Vascular Trauma Secondary to Diagnostic and Therapeutic Procedures: Laparoscopy Paul T. McDonald, MD, LTC MC USA, Washington, DC Norman M. Rich, MD, FACS, COL MC USA, Washington, DC George J. Collins, Jr, MD, LTC MC USA, Washington, DC Charles A. Andersen, MD, LTC MC USA, Washington, DC Louis Kozloff, MD, MAJ MC USA, Washington, DC
The importance of identifying diagnostic and therapeutic procedures that may cause vascular injury has been emphasized in a previous report from our Service [I], Cardiac catheterization and angiography for peripheral vascular diseases account for the majority of iatrogenic vascular injuries, but these injuries generally do not cause massive hemorrhage. Injury to a major artery in an exposed operative field poses a threat of massive hemorrhage but is readily diagnosed, and bleeding can be easily controlled by pressure. However, injury to intraabdominal vessels by percutaneously introduced instruments may result in significant blood loss because of delayed recognition and treatment. Our recent experience with two cases of major vascular injury caused by laparoscopy prompted a review of this problem. Laparoscopy is a commonly used diagnostic and therapeutic procedure with low morbidity and mortality. Paterson and Grimwade [2] in a personal series of 600 inpatient laparoscopic sterilizations had no mortality. Minor morbidity consisted of two cases of colonic perforation requiring no treatment, one case of bleeding from a site of tubal division, one case of inconsequential hypotension, and six cases of mild postoperative abdominal pain. None of these cases required laparotomy. They reviewed the English language literature and found only two deaths in 10,193 gynecologic laparoscopies. There were 34
From the Peripheral Vascular Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Armv or the Deoartment of Defense. Reprik ~equests&ould be addressed to Paul T. McDonald, MD. LTC MC USA, Peripheral Vascular Surgery Service. Walter Reed Army Medical Center, Washington, DC 20012.
vohnne
100, May w70
deaths in 72,029 nongynecologic laparoscopies, 30 of which were associated with significant intraperitoneal hemorrhage or bile peritonitis due to liver injury. Thompson and Wheeless [3] reported 666 outpatient laparoscopic sterilizations. Fifteen cases of minor bleeding required treatment with coagulation through the laparoscope. Laparotomy was required in six cases including two instances of burned bowel, one bleeding adhesion, and three mesosalpinx hemorrhages. Other complications included seven trocar site burns, five uterine perforations, one pelvic abscess, and one late intraabdominal hemorrhage not requiring laparotomy. There were no major vascular injuries and no fatalities. Overall, complications requiring laparotomy occurred in only 0.9 per cent. Complications not related to hemorrhage may be bizarre, such as dehiscence of the laparoscopy site [4], or tragic, such as unrecognized ureteral transection (561. Other problems include perforated urinary bladder [7], gastrointestinal injuries [8], electrosurgical hazards [9,10], and insufflation of gas into a wrong space causing emphysema or cardiovascular changes [II]. (Table I.) Minor bleeding may occur from skin incisions or from other parts of the abdominal wall and responds to pressure or electrocoagulation. Injuries to an epigastric vessel resulting in hemorrhage or hematoma formation require incision, evacuation of clot, and suture ligation [12]. Injury to mesenteric or omental vessels may require laparotomy and suture ligation if bleeding does not stop spontaneously [11,13]. Levinson (121 recommended initial observation for retroperitoneal hemorrhage with laparotomy as necessary, but did not cite case experience. Others [7,11,13] have alluded to potential problems of major
651
McDonald
TABLE
I
et al
Complications of Gynecologic Laparoscopy
Pneumoperltoneum needle’ Gas insuttlatlon
Trocar Electrocoagulatlon’ Infection Miscellaneous
l
Improper intubation, cardiac arrest. Perforation of bowel, stomach, uterus, liver, spleen, vessels. Wrong space with subcutaneous, extraperitoneal, retroperitoneal, or mesenteric emphysema; diaphragm displacement with respiratory compromise; absorption with hypercarbia, arrhythmia. Perforations of viscera, vessels. Burns of skin, viscera or delayed bowel perforations; bleeding from divided mesosalpinx. Wound, salpingitis, pelvic abscess. Wound dehiscence; ureteral transection; mesenteric hematoma; skin, adhesion, or epigastric artery bleeding.
