JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 14, Number 2, 2004

© Mary Ann Liebert, Inc.

Major Retroperitoneal Vascular Injuries During Laparoscopic

Cholecystectomy and Appendectomy

RECEP GULOGLU, MD,1 SUKRU DILEGE, MD,2 MURAT AKSOY, MD,1

ORHAN ALIMOGLU, MD,3 NIHAT YAVUZ, MD,4 MEHMET MIHMANLI, MD,5
and MUSTAFA GULMEN, MD6

ABSTRACT

Background: Serious complications may occur during laparoscopic surgery, as in any surgical pro-
cedure. Injuries of major retroperitoneal vascular structures are uncommon but important com-
plications of laparoscopy.
Methods: We report on 9 major vascular injuries in 8 patients in the course of 8 laparoscopic pro-
cedures between 1994 and 2002.
Results: The primary operations were cholecystectomy in 7 patients and appendectomy in one pa-
tient. Six vascular injuries occurred during placement of the first umbilical trocar, two in the course
of the insertion of a Veress needle, and one during the insertion of the second trocar. A laparotomy
was performed immediately in all cases. Left common iliac arteries were injured in two patients,
aorta in three patients, right common iliac vein in one patient, both right common iliac artery and
vein in one patient, and inferior vena cava in one patient. Polytetrafluoroethylene (PTFE) graft in-
terposition was employed in two common iliac arteries and a tubular PTFE graft in one aortic in-
jury, and Dacron patchplasty in one common iliac artery injury. Two aortic, two common iliac vein,
and an inferior vena cava injury were repaired primarily. There were also four visceral organ in-
juries, which were repaired primarily. The major retroperitoneal vascular complication rate was
0.07%. An average of 3.5 units of whole blood were transfused in each case and the average stay in
hospital was 6.8 days. There was no mortality.
Conclusions: The surgeon’s experience and knowledge are the essential factors for prevention of
major vascular injuries during laparoscopic procedures. In case of an injury, immediate laparo-
tomy must be performed to achieve hemostasis and a surgeon who is familiar with vascular surgery
should employ the definitive treatment.

INTRODUCTION tions in the course of these procedures, they are the most
serious and life-threatening ones. The risk of a compli-

L APAROSCOPIC PROCEDURES ARE INCREASINGLY PRE-

FERRED in many fields of surgery worldwide. Al-
though major vascular injuries are uncommon complica-
cation during laparoscopy can be reduced with adequate
training. The incidence of complications in the hands of
inexperienced surgeons who had performed fewer than

1 Department of General Surgery, 2 Department of Thoracic Surgery, School of Medicine, University of Istanbul; 3 Department

of General Surgery, Vakif Gureba Training Hospital; 4Department of General Surgery, School of Medicine, University of Cer-
rahpasa; 5Department of General Surgery, Sisli Etfal Training Hospital; 6Department of General Surgery, Kartal Training Hos-
pital, Istanbul, Turkey.
The initial cases of this report were presented at the 6th European Congress of Surgery, Rome, Italy, October, 1996.

73
74 GULOGLU ET AL.

