Iatrogenic operative injuries of abdominal and pelvic veins: a potentially lethal complication

The substantial burden of iatrogenic vascular injury on the vascular surgery workforce at an academic medical center

OBJECTIVE

Vascular surgeons are often called upon to provide emergent surgical assistance to other specialties for iatrogenic complications, both intraoperatively and in the inpatient setting. The management of iatrogenic vascular injury remains a critical role of the vascular surgeon, especially in the context of the increasing adoption of percutaneous procedures by other specialties. This study aims to characterize consultation timing, management, and outcomes for iatrogenic vascular injuries.

METHODS

This study identified patients for whom vascular surgery was consulted for iatrogenic vascular complications from February 1, 2022, to May 12, 2023. Patient information, including demographic information, injury details, and details of any operative intervention, was retrospectively collected from February 1, 2022, to October 13, 2022, and prospectively collected for the remainder of the study period. Analyses were performed with R (version 2022.02.03).

RESULTS

There were 87 patients with consultations related to iatrogenic vascular injury. Of these, 42 (46%) were female and the mean age was 59 years (±18 years). The most common consulting services were cardiology (32%), cardiothoracic surgery (26%), general surgery (8%), and neurointerventional radiology (10%). Reasons for consultation included hemorrhage (36%), limb ischemia (36%), and treatment of pseudoaneurysm (23%). A total of 24% of consults were intraoperative, 20% of consults related to extracorporeal membrane oxygenation cannulation, and 16% of consults related to ventricular assist devices including left ventricular assist device and intra-aortic balloon pump. The majority of these consult requests (60%) occurred during evening and night hours (5 PM to 7 AM). Emergent intervention was required in 62% of cases and consisted of primary open surgical repair of arterial injury (54%), endovascular intervention (21%), and open thromboembolectomy (15%). Overall, in-hospital mortality for the patient cohort was 20% and the reintervention rate was 23%, reflecting the underlying complexity of the illness and nature of the vascular injury in this patient group.

CONCLUSIONS

Vascular surgeons play an essential role in managing emergent life-threatening hemorrhagic and ischemic iatrogenic vascular complications in the hospitalized setting. The complications require immediate bedside or intraoperative consult and often emergent open surgical or endovascular intervention. Furthermore, many of these require urgent management in the evening or overnight hours, and therefore the high frequency of these events represents a potential significant resource utilization and workforce issue to the vascular surgery workforce.

REMOVED: Successful management of an Iatrogenic portal vein and hepatic artery injury in a 4-month-old female patient: A case report and literature review

This article has been removed: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/policies/article-withdrawal).

Sutureless Repair for Iliac Vein Bleeding Using an Elastomeric Sealant

Addressing venous bleeding is a frequent complication of vascular and abdominopelvic surgeries. We present a novel sutureless repair technique using HydrofitⓇ (Terumo, Tokyo, Japan), an elastomeric sealant. In a patient experiencing common iliac vein bleeding during abdominal aortic aneurysm surgery, this technique successfully achieved complete hemostasis. By applying the elastomeric sealant with an autologous arterial patch to the bleeding site, we demonstrate the simplicity and effectiveness of sutureless hemostasis for venous bleeding.

Spectrum of Multidetector Computed Tomography Imaging Findings in Iatrogenic Abdominopelvic Injuries: A Comprehensive Pictorial Review

Iatrogenic injuries are unavoidable complications of surgeries and minimally invasive procedures. They are generally classified into vascular and nonvascular injuries and based on the time of injury into early and late injuries. Iatrogenic injuries, particularly vascular injuries, increase the mortality and morbidity, with prolongation of hospital-stay. Multidetector computed tomography (MDCT) is a highly sensitive, and often the first imaging modality in suspected iatrogenic injuries. This pictorial review elucidates the imaging considerations and appearances of iatrogenic injuries of the abdominopelvic organs on MDCT.

Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location

OBJECTIVE

To demonstrate the surgical and morbidity differences between upper and lower parametrial placenta invasion (PPI).

MATERIALS AND METHODS

Forty patients with placenta accreta spectrum (PAS) into the parametrium underwent surgery between 2015 and 2020. Based on the peritoneal reflection, the study compared two types of parametrial placental invasion (PPI), upper or lower. Surgical approach to PAS follows a conservative-resective method. Before delivery, surgical staging by pelvic fascia dissection established a final diagnosis of placental invasion. In upper PPI cases, the team attempted to repair the uterus after resecting all invaded tissues or performing a hysterectomy. In cases of lower PPI, experts performed a hysterectomy in all cases. The team only used proximal vascular (aortic occlusion) control in cases of lower PPI. Surgical dissection for lower PPI started finding the ureter in the pararectal space, ligating all the tissues (placenta and newly formed vessels) to create a tunnel to release the ureter from the placenta and placenta suppletory vessels. Overall, at least three pieces of the invaded area were sent for histological analysis.

RESULTS

Forty patients with PPI were included, 13 in the upper parametrium and 27 in the lower parametrium. MRI indicated PPI in 33/40 patients; in three, the diagnosis was presumed by ultrasound or medical background. The intrasurgical staging categorizes 13 cases of PPI performed and finds diagnosis in seven undetected cases. The expertise team completed a total hysterectomy in 2/13 upper PPI cases and all lower PPI cases (27/27). Hysterectomies in the upper PPI group were performed by extensive damage of the lateral uterine wall or with a tube compromise. Ureteral injury ensued in six cases, corresponding to cases without catheterization or incomplete ureteral identification. All aortic vascular proximal control (aortic balloon, internal aortic compression, or aortic loop) was efficient for controlling bleeding; in contrast, ligature of the internal iliac artery resulted in a useless procedure, resulting in uncontrollable bleeding and maternal death (2/27). All patients had antecedents of placental removal, abortion, curettage after a cesarean section, or repeated D&C.

CONCLUSIONS

Lower PAS parametrial involvement is uncommon but associated with elevated maternal morbidity. Upper and lower PPI has different surgical risks and technical approaches; consequently, an accurate diagnosis is needed. The clinical background of manual placental removal, abortion, and curettage after a cesarean or repeated D&C could be ideally studied to diagnose a possible PPI. For patients with high-risk antecedents or unsure ultrasound, a T2 weight MRI is always recommended. Performing comprehensive surgical staging in PAS allows the efficient diagnosis of PPI before using some procedures.

Five-year survival after retroperitoneal oncologic resection with and without vascular surgeon intervention

OBJECTIVES

Retroperitoneal tumor resection commonly disturbs major vessels; therefore, surgical teams can recruit vascular surgeons to prevent injuries and improve the prognosis of oncologic patients. The objective of the present study is to establish long-term survival after retroperitoneal tumor resection surgery with an emphasis on the potential impact of preventing or repairing major vessel injuries when tumors are adjacent to the aorta or vena cava.