Most common problems.
vascular injuries, but little first hand information is available, The proximity of the aorta and its branches and the vena cava and its tributaries to other structures that have been injured during laparoscopy makes it likely that they will also be injured occasionally. Similar procedures such as peritoneoscopy and peritoneal lavage for dialysis or diagnosis have resulted in large vessel injuries. Casajus et al [15] reported successful repair of a laceration of the right iliac artery caused by a peritoneal dialysis trocar. Vilardell, Seres, and Marti-Vicente [16] in a survey of complications of peritoneoscopy noted that in addition to other common complications, aortic and venous injury had also occurred. Day and White [I 71 reported the fatality of a child due to retroperitoneal vascular injury by a trocar used for insertion of a peritoneal dialysis catheter. The paucity of reports of vascular injuries confirms their rarity. When they do occur, however, serious morbidity or death may result. Our recent experience with two near fatalities prompts
us to encourage each laparoscopist to be prepared for the possibility of major vascular injury. Case Reports Case I. AL, a thirty-two year old white female, gravida 3, para 3, abortus 0, delivered a normal 5 pound female baby two months prior to admission for elective sterilization by tubal cautery. She had no history of abdominal surgery or bleeding problems. Physical examination revealed no abdominal, back, or pelvic abnormalities. Peripheral pulses were intact, and the admission hematocrit was 39.6 per cent. The patient was anesthetized with intravenous thiopental for induction and intravenous fentanyl (Sublimaze@) with nitrous oxide and oxygen by mask for general anesthesia. Tubocurarine chloride and pancuronium bromide (Pavulone) were utilized for muscle relaxation, With the patient in a supine position, the bladder was emptied, the legs were placed in stirrups, and the perineum and abdomen were prepared and draped in a sterile manner. Towel clips were utilized to grasp the skin of the abdominal wall inferiorly and laterally to the umbilicus, and the abdominal wall was elevated. A 2 cm incision was made in the midline 2 cm below the umbilicus. A 16 gauge Touhey needle with obturator (Figure 1) was inserted through the intact fascia at a 45 degree angle toward the pelvis. The needle was gently rocked to and fro to check for free movement within the abdominal cavity. However, the needle did not move freely; the tip was fixed. It was withdrawn and inserted a second time. Blood oozed from the needle and it was again withdrawn. The patient’s vital signs were stable for 5 minutes, but the systolic blood pressure, which had been 120 mm Hg, precipitously decreased to unattainable levels, and abdominal expansion was noted. Ringer’s lactate solution, albumin, and 2 units of typed and cross-matched packed cells were infused rapidly, increasing the systolic blood pressure to 90 mm Hg as the abdomen was hastily opened in the midline. Approximately 3 units of clotted blood were present in the peritoneal
Figure 1. A 16 gauge Touhey needle is compared to a known lethal weapon, an ice pick. Inset shows needle diameter of almost 2 mm.
652
The American Journal of Surgery
Laparoscopy
cavity. Digital pressure partially controlled blood pulsating from an expanding retroperitoneal hematoma. With digital pressure on the aorta above and the common iliac arteries below, a laceration in the terminal aorta near the origin of the right iliac artery was identified and controlled. The blood pressure was restored to within normal limits. The terminal aorta and right common iliac and left common iliac arteries were mobilized and encircled with vascular tapes. After anticoagulation with 7,000 units of sodium heparin; vascular clamps were applied. (Figure 2.) The 3 mm hole in the aorta was repaired with continuous suture of 4-O Prolene@. Clamps and tapes were removed, and 70 mg of protamine sulfate was given to reverse the heparin effect. The retroperitoneum was closed and the abdominal cavity was inspected for other injuries. Bilateral partial salpingectomies were performed. A total of 3 units of packed red blood cells and 2 units of whole blood was required during the operation. Delayed primary wound closure was done on the fourth postoperative day. There were no postoperative complications. Peripheral pulses were normal at discharge and remained so during follow-up clinic visits over the ensuing year. Case II. MC, a twenty-one year old white nulliparous woman, was admitted to the hospital for evaluation of infertility with a suspected diagnosis of polycystic ovaries. She had no history of abdominal surgery or bleeding problems. Physical examination revealed no abnormalities other than bilaterally enlarged ovaries. Peripheral pulses were normal. The patient underwent general anesthesia and had a 16 gauge Touhey