100 laparoscopic procedures has been reported to be four
times higher than that of experienced surgeons in gyne-
cologic procedures.1 As reported in the literature, the in-
cidence of major retroperitoneal vessel injury during
laparoscopic cholecystectomy is 0.05%, with an 8.3%
mortality rate.2 Although knowledge of how to prevent
vessel injuries is paramount, early diagnosis and appro-
priate management of vascular injuries are important to
reduce morbidity and mortality rates in such complica-
tions.3,4
We report nine major retroperitoneal vascular injuries
in eight patients during laparoscopic procedures and dis-
cuss the prevention and management of major retroperi-
toneal vascular injuries in the course of these procedures.
MATERIALS AND METHODS
The data of 11,746 subjects who had laparoscopic
surgery at eight hospitals in Istanbul, Turkey, between
February 1994 and January 2002 were reviewed and
those with major retroperitoneal vascular injuries were
selected for this study. The cases were identified through
communications via telephone or letter with surgeons
working in these hospitals.
The eight patients were 4 males and 4 females, with a
mean age of 43 years (range, 14–54 years). Seven of the
patients were planned to have a laparoscopic cholecys-
tectomy for cholelithiasis and one was planned to un-
dergo laparoscopic appendectomy for acute appendicitis.
Details including the techniques preferred, the injury
site, injury mechanism, and the treatment methods were
evaluated. The amount of transfused blood, length of hos-
pital stay, and long-term followup of the injured vessels
were analyzed as well.
RESULTS
The incidence of major retroperitoneal vessel injuries
was 0.07% among 11,746 cholecystectomy and appen-
dectomy procedures. Six vascular injuries occurred dur-
ing placement of the first umbilical trocar, two were en-
countered following Veress needle insertion, and one
during second trocar placement; all were noticed imme-
diately in the operating theatre. In the patient who had
an injury during the insertion of the second trocar, the in-
ferior vena cava and duodenum were injured. The injury
resulted from an uncontrolled forced insertion of the tro-
car by an inexperienced senior registrant. All patients un-
derwent urgent laparatomy to control bleeding. Injuries
involved the abdominal aorta in three patients, the left
common iliac artery in two patients, right common iliac
vein in one patient, inferior vena cava in one patient, and
both the right common iliac artery and vein in one pa-
tient. Three patients had a total of four concomitant vis-
ceral organ injuries (two terminal ileum, one transverse
colon, and one duodenal), which were repaired primar-
ily (Table 1).
The primary surgeon performed laparotomy immedi-
ately and controlled the bleeding with tamponade or vas-
cular clips and demanded a vascular surgery consultation
in five cases. The management of three patients was ac-
complished by the primary surgeon. The mean hospital
stay was 6.8 days (range, 6–8 days). The mean transfused
blood was 3.5 units (range, 2–8 units). There was no mor-
tality. During followup ranging from 4 months to 8 years
all of the repaired vessels are patent.
DISCUSSION
Laparoscopic procedures may cause potentially life-
threatening major vessel injuries which are rarely seen
during open surgery. Mortality due to laparoscopy is re-
ported to be between 0.03% and 0.49%.5 The vast ma-
jority of complications in laparoscopy occur in the course
of maintaining pneumoperitoneum and the insertion of
the first trocar.6 Although major vessel injury is estimated
to be rare during laparoscopic surgery, it has been re-
ported that the incidence of vascular injury is 2.6–11.0
per 1,000 operative laparoscopies.7 Most of the vascular

TABLE 1. DETAILS OF VASCULAR INJURIES

Primary operation Age/gender Cause Location Repair

Cholecystectomy 44/M Trocar Left common iliac artery Dacron patch

Cholecystectomy 51/F Trocar Right common iliac artery PTFE graft
Right common iliac vein Primary suture
Cholecystectomy 54/M Trocar Abdominal aorta Primary suture
Cholecystectomy 36/M Trocar Left common iliac artery PTFE graft
Cholecystectomy 50/F Trocar Abdominal aorta PTFE graft
Cholecystectomy 48/F Veress Right common iliac vein Primary suture
Cholecystectomy 45/F Trocar Inferior vena cava Primary suture
Appendectomy 14/M Veress Abdominal aorta Primary suture

