Major vascular injury in laparoscopic urology

Comparison of Optical Trocar Access Versus Veress Needle Insertion Technique for Peritoneal Entry in Laparoscopic Donor Nephrectomy

BACKGROUND

Nearly half of all complications in laparoscopic surgery occur at the intraperitoneal access. We compared direct optical entry (DOE) with Veress needle entry (VNE) in terms of abdominal entry time and entry-associated complications in patients who underwent laparoscopic donor nephrectomy (LDN).

METHODS

Between June 2010 and July 2023, data from 813 patients who underwent LDN were analyzed. Age, male-to-female ratio, American Society of Anesthesiologists (ASA) score, body mass index, operation side, previous abdominal surgery, abdominal entry technique, abdominal entry time, entry-associated complications, conversion to different abdominal entry techniques, and conversion to open surgery were evaluated.

RESULTS

DOE and VNE were performed on 433 and 281 patients, respectively. Age (48.89 ± 12.11 vs 47.59 ± 11.34 years), male-to-female ratio (44.8% vs 40.9% males and 55.2% vs 59.1% females), ASA score (2 vs 2 median ASA score), body mass index (26.72 ± 6.11 vs 27.07 ± 5.83 kg/m2), and operation side (63.0% vs 61.3% left nephrectomy) were not statistically significant differences between the DOE and VNE groups (P > .05). However, abdominal entry time was significantly reduced in the DOE group compared with the VNE group (26.8 ± 20.8 vs 49.5 ± 34.1 seconds, P = .007, respectively). Entry-associated complications were observed in 8 (1.12%) patients. No major (grades 3-5) complications were observed. There were no statistically significant differences in overall (0.6% vs 1.7%, P = .291), grade 1, and grade 2 complication rates between the DOE and VNE groups (0.4% vs 1.4%, P = .366; 0.2% vs 0.3%, P = .714, respectively).

CONCLUSIONS

DOE and VNE are not foolproof. DOE is a safe, feasible, and faster technique in patients who underwent LDN.

Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study

INTRODUCTION

The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n = 30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee.

METHODS

This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared.

RESULTS

Overall, mean OTA insertion time was 56 s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33 s respectively, P = .01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (P = .05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum.

CONCLUSIONS

OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.

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.

Optimizing first trocar access for robot-assisted radical prostatectomy: Optical trocar access through the upper abdominal quadrant using the Kii Fios First Entry trocar

OBJECTIVES

A pre-equipped metal trocar is required to use as a camera trocar due to a specification change in the da Vinci X/Xi system (Intuitive Surgical). We observed slight slippage of a trocar placed by the open method. With optical trocar access (OTA), the initial trocar is viewed directly with a laparoscope during placement. Reports regarding OTA for robotic surgery are limited, particularly for robot-assisted radical prostatectomy (RARP). We modified the OTA procedure such that it was appropriate for RARP.

PATIENTS AND METHODS

A total of 158 patients were enrolled in this study. The first trocar placement time (FTPT) was compared between the open and OTA groups. In the OTA group, the trocar was mainly placed through the upper abdominal quadrant. We also analyzed the differences between the conventional and modified OTA procedures using the Kii Fios First Entry trocar (Applied Medical). We examined the factors affecting the FTPT using linear regression models. A P value <.05 was considered significant.

RESULTS

The FTPT was significantly shorter in the OTA group than the open group (P < .0001). The modified method was associated with a shorter FTPT (P = .0001). None of the patient characteristics affected the FTPT in either group. No major complications were observed.

CONCLUSIONS

OTA was applied successfully during RARP. Use of the Kii Fios First Entry trocar with upper abdominal quadrant placement was suitable for RARP.

Intraoperative complications during laparoscopic total mesorectal excision

Intraoperative complication during laparoscopic mesorectal excision for rectal cancer is a common complication occurring in 11% to 15% of the cases. They are probably underestimated because not systematically reported. The most frequent intraoperative complications are haemorrhage (3-7%), tumour perforation (1-4%), bowel injury (1-3%), ureter injury (1%), urogenital injury (2%), other organ injury (<1%), and anastomotic complications (1%). The mechanisms, management and prevention of vascular port injury, inferior mesenteric artery bleeding, small bowel and colon perforation, ureteral and urethral injury, pelvic nerve damage, tumour perforation and anastomotic failure are described. This review underlines the necessity to prevent intraoperative complication to avoid operative death and severe side-effects.

[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.

OneShot-M: A New Device for Close Laparoscopy Pneumoperitoneum

INTRODUCTION

The induction of pneumoperitoneum is the first and most critical phase of laparoscopy, due to the significant risk of serious vascular and visceral complications. The closed technique for the creation of pneumoperitoneum could lead to several surgical complications. The present study aimed to overcome the complications associated with the insertion of Veress needle, improving its use, and facilitating the rapid creation of pneumoperitoneum.

METHODS

Thirty large white female pigs were enrolled in our study. A common plunger was modified in order to allow the passage of a 15-cm long Veress needle. This method was applied to 26 laparoscopic procedures (26 pigs) of several specialist branches.

RESULTS

OneShot-M close laparoscopy pneumoperitoneum creation device allowed us to obtain pneumoperitoneum quickly in all attempts, without any intraoperative and postoperative complications related to the use of the Veress needle.

CONCLUSION

The use of the proposed device showed an induction time as quick as the standard laparoscopic closed abdominal entry. The patented device is cheap and allows a safe abdominal entry. In addition, abdominal entry is much faster than the classic open technique.