METHODS

Retrospective case series including all cases of surgical removal of retroperitoneal tumors between 2007 and 2020 in a highly specialized hospital in Mexico City. Long-term survival was defined as 5 years after surgical intervention. Descriptive statistics, group-comparison tests, and regression analysis were performed using Stata 16.

RESULTS

From a total of 70 cases, vascular injury occurred in 30 (42.8%) and the vascular surgeon intervened in 19 (27.1%) of them, 4 (21%) were performed by a vascular surgeon with planned intervention, and in 9 (47.3%) cases the vascular surgeon was called to join the surgery due to emergency. Intraoperative bleeding was 2-fold greater in the group with an emergent participation of vascular surgery in contrast with the planned intervention group (4, 235 mL vs 2, 035 mL, p = 0.04). The regression model revealed a significant association between the intervention of a vascular surgeon and long-term survival (OR 59.3, p = 0.03) after adjusting for sociodemographic and characteristics of oncologic nature.

CONCLUSIONS

Planned intervention of vascular surgeons in retroperitoneal tumor resection may have a positive impact not only in trans-operatory period, but also on long-term survival.

Anatomical basis for the uterine vascular control: implications in training, knowledge, and outcomes

The efficiency of uterine vascular control depends on the precise management of its arterial pedicles and anastomotic network. Although all specialists know the uterine and ovarian arteries, only a few are familiar with the anatomy of the inferior supply system and the connections of the pelvic vessels. For this reason, specific proven inefficient hemostatic procedures are still used worldwide. The pelvic arterial system is extensively interconnected with the aortic, internal iliac, external iliac, and femoral anastomotic components. Most uterine vascular control methods act on the blood supply to the uterus and ovary but rarely on the anastomotic network of the internal pudendal artery. Therefore, the effectiveness of vascular control procedures depends on the topographic area in which they are performed. In addition, the procedure's effectiveness depends on the skill and experience of the operator, among other factors. From a practical point of view, the uterine arterial supply is divided into 2 sectors, sector S1, which involves the uterine body, supplied by the uterine and ovarian arteries, and sector S2, which includes the uterine segment, the cervix, and the upper part of the vagina, provided by pelvis subperitoneal pedicles arising from the internal pudendal artery. As both sectors receive different arterial pedicles, the hemostatic procedures for one or the other are also different. The urgent nature of obstetrical hemorrhage, correct application of a specific technique, surgeon experience, time to provide accurate informed consent in a person under a life-threatening condition, lack of precise or possible harmful consequences of the proposed method, lack of randomized controlled trials or multiple phase II trials, epidemiologic data, qualitative data, and reports from the field from clinicians using an intervention multiple other aspects could be impossible to randomize all patients to obtain more precise information. Apart from actual effectiveness, there are no reliable morbidity data, as most complications are rarely published for various reasons. However, a simple and current presentation of pelvic and uterine blood supply and its anastomotic system allows readers to understand the value of different hemostatic procedures.

Acute venous problems: Integrating medical, surgical, and interventional treatments

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.

An extremely rare disconnection of the external iliac artery and novel collateral remodeling in an endometrial stromal sarcoma woman

Background

Injury to the external iliac artery can have serious consequences and can be extremely challenging for surgeons. Here, we report a patient with bizarre disconnection of the external iliac artery during a laparoscopic operation.

Case presentation

On May 27, 2020, during a laparoscopic pelvic lymphadenectomy operation to treat endometrial stromal sarcoma, we encountered an unusual anatomy: abnormal disconnection of the left external iliac artery in a 26-year-old female patient. The proximal and distal ends of the left external iliac artery demonstrated old narrowing without active bleeding, and the distance between the two disconnected ends was more than 3 cm. The scenario was surprising to all the staff in the operating theater. After a comprehensive assessment of skin temperature, arterial pulsation and arterial blood flow, a multidisciplinary team determined that collateral circulation of the left lower limb had been established and could meet the blood supply of the lower limbs, which was also confirmed three times by computed tomography angiography and Doppler ultrasound of the blood vessels in the abdomen and lower limbs. Sixteen months after the operation, the patient had no obvious abnormality, and the daily activities of the left lower limb were not affected. Follow-up after treatment for the patient is still in progress.

Conclusions

We describe the details of the whole case of disconnection of the external iliac artery. We hope to summarize the experience and lessons learned through this case and a relevant literature review to improve the safety and orderliness of our future clinical work.

The role of oncovascular surgery in gynecologic oncology surgery

Oncovascular surgery is a new term used to define tumor resection with simultaneous reconstruction of the great vessels when the tumor infiltrates or firmly adheres to such vessels. The benefit of oncovascular surgery has been widely described in patients with hepato-biliary-pancreatic cancers, retroperitoneal soft tissue sarcoma, and in other areas of gynecologic oncology, such as the lateral compartment of the pelvis, retroperitoneum, and hepato-biliary-pancreatic region, with an increase in complete resections and without increasing the morbidity and mortality rates. In the latter decades of the past century, several advances and accumulating scientific evidence led gynecologic oncologists to perform more thorough cytoreductive surgeries that included multivisceral resections. But to our knowledge, published studies on the frequency and relevance of vascular surgery in gynecological oncology are scarce. Gynecologic oncologists still do not receive formal training in vascular surgery and additionally, with the current reduction in experience with pelvic and para-aortic lymphadenectomy, as well as other types of radical abdominal and pelvic surgeries, trainees will encounter fewer vascular injuries and the opportunity to deal with a variety of management types required. Well-organized collaboration between each subspecialty with a multidisciplinary approach and adequate pre-operative planning are pivotal. The aim of this review is to pave the way towards the understanding that patients with suspicion of great vessels' infiltration or encasement by tumor require personalized and specialized treatment with the need to form an oncovascular surgery team, and that it is necessary for gynecologic oncology surgeons to take a step forward in surgical training.

Gender, Racial and Ethnic Disparities in Iatrogenic Vascular Injuries among the Ten Most Frequent Surgical Procedures in the United States

OBJECTIVE

Iatrogenic vascular injuries (IaVI's) appear to be increasing, with disparate prevalence across gender, race and ethnicity. We aim to assess the risk of IaVI's across these characteristics.

METHODS

Using the Nationwide Inpatient Sample for the years 2008 to 2015, we identified rates of IaVI's among the top ten most frequently performed inpatient procedures in the United States. Joint point regression was employed to examine the trends in the rates of IaVI's. We also calculated the adjusted odds ratios for IaVI's using survey logistic regression.

