Vascular complications in minimally invasive surgery

Injuries to major vessels in the course of laparoscopic surgery are rare but serious, life-threatening complications. We report nine iatrogenic vascular injuries during minimally invasive surgery that occurred between January 1991 and December 1995 in surgical and obstetric-gynecologic services in the Austrian province of Styria. The total vascular complication rate is 0.08%. As these data show, the distal abdominal aorta and vena cava, as well as the large pelvic vessels, are especially susceptible to injury when the Veress needle and trocars are inserted into the abdomen. Surgical reconstruction of these eight arterial lesions required a polytetrafluorethylene (PTFE) patch in one case, and the resection of the damaged section of the artery and reanastomosis in two others. The remaining lesions, as well as an isolated vein injury, were corrected with direct suturing of the vessel. Pelvic circulation was completely restored in all patients, and permanent damage was avoided.

Repair of a post-traumatic common iliac arteriovenous fistula

The management of a patient with a post-traumatic common iliac arteriovenous fistula which was repaired surgically is reported. The current use of less-invasive endoluminal techniques is reviewed.

Iliac vessel injury: operative physiology related to outcome

BACKGROUND

Fifty-three patients treated at a level I trauma center with iliac vessel injury were studied to determine if body temperature and acid-base status in the operating room predicts outcome.

METHODS

Records were reviewed for demographics, mechanism of injury, body temperature, acid-base status, operative management, and outcome. Statistical methods included Student's t test, odds ratio determination, and chi-square analysis to determine statistical significance.

RESULTS

Fifty-three patients (47 male, 6 female) sustained 92 iliac vascular injuries (36 arterial, 56 venous). Mortality was 34%, with 72% of deaths due to shock within 24 hours. Physiologic parameters differed significantly between survivors and nonsurvivors. Odds ratio identified six conditions; the number present predicted outcome.

CONCLUSIONS

(1) There are significant differences between initial and final operating room temperature and acid-base status in survivors versus nonsurvivors with iliac vessel injury. Conditions for odds ratio can be calculated and correlated with outcome. (2) A patient with two or more conditions should be considered for an abbreviated laparotomy to allow for reversal of "physiologic failure."

Haemodynamic conditions enhancing gas embolism after venous injury during laparoscopy: a study in pigs

This study was designed to determine the conditions that promote carbon dioxide embolism after venous injury during laparoscopy in pigs. Injury to an iliac vein was filmed during laparoscopy in the presence of a pneumoperitoneum created at increasing pressures from 0 to 30 mm Hg in 5-mm Hg increments. At intraperitoneal pressures less than 20 mm Hg, there was a parallel increase in femoral venous pressures, resulting in haemorrhage, with persistent blood flow to the inferior vena cava. At intraperitoneal pressures of 20-30 mm Hg, there was collapse of the femoral vein, occurring earlier in the presence of hypovolaemia. Between these two states (haemorrhage and collapse), there was a point of equilibrium which allowed retrograde venous penetration of carbon dioxide bubbles. During release of the pneumoperitoneum, these bubbles were exteriorized through the area of the injury, but some passed into the inferior vena cava where their presence was detected by an oesophageal Doppler probe.

Extended intravascular shunting in an experimental model of vascular injury

PURPOSE

To examine the extended patency (> 24 hrs) of heparin-bonded intravascular shunts in a porcine model of vascular injury.

PROCEDURES

Adult swine underwent bilateral, common iliac artery resection (n = 5) or bilateral common iliac vein resection (n = 5) and vessel replacement with interposition, heparin-bonded shunts. Three control swine had vessel dissection only. Hematologic and coagulation profiles were measured at baseline and 24 hrs. Limb perfusion was assessed at 24 hrs by clinical exam and angiography.

RESULTS

At 24 hrs, all limbs in both shunt groups were well perfused. All arterial shunts were angiographically patent. No distal emboli were detected. Nine of 10 venous shunts were patent, seven were lined with non-occluding thrombus. No alterations in hematologic or coagulation profiles were noted.

CONCLUSIONS

Heparin-bonded shunts remained patent in arteries for 24 hours. Shunts placed in the venous system were prone to thrombus formation but most remained patent.