needle inserted for insufflation of carbon dioxide, as in case I. A drop of blood returned through the needle when the obturator was removed. The needle was withdrawn and vital signs were observed for several minutes. A second insertion was then made with the needle tip directed more caudally. Blood spontaneously returned from the needle; it was withdrawn, and vital signs were again observed. The blood pressure was normal for 3 minutes, then drifted from 120 to 90 mm Hg. The abdomen was hastily opened in the midline. After 1 minute blood pressure was unobtainable, but a thready pulse was maintained. Rapid infusion of Ringer’s lactate solution, albumin, and type 0 Rh-negative blood over 2 minutes raised the blood pressure to 50 mm Hg. Approximately 3 units of:ciotted blood were noted in the peritoneal cavity when the abdomen was opened. An expanding retroperitoneal hematoma was centered over the terminal aorta. Digital compression of the aorta and common iliac arteries controlled bleeding. However, each time pressure was eased enough to attempt dissection, venous blood welled into the field. Therefore, the t.erminal aorta, iliac arteries, inferior vena cava, and both iliac veins were controlled by pressure from sponges held in clamps. Upon opening the peritoneum, a through and through perforation of the right side of the aorta and a small tear in the vena cava were noted. In addition there was a through and through perforation of the right common iliac artery and a 1.5 cm rent in the left iliac vein as it passed
Volume 135, May 1976
under the right iliac artery. (Figure 3, left.) The arterial injuries were sequentially repaired by lateral suture technic with 5-O Prolene. After repair of the arterial injuries, the terminal aorta and iliac arteries were mobilized, and the lacerated left iliac vein and the vena cava were brought into view. The venous injuries were also repaired by lateral suture technic. There were no other intraabdominal injuries. The diagnosis of bilateral polycystic ovaries was confirmed, and bilateral wedge biopsies were obtained. Four units of type 0, Rh-negative blood were given to replace the estimated blood loss of 3,000 cc. There were no postoperative complications. Delayed primary closure of the wound was done on the fourth postoperative day. Six months after operation peripheral pulses were normal. Comments Recognized complications,
conditions causing increased such as a history of previous
risk for
abdominal surgery or bleeding tendency, were not present in either ease. The technic of insertion of the insufflation needle was thought to be the same as that
Flgure 2. lop, laceration of the terminal aorta in case 1. Arrow pofnts to pulsating blood sfream. Bottom, vascular cl~8ps occluding aorta and common iliac arteries.
653
McDonald et al
VENA
CAVA
~--RIGHT
ILIAC
*.-PUNCTURE LEFT ILIAC-\‘-RIGHT VEIN
ARTERY
AORTA
CASE
AND
VENA
CASE I D=Z.O
CAVA CASE
ILIAC
I
CASE
ARTERY
I
used in 400 other inpatient cases at Walter Reed Army Medical Center over the past four years. In case I, the patient had a very slight lumbar lordosis and a thin abdominal wall so that the distance from the skin to the aorta was only 2 cm. (Figure 3, right.) The importance of inserting the needle at a 45 degree angle to the abdominal wall has been emphasized by Palmer [14]. If the angle is too flat, the needle may enter the potential space between the peritoneum and fascia. If the angle of insertion is too steep, injury to retroperitoneal structures may result. In both of our cases, the operators thought they inserted the Touhey needle correctly. However, the location of the injuries indicates that the needles may have been inserted nearly perpendicular to the abdomen, since the injuries were almost directly posterior to the umbilicus. (Figure 3.) The safety of perforating the abdominal aorta from a retroperitoneal approach has been proven by thousands of translumbar aortograms. Oniy rarely will hemorrhage result, since extravasated blood is trapped in the tough periaortic connective tissue, and the aortic hole is tamponaded. Anteriorly, however, the thin peritoneal covering of the aorta offers little or no protection. The reservoir of the free peritoneal cavity allows large quantities of blood to escape undetected. As shown by canine experiments, the closed abdomen does offer some resistance to hemorrhage. A perforation of the aorta bleeds more rapidly with the abdomen open than with it closed [18]. Clinically, as in our cases with the abdomen closed, several minutes may elapse before hemorrhage is recognized on the basis of altered vital signs. If the abdomen were open, these catastrophies would be readily recognized by a stream of blood pumping toward the
654
cm
2
2 D--5 cm
Figure 3. Left, sites of vascular InJuries. Right, correct insertlon of pneumoperltoneum needle (dotted line sketch) compared to technlc used In two cases of maJor vascular InJury.