Internal iliac artery transposition for vascular reconstruction in a patient with life-threatening iatrogenic common iliac artery injury

Major vascular injury during surgery is life threatening and can be a nightmare for any surgeon.We share our experience of a 42-year-old woman where right common iliac artery and both common iliac veins were accidentally injured during lumbar discectomy leading to haemorrhagic shock. Patient was resuscitated and explored. A 4 cm segment of right common iliac artery was found lacerated along with perforations of both iliac veins. Proximal segment of internal iliac artery was mobilised quickly and vascular continuity was restored by end-to-end anastomosis of this segment to the proximal segment of common iliac artery after excising the damaged segment. Iliac veins were repaired primarily. Patient made an uneventful recovery. We share this technique as it was found expeditious and effective and may benefit surgeons working in this field.

Vascular injury at laparoscopy: a guide to management

Vascular laparoscopic injuries are rare (0.2/1000), however, they are associated with 6-13% morbidity and mortality. Commonest sites for catastrophic haemorrhage are the right iliac vessels, inferior vena cava and less commonly the abdominal aorta. The injuries commonly occur at entry using a Veress needle or insertion of trocars. These risks are inherent to all laparoscopic surgery. A systematic approach for managing these includes prompt recognition, communication within the operative team, immediate resuscitation and specific operative strategies for the control of vascular haemorrhage based on the location and severity of the injury. Major vascular injuries may require midline laparotomy and vascular surgeons. 1:1:1 resuscitation and adjunct haemostatic agents may help. Major vascular injury is a rare but a potentially fatal complication. We propose a skills and drills approach to improve outcomes. We also propose a practical algorithms for the management of haemorrhage in the acute situation.

Laparoscopic Major Vascular Injury Simulation Using a Synthetic Compared With Porcine Model

BACKGROUND

Major vascular injury training may improve clinical skills and reduce patient morbidity during gynecologic laparoscopy; thus, reliable models for simulation should be identified.

METHOD

Two laparoscopic major vascular injury simulations using synthetic or live porcine models were constructed. The primary surgeon was given the opportunity to complete both simulations. After obtaining peritoneal access, the surgeon quickly encountered a major vascular injury. Degrading vital signs and estimated blood loss coupled with the replay of a human heartbeat that increased in volume and intensity were provided to heighten tension during the synthetic simulation.

EXPERIENCE

Twenty-two gynecologic surgery educators evaluated the simulations. Educators considered the porcine model superior to the synthetic model with regard to tissue handling. The synthetic model simulation was found to be equivalent to the porcine model on how likely the simulation would be able to improve performance in a clinical setting. Educators were more likely to implement the synthetic simulation over the porcine simulation.

CONCLUSION

The synthetic model was found to be more feasible and as effective as the porcine model to simulate and teach the initial management steps of major vascular injury at laparoscopy by gynecologic educators.

Safe and easy access technique for the first trocar in laparoscopic surgery

BACKGROUND

Access-related injuries are still an important consideration and may increase morbidity and mortality. This study aimed to present in detail a safe and easy technique for open insertion of the first trocar.

PATIENTS AND METHODS

This technique has been used routinely in the vast majority of laparoscopic procedures at first author's department since 1998. The data were collected prospectively and analyzed retrospectively for the 11-year period of January 2005 through December 2015. The primary site of access is the umbilicus, but this technique can be used for all insertion points.

RESULTS

A total of 2579 laparoscopic surgical interventions were performed. The abdominal access was established in 2252 patients in open and in 321 cases with blind puncture using a Veress needle. There were three cases (0.9 %) of accidental injuries with blind puncture and two cases (0.09 %) with open technique. Injuries sustained with open technique injuries were less severe and immediately discernable. None of the patients were converted to open technique.

CONCLUSION

The method can be used easily and rapidly, even in obese patients. It is safer than blind puncture and reduces costs.

Safer trocar insertion for closed laparoscopic access: ex vivo assessment of an improved Veress needle

INTRODUCTION

Laparoscopic surgery is widely practiced surgical technique in the modern surgical toolbox. The Veress needle insertion technique, while faster and easier, is associated with higher rates of iatrogenic complications (injury to internal organs, major blood vessels, etc.), morbidity and even mortality with a reported overall risk of 0.32% during surgical interventions. In order to increase the safety and ease of closed insertion technique, we designed and tested an improved prototype of the Veress needle.

METHODS

The new Veress needle includes a distal expandable portion that allows elevation of the abdominal wall and safe insertion of the first trocar over it. The needle was assessed by measurement of ease of insertion, ease of trocar advancement, associated tissue damage, device integrity and weight-bearing capacity on an ex vivo Gallus domesticus animal model: The prototype was tested over 20 times using different traction forces. The experiment was qualitatively repeated on an ex vivo porcine model.

RESULTS

In the G. domesticus model, the improved needle supported forces of up to 5.75 kg F. No damage or mechanical malfunction was seen at any stage of the experiment. Needle penetration, ease of trocar insertion, system anchoring and weight-bearing capacity were rated (1-5) by four raters--mean 4.9 ± 0.31. Inter-rater agreement was high (free marginal κ 0.75). The porcine experiment revealed similar ease of use with neither complication nor damage to the abdominal wall.

CONCLUSIONS

We believe that the new Veress system is easy to use, requires no additional training, non-inferior in its capabilities compared to the traditional Veress needle, with the advantage of improving the safety of the first trocar insertion phase of the operation.