Laparoscopic pelvic lymphadenectomy in an anatomical model: results of an experimental comparative trial

OBJECTIVES

The aim of this paper was to compare the accuracy of laparoscopic versus open pelvic lymphadenectomy in an experimental trial.

STUDY DESIGN

We performed unilateral laparoscopy pelvic lymphadenectomy (LPL) in 33 non-embalmed cadavers between the external iliac vein, the obliterated umbilical artery and the obturator nerve. Then a laparotomy was performed to inspect the LPL limits, look for laparoscopic complications and finally realize a controlateral lymphadenectomy. The LPL side was randomly decided. A pathologist counted the number of lymph nodes collected with both techniques. We compared the number of retrieved lymph nodes, the completeness of the dissection and the complication rate with those two procedures. Student's t-test, chi 2-test and non-parametric tests were used when appropriate.

RESULTS

No dissection had to be aborted. One hundred and twelve nodes were removed laparoscopically (mean, 3.73; S.E., 2.9) and 84 at laparotomy (mean, 2.77; S.E., 2.06). There was no significant difference in the number of nodes retrieved with both procedures. Effectiveness of laparoscopy was not significantly different in the first ten procedures, in the second ten or in the last ten LPL. Residual tissue was observed after LPL in 13.3% of the procedures whereas all open lymphadenectomies were complete. LPL sensitivity reached at least 86% in this paper. Failures were more frequent at the beginning of the study (50% among the first ten dissections), in obese subjects or in subjects with prior history of laparotomy (but the difference was not significant). Two venous injuries occurred during LPL (6.7%). Complication rates for the two techniques were not significantly different. However, the LPL complication rate was higher at the beginning of the study and increased significantly in subjects with prior history of laparotomy (P < 0.05).

CONCLUSIONS

This randomized study shows that LPL and laparotomy have similar effectiveness. Incomplete dissections and complications are more frequent in obese subjects or in case of prior history of laparotomy. Fifteen procedures seems necessary to learn the technique and provide constant and safe results in routine practice.

Clinics in diagnostic imaging (23). Traumatic rupture of the left iliac vein

A 3-day-old male baby with neonatal necrotising enterocolitis had a central line (Cavafex No. 18) inserted through the left femoral vein for administration of parenteral nutrition. Forty-eight hours later, he developed progressive abdominal distention with evidence of free abdominal fluid. A contrast injection done through the left femoral vein revealed retroperitoneal leakage of contrast from a traumatic rupture of the left iliac vein. The intravenous catheter was removed and he was treated conservatively with eventual recovery.

Role of the anesthesiologist in the early diagnosis of life-threatening complications during laparoscopic surgery

Two cases of massive hemorrhage following blind introduction of laparoscopic instruments are presented. The role of the anesthesiologist in the early diagnosis of potentially life-threatening complications of laparoscopic surgery is discussed.

Outcome of complex venous reconstructions in patients with trauma

PURPOSE

The role of complex venous reconstructions (CVRs) in patients with major trauma remains a controversial topic. This study evaluates the patency and clinical outcome of CVRs in a major urban trauma center.

METHODS

Between 1979 and 1994 the records of 92 patients with 100 injuries to the iliac, femoral, and popliteal venous system were reviewed. The incidence of edema, pulmonary embolism, and limb loss was documented in 75 men and 17 women (mean age of 27 years, range 14 to 59 years). The 30-day patencies were assessed in all patients with either impedance plethysmography (n = 16), venography (n = 40), or duplex scan (n = 36). Long-term patencies were assessed in 14 patients monitored for 0.5 to 9 years (mean 3.2 years).

RESULTS

Mechanisms of injury consisted of 58 gunshot wounds, 23 stab wounds, 6 shotgun wounds, and 5 blunt injuries. There were 112 associated injuries, 41 of which were concomitant arterial injuries. Forty-five of the 100 venous injuries were repaired with CVRs and included 6 (13%) spiral vein grafts, 8 (18%) panel vein grafts, 8 (18%) reversed saphenous vein interposition grafts, 8 (18%) end-to-end repairs, and 15 (33%) vein patch repairs. Thirty-day patency rates for these repairs were 50%, 50%, 75%, 88%, and 87%, respectively, and an overall patency rate of 73% was observed. The remaining 55 injuries were treated with ligation (n = 27) or lateral venorrhaphy (n = 28). The cumulative 30-day patency rate for all venous repairs was 81% (59 of 73). Fourteen patients, nine of whom had CVRs, were available for long-term follow-up. In this group CVRs demonstrated a 100% patency. One patient with a spiral vein graft repair of the common femoral vein had severe reflux causing intermittent edema and mild lipodermatosclerosis. No pulmonary emboli, limb loss, or deaths were identified in patients undergoing CVRs.

