Vascular injury at laparoscopy: a guide to management

Abstract

Vascular laparoscopic injuries are rare (0.2/1000), however, they are associated with 6-13% morbidity and mortality. Commonest sites for catastrophic haemorrhage are the right iliac vessels, inferior vena cava and less commonly the abdominal aorta. The injuries commonly occur at entry using a Veress needle or insertion of trocars. These risks are inherent to all laparoscopic surgery. A systematic approach for managing these includes prompt recognition, communication within the operative team, immediate resuscitation and specific operative strategies for the control of vascular haemorrhage based on the location and severity of the injury. Major vascular injuries may require midline laparotomy and vascular surgeons. 1:1:1 resuscitation and adjunct haemostatic agents may help. Major vascular injury is a rare but a potentially fatal complication. We propose a skills and drills approach to improve outcomes. We also propose a practical algorithms for the management of haemorrhage in the acute situation.

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

“…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 ].…”

“…Every fourth MVI occurs during diagnostic procedures [ 15 , 18 ], whereas lymphadenectomy and hysterectomy are associated with the highest risk for MVI [ 18 – 21 ]. While injuries to the abdominal vessels can be commonly managed laparoscopically, the repair of the great retroperitoneal vessels usually requires (in at least 88% of cases [ 21 ]) an immediate laparotomy [ 3 , 19 , 172 ].…”

“…Major vascular injuries (MVI) are associated with a 6–31% mortality rate [ 16 , 19 , 20 , 172 ] and responsible for 74–82% of all laparoscopy-related deaths [ 23 , 27 , 52 ]. Venous injuries are more frequently lethal than the arterial ones [ 18 ].…”

Clinical Perspective Concerning Abdominal Entry Techniques

“…The most common vascular injuries are to the vessels of the anterior abdominal wall [28]. In most patients, the inferior epigastric artery runs 5 cm lateral to the umbilicus [29].…”

Major Intraoperative Injuries During Hysterectomy: Prevention, Recognition and Management

“…These steps should be rehearsed in a low-stress environment (dry rehearsal in the operating room, porcine laboratory) on a regular basis as such vascular complications are rare but potentially fatal. 4 In their articles, Dr. Hoffman and Dr. Khalife cite the value of surgical volume, which is a surrogate measure for the surgeon's experience. 5 For low-volume surgeons, having a mentor if available is arguably the most important resource when complications are encountered.…”