PTFE, polytetrafluoroethylene
VASCULAR INJURIES DURING LAPAROSCOPY
injuries involve the inferior epigastric vessels.8 In one
study, the incidence of various complications after trocar
and Veress needle insertion was 0.182% (22 injuries)
among 4,243 various laparoscopic procedures. In the
same report, while six (0.04%) patients had minor ves-
sel injuries, one patient had a major retroperitoneal ves-
sel injury.9 Although the mortality and morbidity rates
seem to be very low, there is agreement that complica-
tions of laparoscopy may be underreported and that the
true incidence may be higher.2,9–11
The distal abdominal aorta and the large pelvic vessels
are especially susceptible to injury during the insertion
of the Veress needle or trocar into the retroperi-
toneum.3,12 Seventy-five percent of vessel injuries take
place during the first step of the laparoscopic procedure;
30% due to Veress needle insertion and 43% during um-
bilical trocar insertion.13 In the present study, six major
vessel injuries occurred during the first 10 mm trocar
placement (66%), two in the course of Veress needle in-
sertion (22%), and one during the second trocar place-
ment (11%).
In a review of 24 cases by Nordestgaard et al. the
mechanism of injury was Veress needle insertion in 12
cases, trocar placement in 7 cases, and sharp dissection
in 2 cases. The mechanism of injury was not reported in
2 cases. When early diagnosis and laparotomy were es-
tablished, no further complications occurred. Three of 8
patients who were not diagnosed immediately were lost
to followup. One patient who had no diagnosis of vessel
injury had to be operated urgently due to a ruptured
pseudoaneurysm three months later.14
Complications of laparoscopy can be reduced with ap-
propriate training. Proper placement of the first trocar is
important to prevent such major vessel injuries. It is not
surprising that the majority of complications take place
during the insertion of the Veress needle or the first tro-
car, since placing a needle through a cavity that cannot
be seen can always be worrisome. Although it is not to-
tally safe, the open Hasson technique, which is defined
as the open introduction of the first trocar under direct
vision,15 is recommended in order to prevent injuries re-
lated to laparoscopic procedures. The safety of this tech-
nique was recently confirmed by Rice et al., who reported
no major vessel injuries in more than 2,000 general sur-
gical laparoscopies.16 Hence open laparoscopy is claimed
to be a secure way of starting the procedure and may
greatly reduce the potential risk of injury. However, sur-
geons who are still in favor of using the Veress needle
should be advised to lift the abdominal wall and insert
the Veress needle and trocar oblique to the abdominal
wall (Fig. 1). The first trocar should be inserted only af-
ter the establishment of the pneumoperitoneum is proven.
Early diagnosis is important to manage a major blood
vessel injury. If the surgeon is not experienced in vascu-
lar surgery, a laparotomy should be performed immedi-
75
FIG. 1. Appropriate placement of trocar is indicated in gray.
ately; once hemostasis is achieved either by packing or
vascular clamps, consultation of a vascular surgeon is
necessary. One case in this study had an abdominal aor-
tic injury on both the anterior and posterior walls, and
underwent repair of the vessel twice by the primary sur-
geon, which resulted in loss of the distal pulses. The his-
tory of this case points to the essential role of a vascular
surgeon who is capable of managing a major vessel in-
jury and marks the possibility of both anterior and pos-
terior wall injuries in such cases. In the present study, de-
finitive management of six vascular injuries was obtained
by vascular surgeons, and three repairs were accom-
plished by a general surgeon who is familiar with vas-
cular surgery.
Four of the vessels were repaired with a prosthetic graft
in this series. None of the patients presented with a graft
infection. Repair with a prosthetic graft might result in
devastating graft infection. However, injuries which are
encountered during laparoscopic surgery are usually tiny
holes that may be managed by primary sutures, to avoid
contamination of the peritoneal cavity. It is essential to
perform a proper cleaning of the abdominal cavity and
start a broad-spectrum antibiotic regimen in order to