CONCLUSION

Patients with CVRs had a 30-day patency rate of 73%. Of this group panel and spiral vein grafts were less successful, exhibiting only a 50% 30-day patency rate, whereas end-to-end and vein patch repairs were successful in 88% and 87% of cases, respectively. Our overall evaluation suggests that use of CVRs results in successful venous repair; however, the postoperative patency of interposition panel and spiral grafts suggests selective use of these techniques.

[Iatrogenic vascular lesions in laparoscopic interventions in gynecology]

Injuries to major vessels in the course of gynecological laparoscopic surgery are rare but serious, life-threatening complications. We report on five iatrogenic vascular injuries during minimally invasive surgery that occurred between January 1991 and May 1996 in obstetrical-gynecological services in the Austrian province of Styria. The total vascular complication rate is 0.05%. As this data shows, the distal abdominal aorta and vena cava as well as the large pelvic vessels are especially susceptible to injury when the Veress needle and trocars are inserted into the abdomen. Surgical reconstruction of these five arterial lesions required a PTFE patch in one case and the resection of the damaged section of the artery and reanastomosis in a second case. The remaining lesions, as well as an associated injury to the pelvic vein in one case was corrected with direct suturing of the vessel. Pelvic circulation was completely restored in all patients and permanent damage was avoided.

Vascular complications in lumbar disk surgery: report of four cases

Vascular injuries in lumbar disk surgery, although rare, are serious complications which may be overlooked due to a broad range of clinical manifestations. It is important that surgeons and radiologists be aware of these potentially fatal complications and develop an appropriate symptom-based diagnostic paradigm. We reviewed 8099 consecutive cases of lumbar disk surgery, performed over a 14-year period at a single institution, for postoperative vascular complications. We identified four patients (0.05%) with lumbar disk surgery-related vascular complications: intraoperative lacerations of the abdominal aorta and median sacral artery, an arteriovenous fistula between the left common iliac artery and vein detected 19 days postdiskectomy, and a partially thrombosed aortic aneurysm with an arteriovenous fistula between the aneurysm and the inferior vena cava, diagnosed 11 months after surgery. The majority of cases in the literature of vascular injury in lumbar disk surgery were reported prior to 1965. Diagnostic approaches described in that period do not reflect the great range of diagnostic techniques available today. Angiography remains the gold standard for diagnosis and guidance as to surgical repair. However, a high index of suspicion based on clinical signs and/or the use of sonography or CT is important in the detection of these complications.

Penetrating trauma to the abdominal vessels

Between January 1975 and December 1989, 1860 patients were admitted to the American University of Beirut Medical Centre with abdominal injuries. Their mean age was 23 years. Of these patients 107 had vascular injuries (an incidence of 6%). Bullets were the most common injurious agents (72%), followed by shrapnel (22%). There were 28 arterial and 113 venous injuries. All patients presented to the emergency unit within 5 h of injury (mean 45 min) and were surgically explored. The overall mortality rate was 36.5%. Patients who were haemodynamically stable had a better outcome than those who presented in shock (P < 0.005). The major cause of death was haemorrhage from uncontrolled bleeding. Two subgroups with a higher mortality were identified: patients with inferior vena caval injury associated with a liver injury had a mortality rate of 78.5%, and those with vascular injury associated with pelvic fracture had a mortality rate of 57% (P < 0.05). Abdominal vascular injuries have a high mortality rate, especially if the inferior vena cava is involved or associated pelvic fractures are present. Prompt resuscitation and control of bleeding are the key to an improved salvage rate.

