Abstract
Abstract
Introduction
L
“Closed” laparoscopy requires the blind insertion of a Veress needle and the first trocar, usually in an umbilical location. 4 During this initial phase of the procedure, inadvertent injury of blood vessels, solid organs, or a hollow viscus may occur. 5 Most complications occur during entry. 6 Knowledge of complications in laparoscopy is valuable for establishing etiologic factors, developing preventative strategies, and implementing management.
Case
Ethical approval was not required for this case report. The patient consented to the sharing of this information, which was made anonymous. A general practitioner (GP) referred this postmenopausal woman to a gynaecology clinic because she had vaginal bleeding. The patient had experienced two episodes of postmenopausal bleeding while she was receiving hormone-replacement therapy to relieve her menopausal symptoms. Her GP arranged an ultrasound (US) scan which showed a uterus with multiple fibroid growths, a normal endometrial thickness, and a 50 mm ×46 mm ×45 mm simple left adnexal cyst. An endometrial biopsy yielded normal results. Her Ca 125 level was 30. Because of the low probability of ovarian cancer, based on the findings, a repeat US scan after 3 months was arranged; this second scan revealed that the cyst was persistent with a single thin septum and no solid elements. Management options, including expectant management with surveillance, were discussed with the patient and she opted for surgical removal as she was very anxious about the potential for malignant transformation. She had had two normal vaginal deliveries; a normal cervical smear history; and a past history of fibromyalgia, anxiety, and osteoporosis. Her body mass index was normal.
General anesthesia was induced with 150 mcg of fentanyl, 180 mg of propofol, and 10 mg of vecuorium. Endotracheal intubation was immediately performed without any apparent difficulty. After routine skin cleansing and sterile draping, a urinary catheter and a uterine manipulator were inserted. While the bed was flat, the patient's abdominal wall was lifted and a Veress needle was inserted vertically at the base of her umbilicus through a 10-mm intraumbilical incision, until 2 clicks were heard, and was stopped at 4 cm depth. The saline drop test seemed to indicate that all was well.
However, the initial entry pressure was noted to be high at 10 mm Hg. The Veress needle was removed and reinserted again, using the same technique, but again the entry pressure was noted to be high at 10 mm Hg. The Veress needle was withdrawn again and reinserted for a third time. This time the entry pressure was 8 mm Hg, but on lifting the abdominal wall, the pressure dropped to 4 mm Hg. This entry was therefore deemed to be satisfactory, as it was <8 mm Hg. Pneumoperitoneum was therefore started at an insufflation pressure of 25 mm Hg; there was high flow low pressure gas entry which appeared to indicate that all was going well. At 25 mm Hg, a primary 10-mm port was inserted, using a bimanual vertical controlled entry technique, then another two 5-mm ports and a suprapubic 10-mm port were inserted, while being visualized, at 25 mm Hg while the bed was still flat. A 360° view around showed no bowel adhesions or injuries while the bed was still in the flat position. A thorough inspection of the bowel was undertaken, as it is known that the rate of complications increases with an increasing number of Veress insertions.7,8 The pressure was now reduced to a maintenance pressure of 15 mm Hg.
In the bed-flat position, inspection underneath the primary port showed 3 small punctures of the stomach serosa on the greater curvature. The stomach was noted to be extremely distended and reaching underneath the umbilicus while the bed was still flat. The stomach was possibly distended with air, which was likely caused by the anesthetic insufflation, possibly related to anesthetic-tube insertion. There was no contamination of the peritoneal cavity noted and no leakage from the stomach. An on call surgeon was asked to attend, and the findings were confirmed. This surgeon performed 3 intracorporeal interrupted over sewing sutures with Vicryl 3–0 sutures to the stomach serosa. No other abnormality was noted at the time. The simple 5-cm left ovarian cyst was removed uneventfully via a laparoscopic left salpingo-oophorectomy. The pelvis, uterus, right tube, and ovary all appeared to be normal. The specimen was retrieved using a bag through a suprapubic port, with no spillage, and was sent for histologic examination.
Results
Postoperatively the patient made an excellent recovery and was discharged to go home on the following day. Histology confirmed later that the patient had a serous cyst of her left ovary with no evidence of malignancy.