RESULTS

During the eight-year study period, a total of 29,877,180 procedures were performed (33.6% hip replacement, 14% knee arthroplasty, 11.2% cholecystectomy, 10.3% spinal fusion, 8.9% lysis of adhesions, 8% colorectal resection, 7.9% partial bone excision, 5% appendectomy, 0.6% percutaneous coronary angioplasty, 0.6% laminectomy). A total of 194,031 (0.65%) IaVI's were associated with these procedures. The incidence of IaVI's increased over time with an average annual percentage change (AAPC) of 4.2% (95% CI: 3.1, 5.4; P < 0.01). More females (105,747; 54.5%) than males (88,284; 45.5%) suffered IaVI's during their hospital admission (P < 0.01). Patients 70 years of age and older had the highest incidence of IaVI's (12,244,082; 34.3%; P ≤ 0.01). Among the ten index procedures, Non-Hispanic (NH) Whites underwent the highest proportion of procedures (14.1 procedures/100 hospitalizations; P < 0.01) and cholecystectomy was associated with the highest rate of IaVI's (19.4 per 1000 hospitalizations, P ≤ 0.01). Overall, patients from the lowest income quartile were least likely to suffer IaVI's (0.83 95% CI 0.79-0.88, P < 0.01) compared to the highest income quartile. All form of healthcare coverage increased the odds of IaVI's: Medicaid (1.07 95% CI 1.07-1.13, P < 0.01); Private insurance (1.35 95% CI 1.3-1.39, P < 0.01); Self-pay or no charge (1.45 95% CI 1.38-1.52, P < 0.01). IaVI's increased the odds of in-hospital mortality in all groups (1.25 95% CI 1.14-1.35, P < 0.01) and more pronounced in NH-Blacks (1.51 95% CI 1.15-1.99, P < 0.01). In the overall cohort, urban teaching hospitals observed the highest odds of in-hospital mortality (1.11 95% CI 1.07-1.15, P < 0.01).

CONCLUSION

Between 2008 to 2015, IaVI's rates for the top ten most frequently performed inpatient procedures increased by 33.6% (4.2% annually; P < 0.01). The elderly, females, and Hispanics more frequently had hospitalizations complicated by IaVI's. Overall, IaVI's independently increased the adjusted odds of mortality by 25%. IaVI's were most fatal among Blacks, about 50% elevated risk of death compared to NH-Whites. These benchmarks will be critical to future efforts to reduce IaVI, and associated healthcare disparities.

Absence of right common iliac vein causing suprapubic and scrotal varices in a young athletic man

We have described the case of a 26-year-old man who had presented to his primary care physician with persistent, painful varices across his lower abdomen and bilateral tender scrotal varicoceles, which intensified with exercise. Thorough investigations revealed a congenitally atretic right common iliac vein with right-to-left collateralization of the femoral and internal iliac veins. This shunting resulted in the development of suprapubic and pelvic and gonadal varicosities, which provided a critical venous outflow pathway for his right lower extremity. Heightened vigilance is, hence, paramount if our patient requires future abdominal and urologic procedures. Moreover, the present case has highlighted the importance of considering deep system venous anomalies when determining the differential diagnosis for venous diseases.

Postoperative complications of colorectal cancer

Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.

Postoperative adverse events secondary to iatrogenic vascular injury during anterior lumbar spinal surgery

BACKGROUND

Anterior lumbar spine surgery (ALSS) requires mobilization of the great vessels, resulting in a high risk of iatrogenic vascular injury (VI). It remains unclear whether VI is associated with increased risk of postoperative complications and other related adverse outcomes.

PURPOSE

The purpose of this study was to (1) assess the incidence of postoperative complications attributable to VI during ALSS, and (2) outcomes secondary to VI such as procedural blood loss, transfusion of blood products, length of stay (LOS), and in hospital mortality.

STUDY DESIGN

Retrospective propensity-score matched, case-control study at 2 academic and 3 community medical centers, PATIENT SAMPLE: Patients 18 years of age or older, undergoing ALSS between January 1st, 2000 and July 31st, 2019 were included in this analysis.

OUTCOME MEASURES

The primary outcome was the incidence of postoperative complications attributable to VI, such as venous thromboembolism, compartment syndrome, transfusion reaction, limb ischemia, and reoperations. The secondary outcomes included estimated operative blood loss (milliliter), transfused blood products, LOS (days), and in-hospital mortality.

METHODS

In total, 1,035 patients were identified, of which 75 (7.2%) had a VI. For comparative analyses, the 75 VI patients were paired with 75 comparable non-VI patients by propensity-score matching. The adequacy of the matching was assessed by testing the standardized mean differences (SMD) between VI and non-VI group (>0.25 SMD).

RESULTS

Two patients (2.7%) had VI-related postoperative complications in the studied period, which consisted of two deep venous thromboembolisms (DVTs) occurring on day 3 and 7 postoperatively. Both DVTs were located in the distal left common iliac vein (CIV). The VI these patients suffered were to the distal inferior vena cava and the left CIV, respectively. Both patients did not develop additional complications in consequence of their DVTs, however, did require systemic anticoagulation and placement of an inferior vena cava filter. There was no statistical difference with the non-VI group where no instances (0%) of postoperative complications were reported (p=.157). No differences were found in LOS or in hospital mortality between the two groups (p=.157 and p=.999, respectively). Intraoperative blood loss and blood transfusion were both found to be higher in the VI group in comparison to the non-VI group (650 mL, interquartile range [IQR] 300-1400 vs. 150 mL, IQR 50-425, p≤.001; 0 units, IQR 0-3 vs. 0 units, IQR 0-1, p=.012, respectively).

CONCLUSION

This study found a low number of serious postoperative complications related to VI in ALSS. In addition, these complications were not significantly different between the VI and matched non-VI ALSS cohort. Although not significant, the found DVT incidence of 2.7% after VI in ALSS warrants vigilance and preventive measures during the postoperative course of these patients.

Safety and Feasibility of No.12a Lymph Node Dissection by Portal Vein Approach in Radical Laparoscopic Gastrectomy for Gastric Cancer

Background:

Traditional laparoscopic No.12a lymph node dissection in radical gastrectomy for gastric cancer may damage the peripheral blood vessels, and is not conducive to the full exposure of the portal vein and the root ligation of the left gastric vein. We recommend a new surgical procedure, the portal vein approach, to avoid these problems.

Methods:

25 patients with advanced gastric cancer underwent radical laparoscopic gastrectomy and No.12a lymph node were dissected by portal vein approach, including 7 cases with total gastrectomy, 18 cases with distal gastric resection, 14 males and 11 females. Operative time, intraoperative blood loss, time to first flatus, postoperative hospital stay, number of total lymph node dissection and No.12a lymph node dissection, No.12a lymph node metastasis rate and postoperative complications were statistically observed.