Transvenous approach to salvage incomplete arterial embolization of compound traumatic arteriovenous fistulae

Two patients with compound arteriovenous fistulae, in whom transarterial embolizations failed, were managed by embolization of the arterial tributaries of their fistulae from retrograde, transvenous access. Transvenous embolizations were successful in both patients. Given multiple arterial tributaries, and large communicating hematomas into which these arteries bleed, transvenous access may be a useful approach for embolizing compound traumatic arteriovenous fistulae.

Iliofemoral venous injuries: an indication for prophylactic caval filter placement

Prophylactic placement of vena caval filters is recommended in trauma patients at high risk for pulmonary embolism (PE). We present a group of patients with iliofemoral venous trauma, and subsequent complications of deep venous thrombosis (DVT) and PE. Of twelve patients with iliac or common femoral venous injuries, seven underwent primary repair. All received DVT/ PE prophylaxis with mini-dose heparin and/or sequential compression hose. In spite of this, two patients suffered DVT, one patient had DVT and PE and one patient had clinical evidence of PE but did not undergo confirmatory testing. Three patients underwent prophylactic caval filter placement without complication. The DVT/PE complication rate in this small group was at least 43% (3 of 7). Patients with repaired iliofemoral venous injuries represent a high risk subset for DVT/PE and prophylactic caval filter placement is recommended.

Clinical follow-up of patients with percutaneously inserted inferior vena caval filters

This is a retrospective clinical follow-up study of 45 consecutive patients who had percutaneous placement of inferior venal caval (IVC) filters in the period 1987 to 1993 to prevent mortality, or severe morbidity, from pulmonary embolism (PE). Ten patients had Gunther filters (GF) and 35 had bird's nest filters (BNF) from 1989. Clinical indications for filter placement were: 23 patients with anticoagulation contraindications, six with anticoagulation failure and recurrent PE, 10 with anticoagulation complications, two with critical PE and four with leg thrombi and PE. Two patients died from recurrent PE after filter placement, one with a GF migrating after replacement, and one with a BNF. Two patients died from severe PE, occurring prior to filter placement. Fifteen patients died in the study period, none due to recurrent PE. Twenty-five patients remain alive, with a mean follow-up period of 21 months, with none having recurring PE. One patient was lost to clinical follow-up. One patient suffered technical difficulty in BNF placement, and underwent surgical removal of a hook penetrating an iliac vein wall. Inferior vena cava filters are efficacious in preventing potentially fatal pulmonary embolism, in both the acute period and the medium term. There are low rates of morbidity associated with their use.

Major vascular injury and laparoscopy

Iatrogenic vascular trauma is a hazard that must be considered constantly during any laparoscopic procedure. We present a case of vessel penetration presenting as CO2 embolism during insufflation where delayed recognition of the vascular implications of this event led to death from exsanguination. The pattern of laparoscopic vascular injuries in Australia as reported to the Medical Defence Union (UK) and the New South Wales Medical Defence Union is reviewed and compared with previously reported cases of vascular trauma in laparoscopy. Recommendations are made for the diagnosis and most importantly for the prevention of CO2 embolism and major vascular injury at laparoscopy.

A case of laparoscopic complication: injury of the left common iliac vessels and subsequent acute compartment syndrome of the left leg

A 45-year-old Japanese woman underwent a laparoscopy-assisted vaginal hysterectomy. Insertion of a trocar injured the left common iliac artery and vein, which were repaired within 2.5 hours. Postoperatively the patient presented an acute compartment syndrome of the left leg. Fasciotomy and rehabilitation rescued her from functional disturbances.

Major vascular injuries during laparoscopic procedures

BACKGROUND

Major vascular complications following laparoscopic procedures are rare, with only 20 cases reported in the literature.

PATIENTS AND METHODS

The cases of 4 patients who sustained 5 vascular injuries during laparoscopic procedures between June 1991 and May 1994 are presented, and previously reported cases in the literature are reviewed.