Discussion
The incidence of gastrointestinal (GI) injuries occurring during gynecologic laparoscopies has been estimated to be between 0.6 and 1.6 per thousand.1,2,6,9 The incidence of trocar and Veress-needle injuries has been described to range from 0.03% to 0.2%. A study of 14,243 patients undergoing standard laparoscopic procedures reported the incidence of trocar or needle injuries to be 0.182%; vascular injuries occurred in 0.049%, and visceral injuries in 0.133% of the cases; there were no cases of gastric injury. 5 Few cases of gastric perforation secondary to needle and/or trocar insertions have been published.9–13
A retrospective study reported 62 cases of GI injuries during gynecologic laparoscopy. 9 Of these, 1 case (0.016%) presented with a gastric injury. Endler and Moghissi 10 reported 2 cases of gastric injury secondary to Veress-needle insertion. Both cases were managed successfully with observation during a 48-hour period. Milliken and Milliken 11 reported a case of gastric injury with a Veress needle. Contributing factors to the injury included patient anxiety, prolonged manual oxygenation, and the placement of the Veress needle 2 cm above the umbilicus. These articles and other reports have associated laparoscopic gastric injuries with insufflation of air or anesthetic gases into the stomach during induction and manual ventilation before endotracheal intubation.9–11
Although gastric injuries account for a very small proportion of these GI injuries, surgeons should be aware of the possibility of gastric distension before attempting laparoscopic abdominal entry. In the absence of gastroptosis or supraumbilical primary trocar placement, gastric distension is the most likely cause of gastric perforation during abdominal entry. Although other factors such as aerophagia can be a cause of this distension, the majority of cases are caused by the positive-pressure ventilation preceding intubation or accidental esophageal intubation. 10
Immediate identification of the injury is essential to avoid further complications. The decision to repair a gastric perforation is dependent on the causative instrument. When a Veress needle causes the injury and there is not significant bleeding, conservative management is indicated because of this needle's small caliber, although visual inspection and a check for haemostasis still are performed.9–11 Conversely, trocar injuries are usually more extensive and repair is necessary to prevent leakage, abscesses, or fistulae. Simple closure, with open or laparoscopic suturing, either with or without the application of an omental patch, is the treatment of choice.13,14
Data from a randomized controlled trial comparing repair of perforated peptic ulcers by laparoscopy and laparotomy has shown that laparoscopy can be used safely and effectively to repair gastric and duodenal perforations. In that study, laparoscopic repair also was associated with a shorter operating time and hospital stay, less postoperative pain and chest complications, and an earlier return to normal daily activities.
14
A safe laparoscopic repair requires a skilled surgeon in laparoscopic GI surgery, an immediate diagnosis, satisfactory exposure, a clean injury, and surgical repair without tension.
Another case of gastric perforation caused by a trocar insertion has been reported; this perforation was repaired successfully by the application of clips. 13 In another case, three full-thickness interrupted stitches of #0 polyglactin suture to repair the perforation were used. The perforation was caused by an umbilical trocar insertion. Following the repair, underwater examination while distending the stomach was used to assure that an airtight closure was achieved. 15
Potential causes of this inadvertent injury were considered. Even though the current patient did not have a difficult intubation or prolonged oxygenation maneuvers, the prominent gastric distension (resulting from inadvertent insufflation of air or anesthetic gases into the stomach during induction and manual ventilation before endotracheal intubation) was likely the contributing factor in this injury. Another possibility is that the patient's peristaltic dysfunction of her colon may have caused gastric dilation and thereby precipitated the injury. In any event, the three gastric punctures noted were caused by the three Veress-needle insertions, injuring the overdistended stomach. Entry by the Veress needle into the distended stomach would also explain the high entry pressures noted and the subsequent need to reinsert the needle until a safe entry pressure was obtained (<8 mm Hg). The authors confirm that Palmer's point was being considered as an alternative entry site if the third and final attempt of the Veress insertion at the umbilicus had proven to be unsuccessful. 16
Conclusions
This article presented a rare complication of gynecologic laparoscopy. Of paramount importance was the fact that the injury was recognized and repaired primarily at the time of the procedure. In this case, laparoscopic primary repair was chosen as the diagnosis was clear and confirmed by surgical consultation. Routine, or at least selective, use of a nasogastric or orogastric tube to decompress the stomach, recognition of risk factors, examination of the epigastrium, and a precise surgical technique may prevent such gastric injuries. In any event, examination of the epigastrium and the placement of a nasogastric tube before starting insertion of a Veress needle would minimize the incidence of gastric injury.
Footnotes
Disclosure Statement
For both authors, there no conflicts of interest.