Results:

All the patients were operated successfully and No.12a lymph node were cleaned by portal vein approach. A total of 683 lymph nodes were dissected, with the average number of lymph nodes dissection and positive lymph nodes were (27.3 ± 12.7) and (3.8 ± 5.6) respectively. The average number of No.12a lymph node dissection was (2.4 ± 1.95) and the metastasis rate of No.12a lymph node was 16% (4/25). The average operation time of radical laparoscopic distal and total gastrectomy were (239.2 ± 51.4) min and (295.1 ± 27.7) min respectively. The mean intraoperative blood loss was (134.0 ± 65.7) ml, and postoperative first anal exhaust time was (2.24 ± 0.86) d. The mean time to fluid intake was (4.2 ± 1.7) d, and postoperative hospitalization time was (9.6 ± 5.0) d. Without portal vein injure, anastomotic leakage, gastrointestinal bleeding, intestinal obstruction and other complications were observed in all patient.

Conclusion:

Our results show that the laparoscopic No.12a lymph node dissection by portal vein approach for gastric cancer is safe, feasible and has certain clinical application value.

Value of Angioembolization in the Treatment of Iatrogenic Renal Vascular Injury Assisted by 3-Dimensional Digital Subtraction Angiography

BACKGROUND This study was conducted to investigate the reliability and efficacy of polyvinyl alcohol combined with coils in the embolization of iatrogenic renal vascular injury with the assistance of 3-dimensional digital subtraction angiography (3D-DSA). MATERIAL AND METHODS Twenty-six patients with minimally invasive renal bleeding who underwent transarterial embolization from January 2012 to January 2019 in our hospital were included in the study. We obtained demographic data from these patients, as well as information on clinical presentation, renal procedures used for treatment, and perioperative details. The changes in renal function tests, serum hemoglobin, serum hematocrit, and technetium Tc 99m dimercaptosuccinic acid (99mTc-DMSA) levels pre- and postembolization were compared. In addition, the embolic area and the technical and clinical success rates were analyzed. Finally, an angiographic manifestation of the renal artery, 3D-DSA, and the effect of embolization were analyzed retrospectively. RESULTS All patients achieved technical and clinical success after embolization (100%, 26/26). There were no significant differences between pre- and postoperative estimated glomerular filtration rate, serum parameters, and 99mTc-DMSA. The embolic area was 12%±10%. Patients did not exhibit severe complications during the follow-up period. CONCLUSIONS Proximal embolization technique assisted by 3D-DSA for renal iatrogenic hemorrhage and vascular lesions is both safe and efficacious, offering high rates for both clinical and technical success. It maximizes the protection of the kidney and reduces the rate of renal resection.

Endovascular balloon occlusion during reconstruction of portal vein injury

PURPOSE

Repair of portal vein injury in a hostile abdomen can be very challenging, complicated by massive hemorrhage or stenosis. It can seldom be successfully carried out, even by experienced hepatobiliary surgeons. The ideal venous clamping technique is often not feasible and increases the risk of lethal portal vein laceration. The common mistake being the forceful use of clamps around the vein in the attempt to obtain vascular control, resulting in additional injuries.

METHODS

We provide a descriptive report of two cases detailing a careful step-by-step technique for the management of portal vein injury by inserting an endovascular balloon inflated with serum to control bleeding and repair the vein.

RESULTS

In patients who required this technique, no bleeding recurrence, nor portal vein thrombosis or stenosis was detected by CT-scan during follow-up.

CONCLUSION

The endovascular balloon occlusion technique for the reconstruction of portal vein injuries in hostile abdomen is a safe and life-saving procedure that should be part of the armamentarium of visceral surgeons.

[Vascular injuries during urologic surgery]

This review article summarizes the epidemiology of vascular injuries during urologic surgery and discusses intraoperative strategies to control bleedings. Techniques of vascular approaches (arteries and veins) are discussed and tricks for vascular repair are explained. Generally, vascular injuries during urologic surgery are rare. However, hemorrhage due to vascular injury is a common cause of critical morbidity and mortality in the perioperative period. Susceptibility to vascular complications such as oncological debulking and revision surgery increase risk for damage. As vascular injuries range from arrosion to avulsion, treatment is also broad, ranging from vascular suture to open or endovascular repair. Prevention of exsanguination requires visual control to stop the bleeding. The surgeon must act quickly to initiate appropriate repair, aiming for damage control and stabilization of the patient. Planning the surgery and consulting an experienced surgeon are decisive for successful management. Catastrophic bleeding has to be controlled and in the case of arterial injury it is often necessary to reconstitute perfusion. Reconstructions such as vascular anastomoses, patch angioplasty or interposition grafts are the preferred surgical techniques which are influenced by the nature of the injury. Vessels have to be thoroughly prepared before cross clamping to prevent injury by vascular clamps. Veins can often be ligated. Endovascular repair is also a possibility to control the bleeding, but nowadays it is often a definitive therapy method. For example, resuscitative endovascular balloon occlusion is useful to stabilize the patient and then to initiate vascular repair. Depending on the type of surgery performed, different vessels are concerned. Severe bleeding is usually located retroperitoneal affecting the aorta, renovisceral and iliac vessels. Predisposing urologic operations are lymphadenectomy, nephrectomy and (cysto)prostatectomy and also the laparoscopic approach can cause bleeding complications.

Vascular repairs in gynecologic operations are uncommon but predict major morbidity and mortality

OBJECTIVE

Gynecologic surgery has potential for adjunct vascular interventions, given the proximity of major intra-abdominal and pelvic blood vessels. Our goal was to determine contemporary incidence, associations, and outcomes of vascular repairs in gynecologic operations.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2005-2017) was queried for patients undergoing elective gynecologic operations. Vascular repairs were performed concurrently or during reoperation. Univariable and multivariable analyses evaluated associations with vascular repairs and 30-day morbidity.

RESULTS

A total of 201,224 gynecologic operations were identified: hysterectomy (88.3%), myomectomy (5.9%), adnexal surgery (3.5%), vulvovaginectomy/other (1.1%), nonadnexal tumor or cyst excision (0.5%), ectopic pregnancy treatment (0.4%), and pelvic lymphadenectomy (0.3%). There were 187 vascular repairs in 176 (0.09%) patients. Repairs were typically concurrent (89.8%) and most commonly included open abdominal blood vessel repair (51.8%), major abdominal artery ligation (25%), vena cava reconstruction/ligation (6%), common iliac vein ligation (4.2%), and aorta/great vessel repair (4.2%). A minority were performed endovascularly (1.7%). Patients undergoing vascular repairs were older (56 vs 46 years), were more likely to have an open vs minimally invasive/vaginal operation (71.6% vs 28.4%), and were more likely to have a hysterectomy (85.2%; P < .001 for all). In multivariable analysis, vascular repairs were observed more often with hysterectomy (odds ratio [OR]; 7.63, 95% confidence interval [CI], 2.28-25.55; P = .001) and open vs minimally invasive/vaginal operations (OR, 5.24; 95% CI, 2.64-10.42; P < .001). Vascular repairs were also more common for patients with malignant disease (OR, 2.84; 95% CI, 1.78-4.53; P < .001), patients assigned to American Society of Anesthesiologists class 3 or class 4 (OR, 1.85; CI, 1.36-2.53; P = .002), and patients without obesity (OR, 1.45; 95% CI, 1.08-1.96; P = .014). Vascular repairs independently predicted major morbidity and mortality (OR, 7.26; 95% CI, 5.26-10.03; P < .001) after adjustment for open operative approach, American Society of Anesthesiologists class 3 or class 4, and hysterectomy.