RESULTS

All injuries occurred during pelvic laparoscopy (2 diagnostic procedures, 1 tubal ligation, and 1 hernia repair). The vascular injury was recognized during laparoscopy in 3 patients. In only 1 patient was immediate vascular surgery consultation requested. The iliac artery was injured in 3 patients, the iliac vein in 1, and the inferior epigastric artery in 1. The mechanism of injury was by the trocar in 2 patients and by sharp dissection in 2 patients. Arterial repair was accomplished by polytetrafluoroethylene (PTFE) interposition, PTFE patch angioplasty, resection and primary anastomosis, and ligation in 1 patient each. The venous injury was repaired by lateral venorrhaphy. Three patients recovered without sequelae, and 1 patient had a stroke. A review of the literature revealed only 20 reported cases of major vascular injuries as a result of the pneumoperitoneum needle or trocar insertion. Characteristically, the terminal aorta, cava, iliac arteries, and veins were injured. Most injuries were treated by direct suture repair. With immediate recognition, recovery was the rule; however, 3 of the 8 patients with delayed recognition died.

CONCLUSION

Laparoscopists must be aware of this rare, serious, and potentially lethal complication. Once recognized, immediate conversion to an open procedure and application of appropriate vascular surgical techniques are required to reestablish arterial and venous continuity and minimize morbidity and mortality.

Major complications during laparoscopy-assisted vaginal hysterectomy--report of four cases and review of the literature

This paper presents four recent cases of complications resulting from of a total 130 cases of laparoscopy-assisted vaginal hysterectomies performed at Chang Gung Memorial Hospital from March 1991 till January 1993. These included two cases of bladder injury, one case of vessel laceration and one case of colon injury. In addition, the literature about complications occurring at laparoscopy are reviewed and classified. This paper will: 1. present precautionary measures for avoiding intraoperative complications; 2. describe management of complications.

Excision of hemivertebrae and wedge resection in the treatment of congenital scoliosis

The results of anterior and posterior excision or wedge resection of a hemivertebra and arthrodesis of the spine were reviewed retrospectively for thirty-seven patients. The degree of correction that was obtained and maintained, the balance and alignment of the trunk, changes in pelvic obliquity, and associated complications were evaluated. The average age at the time of the operation was twelve years (range, six months to forty-two years). The average duration of follow-up was six years (range, two to nineteen years). The resection was at the mid-thoracic level in six patients, at the thoracolumbar level in nine, at the mid-lumbar level in seven, and at the lumbosacral level in seventeen. (Two patients had an excision of a hemivertebra at two levels.) Instrumentation was used in twenty-eight patients. Postoperatively, all patients were managed with a body cast, with a unilateral or bilateral pantaloon extension, for four to six months. The instrumentation allowed early walking and the use of a unilateral rather than a bilateral pantaloon extension. The index curve (the curve containing the hemivertebra) averaged 54 degrees (range, 18 to 132 degrees) preoperatively, 33 degrees (range, 0 to 105 degrees) postoperatively, and 35 degrees (range, 0 to 110 degrees) at the most recent follow-up evaluation. A measurable improvement in balance was achieved and maintained in nineteen patients. Pelvic obliquity did not change appreciably, as it was related primarily to limb-length inequality in this series. Complications included a temporary nerve-root lesion in seven patients, a permanent neurological deficit involving the first sacral nerve root in one patient, a pseudarthrosis in three patients, and a wound infection in three patients. Six patients had extension of the arthrodesis to include additional vertebrae.

Venous injury: to repair or ligate, the dilemma revisited

Controversy continues over management of major venous injuries. The records of 322 patients with venous injury were reviewed. Isolated venous injury was present in 83 patients; 54 (65%) underwent ligation of the injured vein. Combined arterial and venous injuries were present in 239 patients; 170 (71%) patients had ligation. Injured were the inferior vena cava, iliac, femoral, popliteal, distal leg, and arm veins; all were confirmed at surgery. Arterial injuries were repaired with standard techniques; venous injuries were ligated or repaired by end-to-end or lateral phleborrhaphy. Adjunctive fasciotomy was used as clinically indicated. The patients were followed an average of 32 months. No patient with isolated venous injury developed permanent sequelae, although 29 (35%) had transient extremity edema. Transient edema developed in 86 (36%) patients with combined injury, and permanent edema occurred in 4 (2%). Edema developed regardless of vein injury ligation or repair. No extremity was lost after venous injury ligation. While repair of all venous vascular injuries is still the surgical ideal, in civilian practice permanent sequelae of venous injury ligation are rare and in patients with hemodynamic instability from blood loss, extensive local injury, associated organ injury, anesthesia requirements, or other concerns venous ligation is acceptable.