ceiling. (Figure 2, top.) In our cases, both injuries occurred during insertion of the pneumoperitoneum needle. However, the potential for injury also exists during trocar insertion. If this happened, even more rapid blood loss would be expected. Laparotomy was delayed until frank shock occurred in both patients, because life-threatening hemorrhage due to major vessel injury was not seriously considered. Indeed, in case II, the initial injury was not detected until after a second injury had occurred. If blood is returned after needle insertion, serious vessel injury should be suspected. Delaying laparotomy until the blood pressure decreases may be disastrous. Patients with normal blood volume and cardiac reserve will maintain a good blood pressure and possibly a normal pulse throughout a steady loss of large amounts of blood as their capacitance vessels are constricted. As in our two cases, the “golden period” will then be precipitously followed by profound shock. The return of blood after needle puncture warrants taking steps to ensure that the abdomen may be opened in seconds while observation continues. Blood, if not already available, should be typed and cross-matched, and the anesthesiologist alerted to the possible emergency. Any sign of an expanding abdomen or change in vital signs should be indication for laparotomy without further delay. Upon entering the abdomen, control of large bleeding vessels, until the patient is stabilized, should be by digital or sponge pressure. Ideally, the peritoneum overlying the injured vessels can then be opened and control of injured vessels achieved. If arteries are occluded by clamps, we recommend anticoagulation with heparin, as the potential for distal
The American Journal ot Surgery
Laparoscopy
thrombosis exists. If digital or sponge compression is used, which achieves partial or intermittent compression, anticoagulation is unnecessary. Although large vessel venous bleeding may occur in poorly accessible areas, it is readily controlled with pressure. After vascular repair is complete, the abdominal contents, especially bowel, should be inspected for concomitant injury. The availability of the double lumen Veress needle, with its blunted, spring-loaded inner needle, reduces the risk of inadvertent perforation of mobile abdominal contents [14]. The obturator will push bowel away from the advancing tip. However, these needles offer no protection to fixed structures encountered during a vigorous thrust. During insertion, one hand should be used to grasp the needle 2 to 3 cm from the tip to guard against too deep an insertion. The most obvious aid to prevention of retroperitoneal vascular injury is adherence to correct technic with close supervision of personnel in training. As shown by Phillips et al [19], physicians who have performed fewer than 100 laparoscopic procedures have almost four times as many complications (14.7 per 1,000) as those with greater experience (3.8 per 1,000). Summary
Diagnostic and therapeutic laparoscopy are safe procedures that only rarely cause significant morbidity. However, major abdominal arterial and venous injury may occur, requiring prompt recognition and laparotomy. Direct compression will control major hemorrhage until resuscitation is complete. Vascular repair utilizing principles of proximal and distal control, good exposure, appropriate anticoagulation, and lateral suture technic should result in restoration of normal blood flow without significant sequelae.
