JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 5. 1992 Mary Ann Liebert, Inc.. Publishers
Brief Clinical Aortic Laceration: A Rare KULIN N.
Report
Complication of Laparoscopy
OZA, M.D., NANCY O'DONNELL, M.D.,
and JAY B.
FISHER,
M.D.
ABSTRACT Aortic laceration during laparoscopic procedures is a rare but well-known complication with a high mortality rate. Thus far, few cases which were recognized and treated successfully have been reported in the literature; the exact incidence is not known. Such a complication occurred after an elective laparoscopic sterilization in a 35-year-old woman. The situation was recognized early and successfully treated. The common complications of laparoscopy are usually of a minor nature but a few are life threatening. This case illustrates the need for emphasis on the prevention of complications and the appropriate course of action in the event of their occurrence.
INTRODUCTION sterilization by laparoscopy has become a common and preferred method of sterilization for women in the United States. Laparoscopy is a safe and well-tolerated procedure in the hands of an experienced and skilled operator. Although the complication rate for laparoscopic tubal sterilization is generally low, serious complications occur in approximately 2% of procedures; when this occurs, the advantages of a laparoscopic approach disappear.1'2'3 The prevalence of major vessel injury occurring during laparoscopy is unknown, although Mintz's survey of 100,000 laparoscopies in France suggests that three major internal vessel lacerations occur per 10,000 procedures. A similar study conducted in the United Kingdom showed an incidence of 9 per 10,000 laparoscopies.4'5
Over permanent
the past two decades,
CASE REPORT A 35-year-old white female, grávida 2, para 2 was admitted to the hospital for elective sterilization and removal of an IUD in the short procedure unit. There was no past history of abdominal or pelvic surgery and no history suggestive of pelvic inflammatory disease. Physical examination was unremarkable and she was a
From Easton
Hospital, Easton,
PA.
235
OZA ET AL.
healthy, moderately built, well-nourished woman weighing 140 pounds. The patient was taken to the operating room and after induction of general anesthesia, was placed in lithotomy position. The procedure was initiated with an infraumbilical incision. Veress needle was used for the creation of a pneumoperitoneum. There was a drop in blood pressure after starting the insufflation which was stopped immediately. After a few minutes, the blood pressure came back to normal and the sterilization procedure was completed in a routine manner and the peritoneal cavity examined. This examination showed no significant findings and the patient
taken to the recovery room in stable condition. In the recovery room, the patient developed progressive hypotension over 1 h and a significant fall in hematocrit. Abdominal examination showed generalized tenderness and guarding with some distention. The patient was immediately returned to the main operating room. General and vascular surgeons were summoned. Immediate laparotomy was performed using a midline incision. On exploration of the abdomen, large clots were found in the pelvis as well as the right and left paracolic gutter and underneath the left dome of the diaphragm. The most significant finding was a large central retroperitoneal hematoma extending from the infrarenal area down into the pelvis. The hematoma was non-pulsatile and not increasing in size. The patient had received 4 units of blood and 3 liters of crystalloids. The patient's vital signs were stable. On further exploration of the abdomen, a small non-bleeding jejunal mesenteric puncture wound, approximately the size of a Veress needle, was also found. It was decided to explore the retroperitoneal hematoma. Following adequate exposure and retraction of bowel, the retroperitoneal space was opened from the left renal vein above to the aortic bifurcation below. Control of the aorta was obtained just below the left renal vein. Fresh clots were found around the infrarenal aorta. Upon clearing the clots, a small nonpenetrating adventitial aortic tear was found just above the origin of the inferior mesenteric artery. The inferior mesenteric artery was found to be intact. On further removal of clots from the medial aspect of the aorta, a small puncture wound was found on the right lateral aspect of the aorta, midway between the right renal artery and the origin of the inferior mesenteric artery, which began to bleed freely following clot removal. The aorta was clamped below the renal arteries and the puncture wound was repaired with #4-0 prolene suture. The patient tolerated the procedure well and the subsequent hospital course was unremarkable. was
DISCUSSION Unintended
laparotomy during laparoscopic sterilization may be required to manage a complication or to complete procedure due to technical problems. In Frank's series of 5027 women undergoing laparoscopic sterilization, 12 had unintended laparotomy to manage operative complications. Hemorrhage was one of the most common complications requiring laparotomy, occurring in 4 of these 12 cases.6 The long term follow up of patients with penetrating abdominal aortic injuries after 15 years shows no evidence of late compromise; however, there is a suggestion that injury and repair may contribute to the accelerated development of atherosclerosis.7 As new applications of laparoscopic techniques become widely practiced, an honest assessment of their complications is extremely important. Major vessel lacerations are a catastrophic consequence of laparoscopic procedures and can usually be attributed to miscalculations in technique. Insertion of the Veress needle and trocar should be done with careful attention to anatomic landmarks and insertion techniques in order to prevent hemorrhage. Major vessels most likely to be injured are the aorta, iliac artery, and iliac vein.4'8 If such an injury occurs, prompt recognition and exploration are necessary to prevent life threatening complications. Entering the abdomen is the most dangerous part of the laparoscopic procedure and two techniques have been described: percutaneous technique and open laparoscopy and its various modifications. Several important points to remember while using the percutaneous technique are: a
1. 2.