CONCLUSIONS

Whereas vascular repairs during gynecologic operations are rare, they are associated with morbidity and mortality. These findings provide an evidence base for risk assessment and informed consent.

Simulated management of inferior vena cava injury during robotic paraaortic lymphadenectomy utilizing the porcine model

Injury of the inferior vena cava is an infrequent but serious complication of paraaortic lymphadenectomy. Training in the management of this injury might be enhanced through animate simulation. Our objective was to assess a simulated animal model for training in intraoperative management of inferior vena cava injury in the context of robotic paraaortic lymphadenectomy. We used a female domestic pig to create an injury of the inferior vena cava, which was then managed two ways with robotically assisted surgery. Edited videos of the two models were assessed by 32 senior learners and 23 attending faculty. The assessments included key competencies and domains of fidelity. A scale of poor, fair, or good was utilized. The injury and management simulated those seen in humans, both anatomically and surgically, although deficiencies were noted. Specifically, a reduced rapidity of bleeding and a related greater ease of control contributed to lower ratings for some aspects of fidelity. Fidelity and addressing the key competency of suture repair also received some lower ratings, particularly from vascular surgeons and their trainees. The porcine model for simulation of inferior vena cava injury during robotically assisted paraaortic lymphadenectomy may be useful for training purposes.

Anatomical Variations of Iliac Vein Tributaries and Their Clinical Implications During Complex Pelvic Surgeries

BACKGROUND

During high sacrectomies and lateral pelvic compartment exenterations, isolating the external and internal iliac veins within the presacral area is crucial to avoid inadvertent injury and severe hemorrhage. Anatomical variations of external iliac vein tributaries have not been previously described, whereas multiple classifications of internal iliac vein tributaries exist.

OBJECTIVE

We sought to clarify the iliac venous system anatomy using soft-embalmed cadavers.

DESIGN

This is a descriptive study.

SETTINGS

This study was conducted in Chulalongkorn University, Thailand.

PATIENTS

We examined 40 iliac venous systems from 20 human cadavers (10 males, 10 females).

INTERVENTIONS

Blue resin dye infused into the inferior vena cava highlighted the iliac venous system, which was meticulously dissected and traced to their draining organs.

MAIN OUTCOME MEASURES

Iliac vein tributaries and their valvular system were documented and analyzed.

RESULTS

The external iliac vein classically receives 2 tributaries (inferior epigastric and deep circumflex iliac) near the inguinal ligament. However, external iliac vein tributaries in the presacral area were found in 20 venous systems among 15 cadavers (75%). The mean diameter of each tributary was 4.0 ± 0.35 mm, with 72% arising laterally. We propose a simplified classification for internal iliac vein variations: pattern 1 in 12 cadavers (60%) where a single internal iliac vein joins a single external iliac vein to drain into the common iliac vein; pattern 2 in 7 cadavers (35%) where the internal iliac vein is duplicated; and pattern 3 in 1 cadaver (5%) where bilateral internal iliac veins drain into a common trunk before joining the common iliac vein bifurcation.

LIMITATIONS

This study is limited by the number of cadavers included.

CONCLUSIONS

A comprehensive understanding of previously unreported highly prevalent external iliac vein tributaries in the presacral region is vital during complex pelvic surgery. A simplified classification of internal iliac vein variations is proposed. See Video Abstract at http://links.lww.com/DCR/A900.

Iatrogenic Vascular Injuries of the Abdomen and Pelvis: The Experience at a Hellenic University Hospital

Background:

The aim of this study is to present the experience of a Vascular Division at a Hellenic University hospital concerning the management of iatrogenic vascular injuries (IVIs) of the abdomen or pelvis.

Patients and Methods:

This is a retrospective study evaluating all IVIs reported during a 10-year period in our institution. Only injuries warranting a vascular surgeon consultation were included in the study. Non-iatrogenic injuries were not included. Mortality and major complications within 30 days were evaluated.

Results:

Overall, 70 cases were recorded, with 41% being venous and 59% being arterial injuries. Iliac arteries (51%) were the most common location and rupture/lacerations (73%) were the most common type of injury. General surgery (61.5%) and cardiology (30%) procedures were the most frequently involved procedures. A 30-day mortality was 5.7%, with 30% of cases treated conservatively. Synthetic bypass grafting (odds ratio [OR] = 65.0; 95% confidence interval [CI], 4.022-1050.358; P = .003) and male gender (OR = 83.77; 95% CI, 4.040-1736.738; P = .004) were associated with death.

Conclusions:

Iatrogenic vascular injuries of the abdomen or pelvis are usually associated with general surgery and endovascular procedures. When vascular consultation is requested early, mortality could remain low. However, a selected number of stable patients with retroperitoneal or pelvic hematomas could be treated conservatively, yielding satisfying results.

Presentation patterns and prognosis of 109 isolated venous injuries in 99 patients

Objectives

To identify outcome predictors of isolated venous injuries (VIs).

Methods

Retrospective analysis of prospectively collected information.

Results

A total of 99 patients with 109 isolated VI were included. All-cause mortality was 18/99 (18%) and mortality related to the VI was 10/99 (10%). On multivariate analysis, independent predictors of all-cause mortality included age (odds ratio – OR – 1.06, p = 0.042), external cause – trauma and foreign body retention – of VI (OR 34.62, p = 0.002) and the number of red blood cell units transfused intraoperatively (OR 2.10, p < 0.001), while independent predictors of VI-related mortality included external cause of VI (OR 47.60, p = 0.001) and the number of red blood cell units transfused intraoperatively (OR 1.72, p = 0.003).

Conclusions

VIs due to external causes have a high mortality rate. On the other hand, VIs due to internal causes (iatrogenic injuries during a surgical procedure) are managed promptly and have a very low mortality related to the VI.

Vascular Injury During Urologic Surgery: Somebody Call My Mother

PURPOSE OF REVIEW

To provide the critical elements to effectively manage hemorrhage from vascular injuries sustained during planned urological interventions.

