by Carlos A. Suarez MD, FACS
INTRODUCTION
The rapid adoption of minimally invasive surgical techniques by surgeons representing many specialties and varying degrees of expertise has introduced added challenges to reduce the rate of procedure-related complications.
Gaining access to a body cavity prior to the laparoscopic era was not usually associated with serious or life-threatening complications. The establishment of pneumoperitoneum requires the introduction of a sharp insufflating needle or trocar. It is a purposeful stab wound which carries a very small but significant risk to the patient. It is during this beginning step that most vascular injuries in laparoscopy are encountered.
When analyzing the factors that contribute to these complications, it is this first step in the operation that must be made as safe as possible.
It is the aim of this chapter to alert the reader to potential hazards and to suggest methods and practices to minimize these often catastrophic events while offering patients all the benefits of the minimal access approach.
INCIDENCE
Vascular injuries in laparoscopic operations are extremely rare events. However, they contribute to the morbidity and mortality, particularly when compared to the open counterparts such as hernia repair, appendectomy, colon resection and sterilization procedures. The frequency of these complications has been reported to occur in 1 to 7/10,000 cases.1-6
SITES OF INJURY
The distal abdominal aorta is at greatest risk of injury followed by combined iliac artery and vein injuries.7-10 However, other vessels such as the inferior epigastric artery, iliac veins and adnexal vessels can also be injured and bleed profusely.1,2,11-13
These sites are those most often injured as the result of insufflating needles or trocars in the course of diagnostic or operative procedures. With more complex dissections of the cavities, other vessels are exposed to injury.
Halasz found that 7% of cadavers he dissected who had undergone open cholecystectomy had the right hepatic artery ligated.14 Injury to the right hepatic or common hepatic artery often accompanies common bile duct injury.15, 16 Although it is true that most patients tolerate ligation of the common hepatic or the right hepatic artery, occasionally it results in hepatic necrosis, especially if there coexists portal hypertension or portal vein thrombosis.17
THE ANATOMICAL ROAD MAP
Laparoscopic methods deprive the operator of the ability to palpate the surgical field for pulses and other clues to locate important vascular structures. He/she must be guided by topographic features and other anatomical relationships to avoid these vessels. Because of this we must take a new look at anatomic relationships and extrapolate this information to a mental three dimensional image (Figure 1, Figure 2).
It is worthwhile to review pre-operative imaging studies such as CT or MRI studies to understand the relationship of the target organ or pathologic process to these vascular structures. There are many time-proven landmarks that should come to mind during the conduct of these procedures to help identify these structures (Table 1).
PREVENTION OF VASCULAR COMPLICATIONS
“A Stitch in Time Saves Nine”
This popular proverb is certainly true when managing surgical complications. It is far better for the patient as well as the operator to avoid having a complication in the first place than to deal with a complication after it occurs. Although the goal for the surgeon is to experience no complications, reality has dictated otherwise. It is the intent to cause no harm. Certain basic principles must be followed in order to attain that goal.
Almost all the reported major vascular injuries reviewed by the author were the result of the blind passage of an insufflation needle or a trocar. Only two reports mentioned other causes, such as the skin knife or a tear as a result of adhesiolysis. Mintz reported the largest series of complications in laparoscopy. Of the 100,000 cases he analyzed, he found 34 instances of major vascular injuries31 caused by the insufflation needle or the initial trocar. He also reported 12 cases of epigastric arterial injuries also caused by these two instruments. These cases required laparotomy to control the hemorrhage.1
OPEN vs. CLOSED LAPAROSCOPY
Serious mishaps which occur during blind insufflation prompted Hasson to introduce an “open” technique to create a pneumoperitoneum. This consists of placing a blunt tip cannula through a small umbilical cutdown. This technique virtually eliminates inadvertent injury to a major vessel during the establishment of pneumoperitoneum.
It is the author’s opinion that, even though the use of the pneumoperitoneum needle is very popular and the accepted way to perform laparoscopic procedures, it does carry a small but significant risk of vascular injury and thus he favors the Hasson technique.18 This recommendation has particular relevance to physicians who are performing laparoscopy in a setting in which the expertise needed to repair vascular injuries is not readily available. Even though open laparoscopy seems to offer a wider margin of safety in avoiding vascular injuries, most laparoscopists prefer the use of insufflating needles to attain pneumoperitoneum. A survey by the American Association of Gynecologic Laparoscopists noted that only 4% of those questioned used the open Hasson technique.19 Open laparoscopy has its own complications. It is possible to perforate the bowel, but this complication is seldom encountered and it is not usually life-threatening unless the perforation goes undetected. Penfield reported on the experience of 18 board-certified gynecological laparoscopists who used open laparoscopy and, in 10,840 cases, there were only 6 instances of bowel perforation and no cases of major vascular injury.20
EQUIPMENT
Laparoscopy is an image-dependent process. As such, the operator must demand the best video picture possible. Reliable, high resolution cameras and monitors with excellent color reproduction are presently available. Foggy, distorted images can lead to mis-identification of structures. High resolution video cameras and monitors enhance the safety of the procedures by providing the surgical team with a clear image and excellent color reproduction. Additionally, three-dimensional equipment is available which will help with enhancing the hand-eye coordination of the operator. A laparoscope that can offer a 30° or a 45° view may give a better look at certain critical areas during dissection.
There are also disposable trocars available that allow the surgeon to see the tissue layers as they are traversed during insertion. These instruments may decrease the likelihood of inadvertent vascular perforation (Visiport®, US Surgical Corp., Optiview®, Ethicon Endosurgery).
