Aortic laceration during veress needle insertion: a laparoscopic disaster

Abstract

Introduction: More than 50% of all complications associated with laparoscopy occur during the entry phase for pneumoperitoneum and insertion of trocars. Major vascular injuries related to blind entry technique are infrequent, occurring in 0.04–0.1% of laparoscopic procedures. Nevertheless, 13%–50% of all vascular injuries are not detected immediately during the operation, resulting in correspondingly high morbidity and mortality rates. Major vascular injuries are the second most common cause of death during laparoscopy, after death from anesthesia, with a mortality rate of 6.37 %. The first reaction after vascular injury should not be conversion to laparotomy, but instead assessment and possible control of the injury. Obesity, previous abdominal surgeries, surgical experience, inflammatory bowel disease and pelvic inflammatory disease are known risk factors to injuries during the entry phase in laparoscopy. Clinical case: A 47 years old woman, BMI 42.2 kg/m2, without any previous abdominal surgery, was proposed to an elective left hemicolectomy after 2 diverticulitis episodes in a 6 months period, at a secondary hospital. As soon as the Veress needle was inserted, blood was seen. After the first trocar was placed, an median retroperitoneal inframesogastric hematoma was seen and the surgeon did an unsuccessful attempt to control the bleeding. Since there was hemodynamic instability, a conversion was made. An infrarrenal aortic laceration was seen and clamps were put in place to stop the bleeding. The patient was then transferred to a tertiary hospital to be intervened by vascular surgery. An aortoplasty with patch of the great safenous vein and trombectomy of the ilio-distal arteries was performed. The time occurred between the injury and the beginning of the vascular surgery was 2hours. The patient went to an Intensive Care Unit. A total of 15 red blood cells pool (first 2 without compatibility test), 12 plasma units, 3grams of fibrinogen and 1 pool of plaquelets were transfused. During the intensive care stay, the patient developed leg compartment syndrome, with the need of fasciectomy and a moderate ARDS, making it harder to manage the disease. Conclusion: Major Vascular lesions in laparoscopy surgery are rare but are associated with great morbidity and mortality. A close cooperation between laparoscopic surgeons, anesthesiologists, vascular surgeons and intensivists is needed to minimize the damage and the improve the result of the vascular repair. The existence of strict action protocols is necessary to minimize morbidity and mortality.