RECENT FINDINGS

The frequency of intraoperative vascular injuries is increasing. However, literature concerning the management of iatrogenic operative vascular injuries is scarce. Although rare, intraoperative vascular injuries may be associated with potential catastrophic complications and death. The decision-making process following a potential life-threatening intraoperative vascular injury occurs in a very short time frame. Appropriate knowledge of the critical elements to identify the source of bleeding, initiate first-line hemostatic measures, select the candidate for damage control strategies, and perform the indicated operative repairing maneuvers and techniques have been proved crucial to ensure hemodynamic stability and bleeding cessation. The key surgical principles to counteract the impact of exsanguinating bleeding, and the aim to obtain the best achievable outcomes after definitive repair, are described in detail in this review.

Surgical Anatomy of the Superior Mesenteric Vessels Related to Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Mesopancreas dissection with central vascular ligation and the superior mesenteric artery (SMA)-first approach represent the cornerstone of current principles for radical resection for pancreatic head cancer. The surgeon dissecting around the SMV and SMA should be aware regarding the anatomical variants in this area. The aims of this systematic review and meta-analysis are to detail the surgical anatomy of the superior mesenteric vessels and to propose a standardized terminology with impact in pancreatic cancer surgery.

METHODS

We conducted a systematic search to identify all published studies in PubMed/MEDLINE and Google Scholar databases from their inception up to March 2017.

RESULTS

Seventy-eight studies, involving a total of 18,369 specimens, were included. The prevalence of the mesenteric-celiac trunk, replaced/accessory right hepatic artery (RRHA), common hepatic artery, and SMV inversion was 2.8, 13.2, 2.6, and 4.1%, respectively. The inferior pancreaticoduodenal artery has its origin into the first jejunal artery, SMA, and RRHA, in 58.7, 35.8, and 1.2% of cases, respectively. The SMV lacks a common trunk in 7.5% of cases. The first jejunal vein has a trajectory posterior to the SMA in 71.8% of cases. The left gastric vein drains into the portal vein in 58%, in splenic vein (SV) in 35.6%, and into the SV-PV confluence in 5.8% of cases.

CONCLUSIONS

Complex pancreaticoduodenal resections require detailed knowledge of the superior mesenteric artery and vein, which is significantly different from the one presented in the classical textbooks of surgery. We are proposing the concept of the first jejunopancreatic vein which impacts the current oncological principles of pancreatic head cancer resection.

Control of inferior vena cava injury during laparoscopic surgery using a double balloon-equipped central venous catheter: proof of concept in a live porcine model

BACKGROUND

Iatrogenic inferior vena cava (IVC) injury is a rare but potentially life-threatening complication during laparoscopic surgery. This experimental study aimed to assess the hemostatic ability of a new device, double balloon-equipped central venous (DB-CV) catheter, for IVC injury.

METHODS

The DB-CV catheter comprises a triple-lumen sphincterotome combined with two dilating balloons having a diameter of 25 mm. The experimental procedures were performed in five pigs. The DB-CV catheter was inserted via the right femoral vein. For the IVC occlusion test, correct placement of the balloons was confirmed by indocyanine green fluorescence imaging, and hemodynamic data were recorded. For the IVC injury test, a 3- to 4-mm circumferential incision was created in IVC, and hemostasis was initiated using balloon inflation 5 s after the injury.

RESULTS

Hemodynamic changes were minimal, with a 20 mmHg reduction in the mean arterial pressure because of IVC occlusion. All bleeding from IVC injuries was successfully temporarily stopped by direct balloon compression, with a mean time to hemostasis of 69 s and mean blood loss of 32 ml. Subsequently, the positioning of IVC injuries between two balloons made it possible to suture the injured IVC.

CONCLUSIONS

Balloon occlusion using the DB-CV catheter provides a rapid temporal hemostatic effect and can overcome the serious condition of massive hemorrhage from IVC injuries.

Intraoperative Vascular Surgical Consultation during Non-Vascular Surgeries in Tertiary Centers by Vascular Surgeon

Purpose

There are many types of intraoperative consultations by vascular surgeons during non-vascular surgery. Therefore, we examined the current state of intraoperative consultations during non-vascular surgery in a single center.

Materials and Methods

From January 2014 to December 2015, we reviewed records of 40 patients (0.3%) who received an intraoperative consultation from a vascular surgeon for 10,734 non-vascular surgeries in Inha University Hospital. We examined patient characteristics, operative details, and clinical results.

Results

There were 40 intraoperative vascular surgical consultations relating to bleeding (n=14, 35.0%), dissection from the vessel (n=13, 32.5%), arterial occlusion (n=10, 25.0%), and retroperitoneal approach (n=3, 7.5%). The locations of surgery were lower extremity (n=10, 25.0%), kidney (n=8, 20.0%), spine (n=6, 15.0%), pelvis (n=6, 15.0%), head and neck (n=4, 10.0%), abdomen (n=4, 10.0%), and upper extremity (n=2, 5.0%). The methods of surgery included primary closure or ligation (n=17, 42.5%), end-to-end anastomosis (n=12, 30.0%), bypass (n=10, 25.0%), thrombectomy (n=4, 10.0%), retroperitoneal approach (n=3, 7.5%), and embolization (n=2, 5.0%). Postoperative treatment was performed in the intensive care unit for 13 patients (32.5%), while 3 patients (7.5%) died following surgery.

Conclusion

Intraoperative consultation by vascular surgeons during non-vascular surgery occurred in approximately 0.3% of non-vascular surgeries. The region undergoing operation and type of surgery were variable. Therefore, it is necessary for vascular surgeons to have a comprehensive knowledge of vascular anatomy and to make rapid surgical decisions.

Superior Mesenteric Vein Injury During Oncologic Right Colectomy: Current Vascular Repair Modalities

Purpose:

To review the different vascular repair options of superior mesenteric vein (SMV) damage during oncologic right colectomy.

Methods:

This is a retrospective chart review of 5 cases in which severe damage to the SMV occurred during oncological right colectomy in an academic medical center.

Results:

During a 10-year study period, we encountered 5 cases in which severe damage to the SMV and its tributaries occurred. Two of the patients underwent primary venous repair for partial lacerations. The other 3 underwent interposition graft repair using a great saphenous vein (GSV) graft. Two of the grafts remained patent, while the third required replacement with a bovine pericardial patch.

Conclusions:

The SMV injury during oncologic right colectomy is a technically challenging injury. Based on our own experience and review of the literature, we formulated the following set of recommendations: (1) Venous ligation should be avoided, and revascularization should be attempted whenever feasible. (2) Primary venorrhaphy in cases of partial lacerations is the preferred treatment option. (3) End-to-end anastomosis is an efficient but seldom available repair option in the setting of complete SMV transection without segmental loss. (4) Autologous vein graft using the GSV is the preferred mode of repair during SMV injury with tissue loss. (5) Use of polytetrafluoroethylene (PTFE) graft should be avoided if possible due to greater risk of graft contamination. (6) A low threshold for reexploration depending on laboratory and imaging findings is advisable.