3.
Adequate infraumbilical incision, staying close to the lower edge of the umbilical depression. Grasp the lower abdominal wall with the left hand, just above the pubic hair line, and elevate at a 45 degree angle upward and caudally. Introduce the Veress needle at the right angle to this plane, aiming toward the uterus, right angle to the skin and staying in the midline. 236
AORTIC LACERATION 4. Check the position of the needle flow rate of 1 liter/min.910
by measuring pressure, which should not exceed
15 to 20
mmHg at a
The authors present the case of a 35-year-old white female who sustained an aortic laceration during laparoscopic sterilization. Laparoscopy is not an operation for the occasional practitioner and should be approached with circumspection even by the "trained hands" of the gynecologist or general surgeon. Laparoscopy should be used only by those who are experienced in abdominal surgery and are able to recognize and deal with any problems that might arise. When used with care, the laparoscope has a useful place in the operation of female sterilization, increasing patient comfort and reducing hospital stay. With increasing utilization of laparoscopic techniques, the authors feel an obligation to report this complication and encourage other centers to do the
same.
REFERENCES 1. Peterson HB, DeStefano F, Rubin GL, Greenspan JR, Lee NC, Ory HW: Deaths attributable to tubal sterilization in the United States, 1977 to 1981. Am J Obstet Gynecol 1983;146:131-136. 2. Chi IC, Feldblum PJ: 3. 4.
5. 6.
7.
Laparoscopic sterilizations requiring laparotomy. Am J Obstet Gynecol 1982; 142:712. EscobedoLG, Peterson JB, Grubb GS, Kranks AL: Case-fatality rates for tubal sterilization in U.S. hospitals, 1979 to 1980. Am J Obstet Gynecol 1989;160( 1): 147-150. Peterson HB, Greenspan JR, Ory HW: Death following puncture of the aorta during laparoscopic sterilization. Obstet Gynecol 1982;59:133. Mintz M: Risks and prophylaxis in laparoscopy. A Survey of 100,000 cases. J Reprod Med 1977;18:269. Franks AL, Kendrick JS, Peterson HB: Unintended laparotomy associated with laparoscopic tubal sterilization. Am J Obstet Gynecol 1987;157(5):1102-1105. Soldano SL, Rich NM: Long term follow-up of penetrating abdominal aortic injuries after 15 years. J Trauma 1988;28:1358-1362.
8. Katz M, Beck P, Tancer ML:
Major vessel injury during laparoscopy: Anatomy of two cases.
1979;135:544.
Am J Obstet Gynecol
Philadelphia^.B. Saunders, 1988. Campos L, Espinosa M: A modified laparoscopic entry technique using a finger and rubber catheter. J Laparoendosc SurgNo. 3, 1991;1(3):179-182.
9. HulkaJF: Textbook of Laparoscopy. 10.
Address
reprint requests to: Jay B. Fisher, M.D., Chief-Division of Vascular Surgery Easton Hospital, 250, South 21 st Street Easton, Pennsylvania 18042.
