identified. Unless significant injury or bleeding is identified, the situation may be handled expectantly. If there is unexpected extension of the laceration, it should be managed similarly to a trocar injury.
Trocar Injuries
During access technique damage caused by sharp trocar penetration is usually more serious than when needle injury occurs. Most often, the injury is created by the primary trocar because of its blind insertion. However, inadequate attention paid to the insertion of ancillary cannulas may also result in visceral injury.
Diagnosis
If a primary trocar penetrates bowel, the diagnosis is usually made when the surgeon visualizes the mucosal lining of the gastrointestinal structure following insertion of the laparoscope. If large bowel is entered, feculent odor may be noted. However, in some instances, the injury may not immediately be recognized as the cannula may not stay within, or it may pass through, the lumen and out the other side of the viscus. Such injuries usually occur when a single loop of bowel is adhered to the anterior abdominal wall near to the entry point. Consequently, it is important at the end of the procedure to directly view the removal of the primary cannula, either through the cannula itself or via an ancillary port. Routine direct visualization of primary port incisional closure will facilitate the accomplishment of this task. Unfortunately, the injury may go unrecognized until it presents postoperatively as peritonitis, abscess, enterocutaneous fistula, or death.
Prevention
The following measures were reported to reduce the incidence of trocar injuries:
• Disposable laparoscopes are usually sharper. They require less force to insert and thus there is less chance of compressing the trocar against the bowel or blood vessels.
• Some manufacturers provide a plastic sheath which springs and cover the sharp edge of the trocar after insertion. Safety shields will not prevent injury, however, in case of bowel adhesions.
• The use of ultrasound to “map” the abdominal wall for safe entry area is recommended especially when adhesions are present.
• The smaller 5 mm cannula is safer as it requires less pressure to insert. Equipped with a camera it allows safe placement of the larger cannula under vision.
• Hasson described an open surgical approach to placement of the cannula thus reducing the risk of perforation by the blind closed technique.
• Before the conclusion of surgery, a thorough search for bowel injuries must be performed as delay in recognition of such injury can be catastrophic. Thus review of the video tapes can ascertain if safety measures were taken during this critical part of the procedure.
Despite the widespread use of retractable trocars or safety sheaths, injury to bowel or other structures may occur. As stated above, many employ, routinely or selectively, the concept of “open” laparoscopy, where the peritoneal cavity is entered directly via an infra-or intraumbilical incision. Despite the apparent virtues of this approach, bowel entry may still occur. An alternative approach, especially when entering an abdomen with previous laparotomy scars, is the insertion of a narrow caliber cannula in the left upper quadrant following decompression of the stomach. It is unusual for a patient to have had previous surgery in this location. Following placement of the cannula, usually just below the costal margin in the midclavicular line, a narrow diameter laparoscope may be passed, allowing a direct view of the abdominal wall under the umbilicus or other planned site of insertion. If necessary, the small laparoscope may be used to direct the dissection of intestine from under the insertion site. This approach gains additional value with the introduction of a fiber laparoscope small enough to fit through the lumen of an insufflation needle.
Stomach injuries most frequently occur when there has been difficulty in intubation, and may be more common following left upper quadrant insertion if the stomach has not previously been decompressed. Consequently, liberal use of oral or nasogastric decompression will likely reduce the incidence of trocar injury to the stomach.
The most common cause of bowel injuries usually is when the intestine is adherent to the abdominal wall under the site of trocar insertion. Adherence is usually secondary to previous surgery. Consequently, in such patients open laparoscopy or left upper quadrant entry may be used. Preoperative mechanical bowel preparation should be employed in high-risk patients to facilitate repair of colonic defects without the need to perform a laparotomy.
Management
Trocar injuries to small bowels require repair. If it can be ascertained that the injury is isolated, and if the operator is capable, the lesion may be sutured under laparoscopic guidance with a double layer of running 2-0 or 3-0 synthetic absorbable suture. Extensive lesions may require resection and reanastomosis. In well trained and experienced hand, this may be performed under laparoscopic direction. However, in most instances, laparotomy will be required. Regardless of the method of repair, copious irrigation should be employed and the patient admitted for postoperative observation. The patient is kept without oral intake and nasogastric decompression should be liberally used at the discretion of the surgeon.
If the injury is to the sigmoid colon, primary repair may be attempted if the bowel has been mechanically prepared preoperatively. Otherwise, colostomy should be considered, with the possible exception of ascending colon lesions. If uncertainty exists regarding the extent of injury, laparotomy is always indicated.
