Major vessels' injury during laparoscopy are rare, but are the second cause of death in minimal invasive procedures. This is one major reason why alternatives to surgery should be considered when treatment decision time comes. All surgeons have "nightmares" after such a severe complication, or anxiety predicting that some day they will have to deal with a major vascular injury.
I personally had a major vessel complication during a minimal invasive surgery, and I do not wish to have another. After that event, I "dived" in the literature to find out more about this complication, how to deal with it and most of all how to prevent it. There are not much reports of vascular injury in the literature. However I found one interesting review paper published by Victoria Asfour et al from the UK in the Journal of Obstetrics and Gynaecology in 2018, aiming at giving a guide to manage a vascular injury during laparoscopy. I would like to make some comments about this issue to increase your willing to read such work.
Additionally, I strongly advise you to watch the video lecture from Prof. Dr. Thaveau in the WebSurg website, entitled "Vascular complications: what to do and what to know in case of arterial or venous injuries".
According to the author, 75% of vascular injuries occur at entry (and can be immediately fatal) and 25% during dissection (blunt, sharp, or with energy instruments). The global incidence is about 0,2/1000 procedures, and mortality has been reported up to 12-23%. This means that although vascular injuries are rare, all surgeons must be aware of their possibility, must think on how to avoid them and what to do if a vascular injury occur.
About 75% of the vascular injuries occur at entry.
They are due to the Veress needle or trocar placement.
At entry, vascular injuries can be due to the Veress needle, or trocar placement. Iliac artery is the most frequently injured vessel on the right, and the iliac vein on the left. Also the aorta and inferior vena cava (IVC) can be injured during abdominal cavity entry. About 70% of vascular injuries occur on the right side, probably because of the trocars' trajectory during placement as the surgeon stands on the left side of the patient in many procedures. The umbilicus is the preferred location for both the Veress needle and first trocar placement, which justifies the bifurcation of both the aorta and IVC as the preferred local of injury. Surgeons must not forget that in a thin patient only a few centimetres separate the umbilicus from those major vessels. Additionally, multi-gravid patients and elderly patients have an increased risk of vascular injury because a rapid an uncontrolled entry can occur.
What can we do to prevent vascular injuries at entry (Victoria Asfour et al.)?
The safest point to Veress needle placement is in the left upper quadrant in mid clavicular line 3 cm bellow costal margin (Palmer's point).
Placing the trocars at a 45º angle in a supine position can reduce the risk.
However, in the obese patient a 90º is safer.
Inserting lateral trocars trying to avoid epigastric vessels can lead to iliac vessels injury.
Open technique has lower vascular injury rate than close access technique.
Are optical trocars safer? Probably yes...
Secondary ports are placed under camera visualisation, so a major vascular injury must not happen at this time. Surgeons must remember that minor vessels of the omentum and mesentery can be injured, as also the epigastric vessels. Those can ooze slowly and be missed intraoperatively, and a severe hematoma and hemoperitoneum can arise.
Placing the trocars at a 45º angle can reduce the risk.
Is there blood in the Veress needle? is there blood in the abdominal cavity at entry? Is there a retroperitoneal expanding hematoma? If yes...
Vascular injury alert! What am I going to do?
First you must ask yourself if you can identify where the bleeding is coming from. If yes, can you control it with direct pressure laparoscopically or an immediate laparotomy is mandatory? The fastest, simplest, and easiest way to achieve bleeding control is applying direct pressure on the bleeding point. This will eventually allow for patient resuscitation, will give you time to think and will give the operating room staff time to prepare for the vascular repair. Secondly, you must decide if it is an injury you can manage yourself, or if help is going to be needed. In my opinion, even if you can eventually repair it, you should always call for help. Fresh eyes and a "mind free of guilty" are going to be crucial to support your repairing decision and keep you calm in such a stressful situation. Staying calm and maintaining a constant dialogue with the anaesthesiologist and operating room staff, are mandatory during major vascular injury repair.
If a major vascular injury occurs, you should always call for help!
Who can help you? Who should you call for help? This third question should be addressed before any operation. Surgeons, anaesthesiologists and operating room staff must all be prepared to act immediately and according to the place where they are working.
Call for an experienced surgeon is an usual idea. But... Who has a solid and great experience in major vascular injury's repair? Is there any doctor who fulfils this criterion? Vascular injuries are rare which means that the majority of general surgeons do not have nor treat many vascular injuries during their working life. Vascular surgeons have great experience in controlled vascular surgery, experience in traumatic vascular injuries of the limbs, and experience in aortic aneurism rupture (most of the patients die). Ideally, there is not such surgeon with great experience in major vascular injuries during laparoscopy. There are, however, general surgeons and vascular surgeons with experience in several fields of vascular surgery that will give them the "know how" to manage a vascular injury. Although help from a vascular surgeon (if available) or a fellow general surgeon must be called, all surgeons must have a solid knowledge on basic surgical principles that will allow him to deal with these injuries.
Gaining experience from several fields of surgery is what will make you a surgeon capable of dealing with the majority of complications.
How to repair?
For vascular injury repair I strongly advise you to read the entire article and listen to the video lecture.
Link to article:
Link to video lecture:
Dr. Carlos Eduardo Costa Almeida
General Surgeon