237
Brief Clinical Aortic Laceration: A Rare KULIN N.
Report
Complication of Laparoscopy
OZA, M.D., NANCY O'DONNELL, M.D.,
and JAY B.
FISHER,
M.D.
ABSTRACT Aortic laceration during laparoscopic procedures is a rare but well-known complication with a high mortality rate. Thus far, few cases which were recognized and treated successfully have been reported in the literature; the exact incidence is not known. Such a complication occurred after an elective laparoscopic sterilization in a 35-year-old woman. The situation was recognized early and successfully treated. The common complications of laparoscopy are usually of a minor nature but a few are life threatening. This case illustrates the need for emphasis on the prevention of complications and the appropriate course of action in the event of their occurrence.
INTRODUCTION sterilization by laparoscopy has become a common and preferred method of sterilization for women in the United States. Laparoscopy is a safe and well-tolerated procedure in the hands of an experienced and skilled operator. Although the complication rate for laparoscopic tubal sterilization is generally low, serious complications occur in approximately 2% of procedures; when this occurs, the advantages of a laparoscopic approach disappear.1'2'3 The prevalence of major vessel injury occurring during laparoscopy is unknown, although Mintz's survey of 100,000 laparoscopies in France suggests that three major internal vessel lacerations occur per 10,000 procedures. A similar study conducted in the United Kingdom showed an incidence of 9 per 10,000 laparoscopies.4'5
Over permanent
the past two decades,
CASE REPORT A 35-year-old white female, grávida 2, para 2 was admitted to the hospital for elective sterilization and removal of an IUD in the short procedure unit. There was no past history of abdominal or pelvic surgery and no history suggestive of pelvic inflammatory disease. Physical examination was unremarkable and she was a
From Easton
Hospital, Easton,
PA.
235
OZA ET AL.
healthy, moderately built, well-nourished woman weighing 140 pounds. The patient was taken to the operating room and after induction of general anesthesia, was placed in lithotomy position. The procedure was initiated with an infraumbilical incision. Veress needle was used for the creation of a pneumoperitoneum. There was a drop in blood pressure after starting the insufflation which was stopped immediately. After a few minutes, the blood pressure came back to normal and the sterilization procedure was completed in a routine manner and the peritoneal cavity examined. This examination showed no significant findings and the patient
taken to the recovery room in stable condition. In the recovery room, the patient developed progressive hypotension over 1 h and a significant fall in hematocrit. Abdominal examination showed generalized tenderness and guarding with some distention. The patient was immediately returned to the main operating room. General and vascular surgeons were summoned. Immediate laparotomy was performed using a midline incision. On exploration of the abdomen, large clots were found in the pelvis as well as the right and left paracolic gutter and underneath the left dome of the diaphragm. The most significant finding was a large central retroperitoneal hematoma extending from the infrarenal area down into the pelvis. The hematoma was non-pulsatile and not increasing in size. The patient had received 4 units of blood and 3 liters of crystalloids. The patient's vital signs were stable. On further exploration of the abdomen, a small non-bleeding jejunal mesenteric puncture wound, approximately the size of a Veress needle, was also found. It was decided to explore the retroperitoneal hematoma. Following adequate exposure and retraction of bowel, the retroperitoneal space was opened from the left renal vein above to the aortic bifurcation below. Control of the aorta was obtained just below the left renal vein. Fresh clots were found around the infrarenal aorta. Upon clearing the clots, a small nonpenetrating adventitial aortic tear was found just above the origin of the inferior mesenteric artery. The inferior mesenteric artery was found to be intact. On further removal of clots from the medial aspect of the aorta, a small puncture wound was found on the right lateral aspect of the aorta, midway between the right renal artery and the origin of the inferior mesenteric artery, which began to bleed freely following clot removal. The aorta was clamped below the renal arteries and the puncture wound was repaired with #4-0 prolene suture. The patient tolerated the procedure well and the subsequent hospital course was unremarkable. was
DISCUSSION Unintended
laparotomy during laparoscopic sterilization may be required to manage a complication or to complete procedure due to technical problems. In Frank's series of 5027 women undergoing laparoscopic sterilization, 12 had unintended laparotomy to manage operative complications. Hemorrhage was one of the most common complications requiring laparotomy, occurring in 4 of these 12 cases.6 The long term follow up of patients with penetrating abdominal aortic injuries after 15 years shows no evidence of late compromise; however, there is a suggestion that injury and repair may contribute to the accelerated development of atherosclerosis.7 As new applications of laparoscopic techniques become widely practiced, an honest assessment of their complications is extremely important. Major vessel lacerations are a catastrophic consequence of laparoscopic procedures and can usually be attributed to miscalculations in technique. Insertion of the Veress needle and trocar should be done with careful attention to anatomic landmarks and insertion techniques in order to prevent hemorrhage. Major vessels most likely to be injured are the aorta, iliac artery, and iliac vein.4'8 If such an injury occurs, prompt recognition and exploration are necessary to prevent life threatening complications. Entering the abdomen is the most dangerous part of the laparoscopic procedure and two techniques have been described: percutaneous technique and open laparoscopy and its various modifications. Several important points to remember while using the percutaneous technique are: a
1. 2.