Intra-Abdominal Hemorrhage Complicating Electrothermal Arterial Injury During Pelvic Surgery: A Case Report

Iatrogenic vascular injury is a potentially serious complication of surgical procedures. Here we report a case of delayed fatal intra-abdominal hemorrhage because of electrocautery injury of a right external iliac artery. The decedent, a 31-year-old woman, died suddenly on postoperative day 1 after a laparoscopic staging operation for an ovarian tumor. Her past medical history included a recent diagnosis of a microinvasive carcinoma in the background of a mucinous cystic neoplasm of the right ovary. Postmortem examination revealed a young woman with evidence of emergency intervention, recent laparoscopic pelvic surgery, and pale hypostasis limited to the back surfaces of the body. The internal examination confirmed the postmortem computed tomography findings of a large amount of blood in the pelvic and abdominal cavities and evidence of recent surgical intervention. The soft tissues around the aorta and major pelvic vessels showed electrocautery change and marked perivascular hemorrhage preferentially surrounding the right external iliac artery. Histological examination of the vascular bundle showed an electrocautery injury of the arterial wall: transmural necrosis, acute inflammation, and hemorrhage. In this report, we offer an approach to a postmortem examination in postoperative deaths with emphasis on deaths due to iatrogenic vascular injuries and discuss the rationale for determining the manner of death.

Primary Endovascular Repair of Ilio-Caval Injury Encountered during Anterior Exposure Spine Surgery: Evolution of the Paradigm

BACKGROUND

Rates of major venous injury are now being reported at between 1% and 15%. Risk factors for injury include the previous spine surgery, level of exposure, and number of retractors used. To review and describe the evolution of our use of stent grafts for repair of life-threatening ilio-caval injuries encountered during anterior exposure lumbosacral (L-S) spine surgery from rescue utilization after failed direct repair to preferred modality using occlusion balloons and covered stents akin to the modern management of the ruptured abdominal aortic aneurysm (AAA) with endovascular aneurysm repair.

METHODS

Five-year retrospective review of all anterior and retroperitoneal spine procedures was performed at our institution.

RESULTS

One hundred two procedures were done. Major ilio-caval injury occurred in 3/102 (2.9%) cases. Average blood loss per case decreased as our approach evolved from unsuccessful direct open repair with percutaneous endovascular rescue to primary percutaneous endovascular repair. All treated patients had patent venous repair in short-term follow-up with computed tomography angiography.

CONCLUSIONS

Identification and rapid direct repair of major ilio-caval injuries during anterior approach spine surgery can be extremely challenging. When control of these potentially fatal injuries is required, our choice is primary endovascular repair using the modern techniques for endovascular management of ruptured AAA with endovascular aneurysm repair.

The enduring patency of primary inferior vena cava repair

BACKGROUND

Inferior vena cava repair after planned and unplanned venotomy is performed by either interposition bypass, patch venopasty, or lateral venorrhaphy and primary repair. Primary repair of the inferior vena cava avoids the use of foreign material and allows an all-autologous repair in an expeditious fashion. The purpose of this study was to demonstrate the utility of inferior vena cava repair, determine the degree of inferior vena cava stenosis, and examine clinical outcomes after primary repair.

METHODS

We conducted a single-center retrospective review of patients who underwent primary inferior vena cava repairs between January 2002 and January 2014 at a tertiary care center. Primary repair followed lateral venorrhaphy for tumor extraction or for repair of an iatrogenic inferior vena cava injury. Patient demographics, cross-sectional vena cava dimensions, and patient outcomes were tabulated.

RESULTS

In total, 47 (30 men and 17 women) patients underwent primary inferior vena cava repair (median age 58 years, range 31-83 years). Twenty-six patients (15 men and 11 women) underwent en bloc radical nephrectomy, inferior vena cava tumor thrombus extraction, and primary lateral venorrhaphy (median age 61 years, range 39-83 years). The majority, 92% of these patients, had renal cell carcinoma on final pathology, with a median follow-up period of 39 months (range 1-108 months). Twenty-one patients (15 men and 6 women) underwent primary repair for iatrogenic inferior vena cava injury (median age 54 years, range 31-82 years). The median follow-up period was 18.5 months (3-110 months). Clinic follow-up with postoperative imaging was obtained in 76.9% of those undergoing tumor thrombus extraction (n = 20) and 76.2% of those undergoing repair of an iatrogenic injury (n = 16). Overall, there was a 13% infrarenal inferior vena cava diameter loss, 17% inferior vena cava diameter loss at the level of the renal veins, and 10% suprarenal inferior vena cava diameter loss when comparing postoperative with preoperative imaging. All patients remained asymptomatic; therefore, inferior vena cava narrowing associated with primary repair was clinically insignificant.

CONCLUSION

Primary inferior vena cava repair is associated with less than 20% inferior vena cava diameter loss and does not compromise venous outflow from the extremities. Primary inferior vena cava repair is a safe and expeditious technique that provides excellent clinical outcomes and long-term patency.

Iatrogenic vascular injuries with lethal outcome

BACKGROUND

The aim was to study the nature of iatrogenic vascular injuries (IVIs) associated with postoperative death within 30 days.

METHODS

Patients who had undergone vascular surgery for IVIs and were reported prospectively to the Swedish national vascular registry during 1987-2008 were identified. They were cross-checked with the national population registry. Those who died within 30 days of surgery were studied regarding case records and death certificates.

RESULTS

A total of 56 patients with postoperative death within 30 days after IVI were identified. Among them, 52 case records were retrieved (93 %). In 24 cases the IVIs were caused by puncture during endovascular procedures (13 hemorrhage, 11 occlusive thrombosis), 11 by penetrating trauma during open surgery, 6 by occlusion after external compression, 6 by percutaneous accidental arterial puncture. Main symptoms were peripheral ischemia (19/52, 37 %), external bleeding (14, 27 %), and hypovolemic shock without external bleeding (10, 19 %). Main specialties involved were interventional radiology (n = 18), general surgery (n = 9), and interventional cardiology (n = 8). Overall, 22 (42 %) were avoidable, and only 13 (25 %) underwent autopsy. Within 2 weeks, 36 patients (69 %) were dead. Also, there was a higher proportion with uncertain correlation between IVI and death.

CONCLUSIONS

Interventional radiology, general surgery, and cardiology are the main specialities involved in IVIs with lethal outcome. Not all fatalities after IVI are attributable to the injury itself, but almost half of the injuries were considered avoidable.

Application of Guglielmi detachable coils in embolization of iatrogenic renal hemorrhage

BACKGROUND

This study aims to evaluate the application value of Guglielmi detachable coils (GDCs) in the embolization of iatrogenic renal hemorrhage.