volume 135, May 197s
References 1. Rich N, Hobson RW II, Fedde C: Vascular trauma secondary to diagnostic and therapeutic procedures. Am J Surg 128: 715, 1974. 2. Paterson P, Grimwade J: A review of 600 laparoscopic sterilizations. Aust NZ J Obstet Gynaecol13: 165, 1973. 3. Thompson B, Wheeless C: Outpatient sterilization by laparoscopy; a report of 666 patients. Obstet Gynecol38: 912, 1971. 4. Bishop HL, Halpin TF: Dehiscence following laparoscopy. Am J Obstet Gynecolll6: 585, 1973. 5. Irvin TT, Goligher JC, Scott JS: Injury to the ureter during laparoscopic tubal sterilization. Arch Surg 110: 1501, 1675. 6. Stengel JN, Felderman MD, Zamora DZ: Ureteral injury, complication of laparoscopy sterilization. Uro/ogy 4: 341. 1974. 7. Georgy FM, Fetterman HH, Chefetz MD: Complication of laparoscopy: two cases of perforated urinary bladder. Am J Obstet Gynecoll20: 1121, 1974. 8. Thompson BH, Wheeless CR: Gastrointestinal complications of laparoscopy sterilization. Obstet Gynecol 41: 669, 1973. 9. Neufield GR, Johnstone RE, Garcia CR: Electrosurgical hazards in laparoscopy (letter to the editor). JAMA 227: 1261, !974. 10. Corson S: Electrical considerations of laparoscopic sterilization. JReprodhfed 11: 159, 1973. 11. Wortman JS: A review of complications of laparoscopic sterilization, p 37. Advances in Female Sterilization Techniques (Scirra J, Droegenmuller W, Speidel J, ed). Hagerstown, Maryland, Harper lk Row, 1976. 12. Levinson C: Laparoscopy is easy-except for the complications. A review with suggestions. J Reprod Med 13: 187, 1974. 13. Esposito J: Hematoma of the sigmoid colon as a complication of laparoscopy. Am J O&tet Gynecolll7: 581, 1973. 14. Palmer R: Safety in laparoscopy. J deprod Med 13: 1, 1974. 15. Casajus S, Florez W, Zurita A, et al: Puncion de un gran vaso. Revista Clinica Espanola 134: 583, 1974, 16. Vilerdell F, Seres I, Marti-Vicente A: Complications of peritoneoscopy. A survey of 1,455 examinations. Gastrointest Endosc 14: 178, 1968. 17. Day R, Whiie R: Peritoneal dialysis in children; review of 8 years’ experience. Arch Dis Child52: 56, 1977. 18. Richards J Jr, Pano L Jr, Rogers J Jr, Gilbert B: Laceration of abdominal aorta and study of intact abdominal wall tamponade. Ann Surg 164: 321, 1966. 19. Phillips J, Keith D, Hupka J, et al: Gynecologic laparoscopy in 1975. J&prod Mad 16: 105, 1876.
655
The importance of identifying diagnostic and therapeutic procedures that may cause vascular injury has been emphasized in a previous report from our Service [I], Cardiac catheterization and angiography for peripheral vascular diseases account for the majority of iatrogenic vascular injuries, but these injuries generally do not cause massive hemorrhage. Injury to a major artery in an exposed operative field poses a threat of massive hemorrhage but is readily diagnosed, and bleeding can be easily controlled by pressure. However, injury to intraabdominal vessels by percutaneously introduced instruments may result in significant blood loss because of delayed recognition and treatment. Our recent experience with two cases of major vascular injury caused by laparoscopy prompted a review of this problem. Laparoscopy is a commonly used diagnostic and therapeutic procedure with low morbidity and mortality. Paterson and Grimwade [2] in a personal series of 600 inpatient laparoscopic sterilizations had no mortality. Minor morbidity consisted of two cases of colonic perforation requiring no treatment, one case of bleeding from a site of tubal division, one case of inconsequential hypotension, and six cases of mild postoperative abdominal pain. None of these cases required laparotomy. They reviewed the English language literature and found only two deaths in 10,193 gynecologic laparoscopies. There were 34
From the Peripheral Vascular Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Armv or the Deoartment of Defense. Reprik ~equests&ould be addressed to Paul T. McDonald, MD. LTC MC USA, Peripheral Vascular Surgery Service. Walter Reed Army Medical Center, Washington, DC 20012.