3.
Adequate infraumbilical incision, staying close to the lower edge of the umbilical depression. Grasp the lower abdominal wall with the left hand, just above the pubic hair line, and elevate at a 45 degree angle upward and caudally. Introduce the Veress needle at the right angle to this plane, aiming toward the uterus, right angle to the skin and staying in the midline. 236
AORTIC LACERATION 4. Check the position of the needle flow rate of 1 liter/min.910
by measuring pressure, which should not exceed
15 to 20
mmHg at a
The authors present the case of a 35-year-old white female who sustained an aortic laceration during laparoscopic sterilization. Laparoscopy is not an operation for the occasional practitioner and should be approached with circumspection even by the "trained hands" of the gynecologist or general surgeon. Laparoscopy should be used only by those who are experienced in abdominal surgery and are able to recognize and deal with any problems that might arise. When used with care, the laparoscope has a useful place in the operation of female sterilization, increasing patient comfort and reducing hospital stay. With increasing utilization of laparoscopic techniques, the authors feel an obligation to report this complication and encourage other centers to do the
same.
REFERENCES 1. Peterson HB, DeStefano F, Rubin GL, Greenspan JR, Lee NC, Ory HW: Deaths attributable to tubal sterilization in the United States, 1977 to 1981. Am J Obstet Gynecol 1983;146:131-136. 2. Chi IC, Feldblum PJ: 3. 4.
5. 6.
7.
Laparoscopic sterilizations requiring laparotomy. Am J Obstet Gynecol 1982; 142:712. EscobedoLG, Peterson JB, Grubb GS, Kranks AL: Case-fatality rates for tubal sterilization in U.S. hospitals, 1979 to 1980. Am J Obstet Gynecol 1989;160( 1): 147-150. Peterson HB, Greenspan JR, Ory HW: Death following puncture of the aorta during laparoscopic sterilization. Obstet Gynecol 1982;59:133. Mintz M: Risks and prophylaxis in laparoscopy. A Survey of 100,000 cases. J Reprod Med 1977;18:269. Franks AL, Kendrick JS, Peterson HB: Unintended laparotomy associated with laparoscopic tubal sterilization. Am J Obstet Gynecol 1987;157(5):1102-1105. Soldano SL, Rich NM: Long term follow-up of penetrating abdominal aortic injuries after 15 years. J Trauma 1988;28:1358-1362.
8. Katz M, Beck P, Tancer ML:
Major vessel injury during laparoscopy: Anatomy of two cases.
1979;135:544.
Am J Obstet Gynecol
Philadelphia^.B. Saunders, 1988. Campos L, Espinosa M: A modified laparoscopic entry technique using a finger and rubber catheter. J Laparoendosc SurgNo. 3, 1991;1(3):179-182.
9. HulkaJF: Textbook of Laparoscopy. 10.
Address
reprint requests to: Jay B. Fisher, M.D., Chief-Division of Vascular Surgery Easton Hospital, 250, South 21 st Street Easton, Pennsylvania 18042.
237
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