METHODS

Twelve iatrogenic renal hemorrhage patients who failed conservative treatment were randomly treated by superselective transcatheter arterial embolization (TAE) with GDCs, gelatin sponge, and microcoil embolization, respectively. The efficacy of treatment, damage to renal function, and renal infarct size were observed.

RESULTS

Embolizations were successful in all patients on the first attempt. Hematuria disappeared completely after the surgery; no recurrence of hemorrhage and no abnormal renal function were observed during the follow-up period. Postoperative angiography revealed that patients treated with GDC embolization had minimum renal infarcts.

CONCLUSIONS

In summary, while superselective TAE provides a safe and effective therapy in patients with iatrogenic renal hemorrhage, the application of GDCs can better prevent the loss of normal renal tissue after embolization.

Endovascular treatment of an iatrogenic perforation of the internal iliac vein

We describe the case of a 48-year-old woman who developed a pelvic abscess after extensive surgery for recurrent ovarian cancer. While draining the abscess, a massive venous bleeding occurred. The bleeding was controlled by introducing a Foley catheter transrectally, occluding the perforated internal iliac vein. However, the catheter was positioned unintentionally in the inferior vena cava, causing hemodynamic instability. The iatrogenic perforation of the internal iliac vein was managed successfully with an endovascular approach using thrombin in combination with balloon-induced thrombosis. If iatrogenic venous bleeding occurs and the placement of a stent is precluded, balloon-induced thrombosis in combination with thrombin injection can be used successfully.

Treatment of major vein injury with the hemostatic fleece TachoSil by interposing a peritoneal patch to avoid vein thrombosis: A feasibility study in pigs

Background:

Vein lacerations in awkward locations are difficult to repair and carry high mortality. The hemostatic fleece, TachoSil, is effective in preventing intraoperative bleeding in different settings, but has not been recommended for use in large vein injury. TachoSil with a peritoneal patch interposed to avoid vein thrombosis has been reported as a method to obtain hemostasis in vein laceration, but further studies of this method are needed.

Materials and Methods:

A 1.5 × 1 cm defect was created in the vena cava in five pigs. A 26 × 32 mm peritoneal patch was applied on the coagulant side of a 48 × 48 mm TachoSil sheet, and used to cover the defect. Light compression with a wet sponge was applied for 3 min. No vascular suturing was performed.

Results:

Successful hemostasis was obtained in four out of the five pigs although the minimum TachoSil gluing zone surrounding the peritoneal patch was only 0–2 mm. The fifth pig died of hemorrhage 30 min after surgery due to a 4-mm stretch with no TachoSil gluing zone outside the peritoneal patch. At six days postoperatively the peritoneal patch was well integrated into the vein wall. After 28 days, the peritoneal patch was almost indiscernible from surrounding vein endothelium.

Conclusions:

Vein wall defects can be repaired using TachoSil with a peritoneal patch interposed to prevent contact between the thrombogenic TachoSil sheet and the vein lumen. An adequate TachoSil gluing zone all around the patch is essential.

Venous injury during lymphadenectomy: management without laparotomy

During robotically-assisted pelvic lymphadenectomy, four venous injuries occurred that did not resolve with pressure. After the application of tightly woven, oxidized regenerated cellulose and a fibrin sealant, all four venotomies were hemostatic. There were no sequelae.

Intraoperative injuries during liver resection: analysis of 1,005 procedures

PURPOSE

Risk of liver resection has been well investigated in many studies. However, the problem of intraoperative injuries is rarely mentioned. The aim of this study was to assess the incidence, the type, and management of intraoperative injuries during liver resection.

METHODS

A total of 1,005 liver resections between 2004 and 2009 were included in this retrospective investigation. We analyzed the incidence of intraoperative injuries, risk factors, and an impact on patients' clinical outcome.

RESULTS

The overall incidence of intraoperative injuries was 4.4% (44 of 1,005). Injuries of the diaphragm (1.6%, 16 of 1,005) and hepatocaval junction (1%, 10 of 1,005) were the most frequent. In multivariate analysis, tumor recurrence (p = 0.0199) and tumor size (p = 0.0317) were the only independent risk factors for diaphragm injuries, whereas the extent of resection (p = 0.0007) was the only independent risk factor for caval or hepatic vein injuries. Injuries of the inferior vena cava or hepatic veins significantly increased perioperative mortality (p = 0.0005).

CONCLUSIONS

Minor injuries causing no significant complications were the most frequent. However, prevention and proper management of the rare injuries of hepatocaval junction are essential to avoid increased mortality in major liver resections.

Stent placement in hemodialysis access: historical lessons, the state of the art and future directions

Vascular access stenosis in patients undergoing chronic hemodialysis is a major issue that is associated with increased morbidity, mortality, and cost of medical care. Recent data have emphasized that endovascular stents could be used in the treatment of central as well as peripheral stenotic lesions. In general, a peripheral or central vein lesion that is elastic or recurs within a three-month period after an initially successful balloon angioplasty or a stenosis where surgical revision is not possible are some indications for intravascular stent placement. Recent reports have expanded the role of stents in the management of pseudoaneurysms associated with dialysis access. In this context, the utilization of these devices must take into account a fair comparison with the traditional (surgical) approaches regarding effectiveness as well as costs. This report describes the role of stents in arteriovenous dialysis access. In addition, some of the recent advances in the structure and complicating issues such as stent fracture, migration, and infection, as well cannulation through the stent, are discussed.

Fatal vascular injury as a result of operations: experience of two surgery-related autopsies

We experienced two autopsy cases of unexpected death during surgical operation. Case 1 was a 60-year-old male. Salvage esophagectomy was performed from the right side of the thrax. After dissection of the lymph node, blood pressure decreased suddenly. Emergency thoracotomy was done for diffuse hemothorax in the left thoracic cavity. The patient died despite aggressive hemostasis. Autopsy findings revealed that the operator dissected the left subclavian artery instead of the lymph nodes. Case 2 was a 60-year-old male with advanced thyroid cancer with pelvic metastasis. Surgical removal of the sacrum was attempted for pain relief. The operation was interrupted because of massive hemorrhage from the iliac veins. After the operation, the patient's left leg quickly became necrotic. Despite the bypass grafting from the right to the left femoral artery, the patient died of reperfusion injury. Autopsy revealed ligation of the left common iliac artery along with the accompanying vein. The leg necrosis was thought to have resulted from the vascular ligation. In these two cases, the demonstration and elucidation of the causes of deaths were required with medicolegal autopsies. However, it proved difficult to visualize the operated vessels in detail. In autopsy investigations related to surgical operations, detailed information of the clinical course is valuable and should be provided by the operators themselves, as well as being obtained from clinical charts.