avoid graft infection.
The diagnosis of retroperitoneal large vessel injuries
may be delayed due to increased intra-abdominal pres-
sure from CO2 insufflation and the tamponade nature of
the retroperitoneal region. In one study, two cases of il-
iac artery injuries were not detected at the proper time
and resulted in re-laparotomy and important morbidity in
each case.7 Therefore the peritoneal cavity should be
evaluated at the end of the procedure after intra-abdom-
inal pressure has been reduced.
76
In order to prevent complications during laparoscopic
procedures
• lifting the abdominal wall is recommended
• unnecessary force on the abdomen should be avoided
• the Veress needle and trocar should be inserted with a
45° inclination
• the first insertion should be performed or supervised
by the most experienced surgeon of the team
• an adequate pneumoperitoneum prior to trocar place-
ment should be obtained.
In conclusion, careful access to the peritoneal cavity
remains one of the most crucial steps in laparoscopic pro-
cedures to minimize the risk of major vessel injury. We
recommend that first entry into the peritoneal cavity
should be accomplished using the Hasson technique, and
the remaining trocars should be placed under direct vi-
sion with the scope. Surgeons who perform minimally
invasive surgery should be aware of the risk of iatrogenic
major retroperitoneal vessel injuries. In case of injury, a
laparotomy must be performed immediately to stop
bleeding by packing or applying vascular clamps at the
vessel and a surgeon who is experienced in vascular
surgery should be invited to manage the definitive treat-
ment of the injury.
ACKNOWLEDGMENT
The authors would like to thank Dr. Mehmet Ali
Gursoy for drawing the illustration in Figure 1.
REFERENCES
1. Phillips J, Keith D, Keith L, et al. Survey of gynecologic
laparoscopy for 1974. J Reprod Med 1975;15:45–50.
2. Deziel DJ, Millikan KW, Economou SG, et al. Complica-
tions of laparoscopic cholecystectomy: a national survey of
4,292 hospitals and an analysis of 77,604 cases. Am J Surg
1993;165:9–14.
3. Fruhwirth J, Koch G, Mischinger HJ, et al. Vascular com-
plications in minimally invasive surgery. Surg Laparosc
Endosc 1997;7:251–254.
GULOGLU ET AL.
4. Lin P, Grow DR. Complications of laparoscopy: Strategies
for prevention and cure. Obstet Gynecol Clin North Am
1999;26:23–38.
5. Kane MG, Krejs GJ. Complications of diagnostic lap-
aroscopy in Dallas: a 7-year prospective study. Gastroin-
test Endosc 1984;30:237–240.
6. Hashizume M, Sugimachi K. Needle and trocar injury dur-
ing laparoscopic surgery in Japan. Surg Endosc 1997;11:
1198–1201.
7. Seidman DS, Nasserbakht F, Nezhat F, et al. Delayed
recognition of iliac artery injury during laparoscopic
surgery. Surg Endosc 1996;10:1099–1101.
8. Hurd WW, Pearl ML, DeLancey JO, et al. Laparoscopic
injury of abdominal wall blood vessels: a report of three
cases. Obstet Gynecol 1993;82:673–676.
9. Schafer M, Lauper M, Krahenbuhl L. Trocar and Veress
needle injuries during laparoscopy. Surg Endosc 2001;15:
275–280.
10. Champault G, Cazacu F, Taffinder N. Serious trocar acci-
dents in laparoscopic surgery: a French survey of 103,852
operations. Surg Laparosc Endosc 1996;6:367–370.
11. Mac Cordick C, Lecuru F, Rizk E, et al. Morbidity in lap-
aroscopic gynecological surgery: results of a prospective
single-center study. Surg Endosc 1999;13:57–61.
12. Baadsgaard SE, Bille S, Egeblad K. Major vascular injury
during gynecologic laparoscopy: report of a case and re-
view of published cases. Acta Obstet Gynecol Scand 1989;
68:283–285.
13. Montero M, Tellado MG, Rios J, et al. Aortic injury dur-
ing diagnostic pediatric laparoscopy. Surg Endosc 2001;
15:519.
14. Nordestgaard AG, Bodily KC, Osborne RW Jr, et al. Ma-
jor vascular injuries during laparoscopic procedures. Am J
Surg 1995;169:543–545.
15. Hasson HM. A modified instrument and method for la-
paroscopy. Am J Obstet Gynecol 1971;110:886–887.
16. Rice JG, McCall JG, Wattchow DA. Improving the ease
and safety of laparoscopy: a technique for open insertion
of the umbilical trocar. Aust N Z J Surg 1998;68:664–665.
Address reprint requests to:
Recep Guloglu, M.D.
Department of General Surgery
Istanbul Medical Faculty
Istanbul University
34390, Istanbul, Turkey
E-mail: rguloglu@yahoo.com
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