Sixty-Four Cases of Major Vessel Injury Associated with Laparoscopic Surgery

Abstract

Abstract

Objective: This report is a sequel to an earlier study that described 31 major vascular injuries associated with laparoscopic procedures. The current study details the factors that are etiologically linked to this catastrophic complication and focuses on which patients are at the greatest risk for sustaining this kind of injury. Given that avoidance of major hemorrhage with its attendant secondary complications was a major reason for the compiling and organizing these data, the aforesaid comprises a significant portion of this article. Study Design: This retrospective cohort study described 68 lacerations sustained during laparoscopic entry and surgical dissection in 64 women. Materials and Methods: Records for women undergoing laparoscopic operations were obtained between 1995 and 2015 (20 years). Two time periods during which data was obtained were 1995–2003 and 2003–2015. Calculations were made based on: body mass index; specific vessel(s) injured; management; and collateral damage. Although other data reflecting blood loss, blood-product replacement, and time elapsed from injury to consultation were obtained, these were, at best, based on estimates. Accurate data were collected relative to phase of procedure when the injury happened (i.e., entry or operative). Results: Among 64 women, 68 major vascular lacerations were recorded. Overweight and obese patients sustained the great majority of injuries. All but 10/64 cases happened at the entry phase of the laparoscopy; 51/64 instances were caused by the trocar; 3 cases were attributed to the Veress needle; and 10 cases were caused by the operative dissection. The most frequently injured vessels were the common iliac arteries or veins; aortic and vena cava lacerations amounted to 13% of the total. The mortality rate was 20/64 or 31%. The first signs of injury and hemorrhage were found in the anesthesia records, with sudden tachycardia, acute drop in blood pressure, and precipitous falls in end tidal CO₂. Observing bleeding within the peritoneal cavity depended on the size of the entry wound made into the retroperitoneum and if the patient was in the Trendelenburg position, particularly a steep Trendelenburg position. The latter conditions resulted in massive retroperitoneal hematomas. The approximate mean blood loss, which was underestimated, ranged between 2500 and 3000 mL. Eleven patients lapsed into a pulseless electrocardiographic state or full-blown cardiac arrest. Coagulopathy was diagnosed in all 20 women who died and in an additional 11 survivors. Conclusions: Major vascular lacerations are an uncommon but peculiar risk with laparoscopy. Such injuries do not happen with laparotomies or vaginal-entry operations. The root causative factors etiologic to major vessel injury include: trocar/needle entry in the periumbilical location at a 90° angle; excessively deep thrusts with trocar/needle devices; and deviation to right or left of the midline during trocar/needle entry at the umbilical location. Major vessel injury during laparoscopic operations is a preventable calamity. (J GYNECOL SURG 32:73)