vohnne
100, May w70
deaths in 72,029 nongynecologic laparoscopies, 30 of which were associated with significant intraperitoneal hemorrhage or bile peritonitis due to liver injury. Thompson and Wheeless [3] reported 666 outpatient laparoscopic sterilizations. Fifteen cases of minor bleeding required treatment with coagulation through the laparoscope. Laparotomy was required in six cases including two instances of burned bowel, one bleeding adhesion, and three mesosalpinx hemorrhages. Other complications included seven trocar site burns, five uterine perforations, one pelvic abscess, and one late intraabdominal hemorrhage not requiring laparotomy. There were no major vascular injuries and no fatalities. Overall, complications requiring laparotomy occurred in only 0.9 per cent. Complications not related to hemorrhage may be bizarre, such as dehiscence of the laparoscopy site [4], or tragic, such as unrecognized ureteral transection (561. Other problems include perforated urinary bladder [7], gastrointestinal injuries [8], electrosurgical hazards [9,10], and insufflation of gas into a wrong space causing emphysema or cardiovascular changes [II]. (Table I.) Minor bleeding may occur from skin incisions or from other parts of the abdominal wall and responds to pressure or electrocoagulation. Injuries to an epigastric vessel resulting in hemorrhage or hematoma formation require incision, evacuation of clot, and suture ligation [12]. Injury to mesenteric or omental vessels may require laparotomy and suture ligation if bleeding does not stop spontaneously [11,13]. Levinson (121 recommended initial observation for retroperitoneal hemorrhage with laparotomy as necessary, but did not cite case experience. Others [7,11,13] have alluded to potential problems of major
651
McDonald
TABLE
I
et al
Complications of Gynecologic Laparoscopy
Pneumoperltoneum needle’ Gas insuttlatlon
Trocar Electrocoagulatlon’ Infection Miscellaneous
l
Improper intubation, cardiac arrest. Perforation of bowel, stomach, uterus, liver, spleen, vessels. Wrong space with subcutaneous, extraperitoneal, retroperitoneal, or mesenteric emphysema; diaphragm displacement with respiratory compromise; absorption with hypercarbia, arrhythmia. Perforations of viscera, vessels. Burns of skin, viscera or delayed bowel perforations; bleeding from divided mesosalpinx. Wound, salpingitis, pelvic abscess. Wound dehiscence; ureteral transection; mesenteric hematoma; skin, adhesion, or epigastric artery bleeding.
Most common problems.
vascular injuries, but little first hand information is available, The proximity of the aorta and its branches and the vena cava and its tributaries to other structures that have been injured during laparoscopy makes it likely that they will also be injured occasionally. Similar procedures such as peritoneoscopy and peritoneal lavage for dialysis or diagnosis have resulted in large vessel injuries. Casajus et al [15] reported successful repair of a laceration of the right iliac artery caused by a peritoneal dialysis trocar. Vilardell, Seres, and Marti-Vicente [16] in a survey of complications of peritoneoscopy noted that in addition to other common complications, aortic and venous injury had also occurred. Day and White [I 71 reported the fatality of a child due to retroperitoneal vascular injury by a trocar used for insertion of a peritoneal dialysis catheter. The paucity of reports of vascular injuries confirms their rarity. When they do occur, however, serious morbidity or death may result. Our recent experience with two near fatalities prompts
us to encourage each laparoscopist to be prepared for the possibility of major vascular injury. Case Reports Case I. AL, a thirty-two year old white female, gravida 3, para 3, abortus 0, delivered a normal 5 pound female baby two months prior to admission for elective sterilization by tubal cautery. She had no history of abdominal surgery or bleeding problems. Physical examination revealed no abdominal, back, or pelvic abnormalities. Peripheral pulses were intact, and the admission hematocrit was 39.6 per cent. The patient was anesthetized with intravenous thiopental for induction and intravenous fentanyl (Sublimaze@) with nitrous oxide and oxygen by mask for general anesthesia. Tubocurarine chloride and pancuronium bromide (Pavulone) were utilized for muscle relaxation, With the patient in a supine position, the bladder was emptied, the legs were placed in stirrups, and the perineum and abdomen were prepared and draped in a sterile manner. Towel clips were utilized to grasp the skin of the abdominal wall inferiorly and laterally to the umbilicus, and the abdominal wall was elevated. A 2 cm incision was made in the midline 2 cm below the umbilicus. A 16 gauge Touhey needle with obturator (Figure 1) was inserted through the intact fascia at a 45 degree angle toward the pelvis. The needle was gently rocked to and fro to check for free movement within the abdominal cavity. However, the needle did not move freely; the tip was fixed. It was withdrawn and inserted a second time. Blood oozed from the needle and it was again withdrawn. The patient’s vital signs were stable for 5 minutes, but the systolic blood pressure, which had been 120 mm Hg, precipitously decreased to unattainable levels, and abdominal expansion was noted. Ringer’s lactate solution, albumin, and 2 units of typed and cross-matched packed cells were infused rapidly, increasing the systolic blood pressure to 90 mm Hg as the abdomen was hastily opened in the midline. Approximately 3 units of clotted blood were present in the peritoneal
Figure 1. A 16 gauge Touhey needle is compared to a known lethal weapon, an ice pick. Inset shows needle diameter of almost 2 mm.