The laparoscopic team must be proficient in trouble-shooting imaging problems when they arise. A complex procedure can be made more difficult and dangerous with a less-than-ideal video image. It behooves the surgeon to proceed only when he/she feels secure that the equipment is functioning well.21
INSTRUMENTS
During the infancy of operative laparoscopy, there was a lack of appropriate instrumentation for cutting, blunt dissection and retraction. Many of the needs for these specific tasks have been fulfilled by innovative instruments,22, 23 so choose the instruments wisely. Each surgical task must be carried out with precision and care. The needles and trocars should be well maintained and sharp. Dull trocars require more force to introduce and this leads to poor control of the depth of insertion.24 Some instruments such as ultrasound probes will help identify major vessels but, as of today, they are not in wide use and most surgeons have yet to acquire the skills to use them.25
As of this writing, there are no laparoscopic instruments specifically designed to create vascular anastomoses entirely laparoscopically. There are now staplers designed for creation of vascular anastomoses which could be adapted to endoscopic work (US Surgical Corp).
MASTERY OF THE TECHNIQUE
Every procedure has its nuances. Those attempting new techniques must make an effort to attain the highest level of coordination and familiarity possible before being offered to patients in an unsupervised setting. Participating as an assistant in procedures being performed by more experienced individuals has also proven very valuable as a way to gain experience. Patient selection is also important in gaining technical proficiency. It is common sense to seek the least complicated cases with ideal patient weight and little or no previous surgical procedures early in the learning curve. An intimate knowledge of tissue planes is essential. These planes offer the least resistance to dissection and are usually very avascular, allowing the surgeon to maintain a clear view of the operative field.
Cali’s article offers an excellent overview of the general technique of laparoscopy which should be of use to those beginning their experience in the field.26
MANAGEMENT OF VASCULAR INJURIES
Vascular injuries which are encountered in laparoscopic procedures are stab wounds or lacerations. It is a form of penetrating vascular trauma and thus should be managed according to well-established surgical principles from our experience in repairing other types of penetrating vascular injuries.
Anyone doing operative laparoscopy should have a basic knowledge in the recognition and control of bleeding from large arteries and veins. This is particularly relevant to those operating in areas where surgeons with skills in vascular surgery are not readily available. Some salient points will be reviewed.
GENERAL PRINCIPLES OF VASCULAR REPAIRS
-Once a potentially serious vascular complication
is suspected, immediate conversion to an open
procedure must be considered.
- Direct compression of the bleeding site is the
quickest and safest way to gain initial control of
blood loss.
This holds particularly true of venous injuries (Figure 3, Figure 4, Figure 5).
- If the patient exhibits unstable vital signs, ade-
quate volume replacement, while controlling the
blood loss, must take place prior to attempting
repair of the injury.
- If the bleeding site is difficult to see, early and
wide exposure of the site and surrounding struc-
tures must be obtained. Inadequate exposure
may lead to difficulties in controlling the injured
vessel and additional blood loss and deterioration
of vital signs.
- The vessel wall must be repaired with precise
intima to intima apposition without tension.
- Venous injuries may be best handled by ligation
rather than suture repair if the patient is unstable.
- If ligation of a vessel does not lead to ischemia,
definitive repair may be postponed until the
patient is stable and/or when the appropriate vas-
cular surgeon is available.
THE RETROPERITONEAL HEMATOMA
When a retroperitoneal hematoma is noted at any time during the course of a procedure, the surgeon may be tempted simply to observe it. This may prove fatal to the outcome of any significant great vessel injury. If there is any possibility that the hematoma has formed as a result of a puncture in a major vessel, it should be explored, and if an injury is found, it should be repaired appropriately.27 These hematomas may expand imperceptibly until signs and symptoms of dangerously large volume losses are manifest. At this point, all measures are directed to life-saving maneuvers.
GAS EMBOLISM
Pneumoperitoneum, or more correctly stated, carboperitoneum, requires that the abdominal cavity be insufflated with positive pressure. This pressure ranges from 10 mm Hg to 15 mm Hg. When there is a communication between the cavity and the lumen of a large vein, if the higher intra-cavitary pressure exceeds the intravenous pressure, a large volume of gas can enter the circulation, interfere with right ventricular output and precipitate complete circulatory collapse.28 There are classic signs of gas embolism which include a machinery-like murmur, and precipitous drop in blood pressure and O2 saturation. If gas embolism is suspected, the insufflation must be immediately stopped, and the cavity vented. The patient should then be placed in Trendelenberg position and if possible, in left lateral decubitus. This allows the right ventricular gas to float to the apex and clear the pulmonary outflow tract.29 It is also suggested that a central venous line be inserted, advanced to the right ventricle and the gas bubbles aspirated.30
VASCULAR INSTRUMENTATION AND SUTURES
It is advisable to become familiar with the basic vascular clamps and needle drivers and have a basic instrument tray nearby for use in emergency laparotomy. Vascular clamps must be of adequate size to occlude the injured vessel and atraumatic to avoid intimal crush injury. Peripheral DeBakey clamps are ideal for controlling the iliac vessels without causing a crush injury which will later result in thrombosis. Larger clamps are available for aortic occlusion. These clamps can be applied with minimum dissection of aortic wall. Vascular forceps which are designed to handle the vascular walls with little trauma, are also available. The most common types include those designed by Dr. DeBakey. Vascular sutures are on fine atraumatic needles and are also very important in repairing vascular tissues by minimizing tissue trauma and decreasing bleeding from a newly created anastomosis.
References
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