News for Your Practice

Major vascular injury during laparoscopy: Pearls to cope

OBG Manag. 2008 April;20(4):62-68

References

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3. Muzii L, Bellati F, Zullo MA, Manci N, Angioli R, Panici PB. Mechanical bowel preparation before gynecologic laparoscopy: a randomized, single-blind, controlled trial. Fertil Steril. 2006;85:689-693.

4. Polyzos D, Papadopoulos N, Chapman L, et al. Where is the aorta? Is it worth palpating the aorta prior to laparoscopy? Acta Obstet Gynaecol Scand. 2007;86:235-239.

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6. Sriprasad S, Yu DF, Muir GH, Poulsen J, Sidhu PS. Positional anatomy of vessels that may be damaged at laparoscopy: new access criteria based on CT and ultrasonography to avoid vascular injury. J Endourol. 2006;20:498-503.

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8. Reich H, Ribeiro SC, Rasmussen C, Rosenberg J, Vidali A. High-pressure trocar insertion technique. J Soc Laparoendosc Surg. 1999;3:45-48.

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13. Hanney RM, Carmalt HL, Merrett N, Tait N. Use of the Hasson cannula producing major vascular injury at laparoscopy. Surg Endosc. 1999;13:1238-1240.

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Control the bleeding

Apply pressure in an atraumatic fashion. Call for vascular instruments and a second suction device.

Control the bleeding digitally at first, followed by proximal and distal occlusion. Never use traumatic clamps because of the high rate of intimal damage associated with thrombi and secondary occlusion. Clips, staplers, or electrosurgery may cause vascular occlusion, thrombi, claudication, or lower-extremity edema.

Debride the blood and clots and identify the defect.

How common is major vascular injury?

The frequency of MVI is thought to range from one in every 1,000 to one in every 10,000 gynecologic laparoscopic procedures.^17-19 In a large review of 29,966 gynecologic laparoscopies, the risk of MVI was 0.02%.²

Repair the laceration

Polypropylene (6-0) can be used to close the defect in an interrupted fashion with sutures running parallel to the line of the vascular structure.

A vascular surgeon can be very helpful in the repair of vessels and should be consulted in the event of MVI. If extensive intimal damage has occurred, primary closure may not be possible and the vascular surgeon may perform a graft angioplasty repair or place a short interposition graft. Proximal and distal control is achieved by applying atraumatic clamps proximal and distal to the injury. Intravenous anticoagulation (5,000 U of heparin) is common but not mandatory. A longitudinal arteriotomy is extended, and any areas of thrombi are removed. The damaged intima is endarterectomized, and tacking sutures, using 7-0 Prolene, can be used to prevent propagation of the intimal dissection. Last, a venous or synthetic patch is sewn into place using 6-0 Prolene.

Patients typically remain on aspirin for 3 to 6 weeks.

CASE Resolved

Sophia’s procedure is immediately converted to a midline vertical laparotomy, a vascular surgery consult is obtained, and exploration reveals a 5-mm defect in the right common iliac artery consistent with an extended Veress needle injury. A vascular patch is used for the vessel repair, and the patient is discharged 4 days later in stable condition. She takes clopidogrel bisulfate (Plavix) for 6 weeks and has no lower-limb compromise.