In a study9 conducted in 7 gynecologic laparoscopy surgery centers in France over 9 years and involving 29,966 diagnostic and operative cases, the overall complication rate was 4.64 per 1,000 laparoscopies (n = 139). Of the 21 major vascular injuries associated with gynecologic surgery, the majority occurred during set-up, and 84.6% during insertion of the primary trocar. Two patients died from their injuries.
Bhoyrul and colleagues10 analyzed data reported to the US Food and Drug Administration and found that 408 of 629 trocar-related injuries involved major blood vessels, as did 26 of 32 deaths (81%). Most of the deaths (87%) were linked to the use of disposable trocars equipped with safety shields; 9% with direct-view trocars. Although surgeons asserted that the trocar malfunctioned in 41 cases, that claim was confirmed in only 1 case (2%).
Another study found that 37 of 79 (46.8%) serious complications involving optical-access trocars between 1994 and 2002 involved major vessels, injuring the aorta, iliac vessels, or vena cava.11
A study12 carried out in the Netherlands in 1994 evaluated the relative number of complications that occurred within a total of 25,764 laparoscopic procedures. The study divided complications into those occurring as the result of the laparoscopic approach (eg, trocar insertion) versus those happening during the performance of the operation. Fifty-seven percent of the 145 complications were caused by the laparoscopic approach; the 2 reported deaths also were secondary to that approach.
Snapshot of vascular injury: A series of 31 patients
In 2003, I published data13 on 31 cases of major vessel injury associated with gynecologic laparoscopy (see). These cases were collected from a variety of sources: medicolegal case files, hospital morbidity-mortality presentations, and quality-assurance departments. Eight cases involved diagnostic procedures, while 23 involved operative laparoscopy.
The medical records of these cases provided details on the nature of the injury. The cases were categorized by body mass index (BMI) and cause, ie, whether they occurred as the result of the laparoscopic approach (ie, entry-related) or arose during surgery.
Of the 31 cases, 22 (71%) involved women with BMIs from 25 to more than 30 (overweight or obese). A large majority—28 cases (90%)—were related to entry. Only 3 injuries occurred during surgery.
In several women, more than 1 vessel was damaged. Of the 49 total injuries, 38 (78%) involved the iliac vessels. Seven (23%) women died as a result of their injuries, all of which involved venous trauma.
Damage to structures in the vicinity of the injured vessels was substantial in 16 cases. Major morbidity included ureteral, nerve, and intestinal injury; arterial and venous thrombosis; compartment syndrome; and suturing of the wrong vessel.
Some patients also experienced edema or pain in an extremity (vascular insufficiency); infection; diffuse intravascular coagulation and/or adult respiratory distress; cardiac arrest; central nervous system injury (stroke); or hospitalization of more than 1 week. Cases also were categorized as early or late diagnosis, depending on whether shock had supervened. Diagnosis was early in 8 cases (26%) and late in 21 (68%). Two patients were diagnosed postoperatively; ie, they had gone to the recovery room prior to developing shock.
The volume of blood loss ranged from 1,000 mL to 7,000 mL, with a mean loss of 3,400 mL. All patients received packed red blood cells and/or a mixture of other blood products. The time required for cross-matching and receiving blood ranged from 10 to 120 minutes.
In all cases, a vascular or general surgeon was called to consult on the case.
Mapping vascular structures to ensure safe trocar entry
Knowing the distances between blood vessels and laparoscopic entry trocars is critical if injury is to be avoided. In pursuit of this goal, Hurd and colleagues14 performed a retrospective study involving women who had undergone magnetic resonance imaging or computed tomography scans of the abdomen. Investigators measured the distance between the lower abdominal wall and the aortic bifurcation in these women, who were all unanesthetized and in the supine position.
Distances increased with BMI
This occurred in the study by Hurd et al,14 as well as in a prospective study by Narendran and Baggish,15 who calculated body mass index in 101 consecutive women who were undergoing diagnostic or operative laparoscopy. These women were anesthetized, with pneumoperitoneum established and a laparoscope inserted; all were in the lithotomy position.
In this study, Narendran and Baggish measured the following distances from the entry trocar:
- perpendicular distance to aortic bifurcation,
- oblique distance to the right and left common iliac vessels,
- oblique distance to the superior margin of the bladder,
- perpendicular distance from the peritoneum to skin at the umbilicus (abdominal wall thickness), and
- oblique distance from the subumbilical peritoneal opening to the right and left common iliac vessels.