652
The American Journal of Surgery
Laparoscopy
cavity. Digital pressure partially controlled blood pulsating from an expanding retroperitoneal hematoma. With digital pressure on the aorta above and the common iliac arteries below, a laceration in the terminal aorta near the origin of the right iliac artery was identified and controlled. The blood pressure was restored to within normal limits. The terminal aorta and right common iliac and left common iliac arteries were mobilized and encircled with vascular tapes. After anticoagulation with 7,000 units of sodium heparin; vascular clamps were applied. (Figure 2.) The 3 mm hole in the aorta was repaired with continuous suture of 4-O Prolene@. Clamps and tapes were removed, and 70 mg of protamine sulfate was given to reverse the heparin effect. The retroperitoneum was closed and the abdominal cavity was inspected for other injuries. Bilateral partial salpingectomies were performed. A total of 3 units of packed red blood cells and 2 units of whole blood was required during the operation. Delayed primary wound closure was done on the fourth postoperative day. There were no postoperative complications. Peripheral pulses were normal at discharge and remained so during follow-up clinic visits over the ensuing year. Case II. MC, a twenty-one year old white nulliparous woman, was admitted to the hospital for evaluation of infertility with a suspected diagnosis of polycystic ovaries. She had no history of abdominal surgery or bleeding problems. Physical examination revealed no abnormalities other than bilaterally enlarged ovaries. Peripheral pulses were normal. The patient underwent general anesthesia and had a 16 gauge Touhey needle inserted for insufflation of carbon dioxide, as in case I. A drop of blood returned through the needle when the obturator was removed. The needle was withdrawn and vital signs were observed for several minutes. A second insertion was then made with the needle tip directed more caudally. Blood spontaneously returned from the needle; it was withdrawn, and vital signs were again observed. The blood pressure was normal for 3 minutes, then drifted from 120 to 90 mm Hg. The abdomen was hastily opened in the midline. After 1 minute blood pressure was unobtainable, but a thready pulse was maintained. Rapid infusion of Ringer’s lactate solution, albumin, and type 0 Rh-negative blood over 2 minutes raised the blood pressure to 50 mm Hg. Approximately 3 units of:ciotted blood were noted in the peritoneal cavity when the abdomen was opened. An expanding retroperitoneal hematoma was centered over the terminal aorta. Digital compression of the aorta and common iliac arteries controlled bleeding. However, each time pressure was eased enough to attempt dissection, venous blood welled into the field. Therefore, the t.erminal aorta, iliac arteries, inferior vena cava, and both iliac veins were controlled by pressure from sponges held in clamps. Upon opening the peritoneum, a through and through perforation of the right side of the aorta and a small tear in the vena cava were noted. In addition there was a through and through perforation of the right common iliac artery and a 1.5 cm rent in the left iliac vein as it passed
Volume 135, May 1976
under the right iliac artery. (Figure 3, left.) The arterial injuries were sequentially repaired by lateral suture technic with 5-O Prolene. After repair of the arterial injuries, the terminal aorta and iliac arteries were mobilized, and the lacerated left iliac vein and the vena cava were brought into view. The venous injuries were also repaired by lateral suture technic. There were no other intraabdominal injuries. The diagnosis of bilateral polycystic ovaries was confirmed, and bilateral wedge biopsies were obtained. Four units of type 0, Rh-negative blood were given to replace the estimated blood loss of 3,000 cc. There were no postoperative complications. Delayed primary closure of the wound was done on the fourth postoperative day. Six months after operation peripheral pulses were normal. Comments Recognized complications,
conditions causing increased such as a history of previous
risk for
abdominal surgery or bleeding tendency, were not present in either ease. The technic of insertion of the insufflation needle was thought to be the same as that
Flgure 2. lop, laceration of the terminal aorta in case 1. Arrow pofnts to pulsating blood sfream. Bottom, vascular cl~8ps occluding aorta and common iliac arteries.
