Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications

Abstract

OBJECTIVE: To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications. DATA SOURCES: A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted. METHODS OF STUDY SELECTION: One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts. TABULATION, INTEGRATION, AND RESULTS: Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08–0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03–0.05), comprising 48% (95% CI 40–55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76–89), and the remainder occurred during surgical dissection (18%, 95% CI 11–24). Most injuries were recognized intraoperatively (93%, 95% CI 87–100), and approximately half (55%, 95% CI 46–63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000–0.004). CONCLUSION: The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review.

“…The perforation of abdominal wall vessels (inferior and superficial epigastric arteries and muscular perforating vessels) by secondary trocars is reported in 0.3% to 2.5% of procedures [ 9 , 21 , 171 ]. The inferior epigastric vessels are the most affected, comprising 48% (95% CI: 40–55) of all vascular injuries [ 21 ]. The use of sharp pyramidal trocars elevates this risk of abdominal wall vessel injury [ 9 ].…”

“…Injuries to large retroperitoneal (aorta, vena cava and the iliac) vessels (usually summarized as “MVI”) occur in 0.2% to 1.0% of procedures, with the most quoted rate of 0.5% [ 9 , 14 , 19 , 172 ]. Amongst large retroperitoneal vessels, the right iliac arteries are affected in 41–48% of cases, followed by the right iliac veins (38%), left iliac veins (29%), aorta (13–25%), inferior vena cava (6–11%) and mesenteric vessels (6–17%) [ 18 – 21 , 173 ]. In 50–83% of cases, MVI occur during laparoscopic entry [ 14 – 21 ].…”

“…Amongst large retroperitoneal vessels, the right iliac arteries are affected in 41–48% of cases, followed by the right iliac veins (38%), left iliac veins (29%), aorta (13–25%), inferior vena cava (6–11%) and mesenteric vessels (6–17%) [ 18 – 21 , 173 ]. In 50–83% of cases, MVI occur during laparoscopic entry [ 14 – 21 ]. VN is causative for MVI in 6–46%, trocars in 54–83% [ 9 , 14 , 16 – 18 , 26 , 27 ], and scalpel (skin incision) in up to 6% of cases [ 174 ].…”

“…Very low BMI and periumbilical adhesions elevate the risk for MVI at the entry stage [ 173 ]. In 10–20% of cases, MVI is caused by ESDs, followed by dissecting instruments or stapling devices [ 18 – 21 ]. Every fourth MVI occurs during diagnostic procedures [ 15 , 18 ], whereas lymphadenectomy and hysterectomy are associated with the highest risk for MVI [ 18 – 21 ].…”

“…sterilization). This is because half of the complications occur during laparoscopic entry [ 9 , 10 , 15 – 17 , 21 , 25 – 27 ]. For some exclusively laparoscopy-related incidents, e.g.…”