653
McDonald et al
VENA
CAVA
~--RIGHT
ILIAC
*.-PUNCTURE LEFT ILIAC-\‘-RIGHT VEIN
ARTERY
AORTA
CASE
AND
VENA
CASE I D=Z.O
CAVA CASE
ILIAC
I
CASE
ARTERY
I
used in 400 other inpatient cases at Walter Reed Army Medical Center over the past four years. In case I, the patient had a very slight lumbar lordosis and a thin abdominal wall so that the distance from the skin to the aorta was only 2 cm. (Figure 3, right.) The importance of inserting the needle at a 45 degree angle to the abdominal wall has been emphasized by Palmer [14]. If the angle is too flat, the needle may enter the potential space between the peritoneum and fascia. If the angle of insertion is too steep, injury to retroperitoneal structures may result. In both of our cases, the operators thought they inserted the Touhey needle correctly. However, the location of the injuries indicates that the needles may have been inserted nearly perpendicular to the abdomen, since the injuries were almost directly posterior to the umbilicus. (Figure 3.) The safety of perforating the abdominal aorta from a retroperitoneal approach has been proven by thousands of translumbar aortograms. Oniy rarely will hemorrhage result, since extravasated blood is trapped in the tough periaortic connective tissue, and the aortic hole is tamponaded. Anteriorly, however, the thin peritoneal covering of the aorta offers little or no protection. The reservoir of the free peritoneal cavity allows large quantities of blood to escape undetected. As shown by canine experiments, the closed abdomen does offer some resistance to hemorrhage. A perforation of the aorta bleeds more rapidly with the abdomen open than with it closed [18]. Clinically, as in our cases with the abdomen closed, several minutes may elapse before hemorrhage is recognized on the basis of altered vital signs. If the abdomen were open, these catastrophies would be readily recognized by a stream of blood pumping toward the
654
cm
2
2 D--5 cm
Figure 3. Left, sites of vascular InJuries. Right, correct insertlon of pneumoperltoneum needle (dotted line sketch) compared to technlc used In two cases of maJor vascular InJury.
ceiling. (Figure 2, top.) In our cases, both injuries occurred during insertion of the pneumoperitoneum needle. However, the potential for injury also exists during trocar insertion. If this happened, even more rapid blood loss would be expected. Laparotomy was delayed until frank shock occurred in both patients, because life-threatening hemorrhage due to major vessel injury was not seriously considered. Indeed, in case II, the initial injury was not detected until after a second injury had occurred. If blood is returned after needle insertion, serious vessel injury should be suspected. Delaying laparotomy until the blood pressure decreases may be disastrous. Patients with normal blood volume and cardiac reserve will maintain a good blood pressure and possibly a normal pulse throughout a steady loss of large amounts of blood as their capacitance vessels are constricted. As in our two cases, the “golden period” will then be precipitously followed by profound shock. The return of blood after needle puncture warrants taking steps to ensure that the abdomen may be opened in seconds while observation continues. Blood, if not already available, should be typed and cross-matched, and the anesthesiologist alerted to the possible emergency. Any sign of an expanding abdomen or change in vital signs should be indication for laparotomy without further delay. Upon entering the abdomen, control of large bleeding vessels, until the patient is stabilized, should be by digital or sponge pressure. Ideally, the peritoneum overlying the injured vessels can then be opened and control of injured vessels achieved. If arteries are occluded by clamps, we recommend anticoagulation with heparin, as the potential for distal
The American Journal ot Surgery
Laparoscopy
thrombosis exists. If digital or sponge compression is used, which achieves partial or intermittent compression, anticoagulation is unnecessary. Although large vessel venous bleeding may occur in poorly accessible areas, it is readily controlled with pressure. After vascular repair is complete, the abdominal contents, especially bowel, should be inspected for concomitant injury. The availability of the double lumen Veress needle, with its blunted, spring-loaded inner needle, reduces the risk of inadvertent perforation of mobile abdominal contents [14]. The obturator will push bowel away from the advancing tip. However, these needles offer no protection to fixed structures encountered during a vigorous thrust. During insertion, one hand should be used to grasp the needle 2 to 3 cm from the tip to guard against too deep an insertion. The most obvious aid to prevention of retroperitoneal vascular injury is adherence to correct technic with close supervision of personnel in training. As shown by Phillips et al [19], physicians who have performed fewer than 100 laparoscopic procedures have almost four times as many complications (14.7 per 1,000) as those with greater experience (3.8 per 1,000). Summary
Diagnostic and therapeutic laparoscopy are safe procedures that only rarely cause significant morbidity. However, major abdominal arterial and venous injury may occur, requiring prompt recognition and laparotomy. Direct compression will control major hemorrhage until resuscitation is complete. Vascular repair utilizing principles of proximal and distal control, good exposure, appropriate anticoagulation, and lateral suture technic should result in restoration of normal blood flow without significant sequelae.
volume 135, May 197s
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