Uncommon Vascular Injury Caused by Scalpel Incision of Umbilicus for Primary Laparoscopy Entry

Introduction

Laparoscopic surgery has evolved over the past 20–25 years and now is accepted as the primary choice for treating most gynecologic problems.

In laparoscopy, primary access into the abdomen is the one of the most challenging things, as it is associated with injuries to the major blood vessels, bowels, and omentum. At least 50% of these complications occur at the time of primary access,^1,2 and their rate has remained the same during the past 25 years. These injuries are common and unique to laparoscopic surgery and are seen a lot less frequently in open surgery.

High morbidity and mortality rates are due to postoperative rather than intraoperative recognition of these injuries and, as a result, the injuries are not addressed quickly, ³ thus, increasing the severity of the complication.

This article reports a rare case of an injury to the superior mesenteric artery (SMA) caused by a surgical incision in the umbilicus during endoscopic surgery.

Case

A 48-year-old female underwent laparoscopic-assisted vaginal hysterectomy (LAVH) and bilateral salpingectomy (BSO) due to menorrhagia, progressive dysmenorrhea, and an 8-cm fibroid uterus. Her past medical history was unremarkable. A general physical examination revealed a proportional woman's body (height: 155.9 cm; weight: 51.8 kg; body mass index [BMI] = 21), with an essentially healthy appearance and normal vital signs. Preoperative laboratory values tested were also normal. A transvaginal ultrasound examination showed a uterine mass measuring 8.2 cm.

During surgery, a surgical incision was made in the umbilicus, using a No. 11 blade. Suddenly, an unusually large amount of bleeding was seen on the incision site; thus vascular injury was suspected. After a Veress needle was induced to establish a pneumoperitonium, a primary trocar was inserted through the same incision to place the videoscope. At that time, a retroperitoneal hematoma with a 1-cm puncture hole was seen over the area of the distal aorta, extending to the area of the right common iliac vessels, with slight bleeding from the puncture site (Figs. 1 and 2). The hematoma was not expanding and the patient's vital signs remained stable. LAVH and BSO were performed. After removal of the uterus, inspection of the wound revealed a stable hematoma and slight bleeding from the puncture site. Ball drains were placed at the Douglas pouch and Morrison pouch. A computed tomography (CT) angiogram was considered to determine the site of the vascular injury but was not performed as the patient was stable in the OR; however, in the recovery room; she was becoming vitally unstable.

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FIG. 1.

Laparoscopic picture of the retroperitoneal hematoma with a 1 cm puncture hole.

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FIG. 2.

Laparoscopic picture of the retroperitoneal hematoma.

After fluid resuscitation and hemodynamic stabilization, CT angiography was performed and showed active contrast medium extravasation at the branch of the right internal iliac artery (Fig. 3) and SMA branches (Fig. 4). The general surgery department was consulted and a decision for urgent exploratory laparotomy was made. Inspection of the peritoneal cavity revealed a massive hemoperitoneum with a blood clot, a large retroperitoneal hematoma at the lower abdominal aorta area, and active bleeding at the bilateral uterine vessel stump. The internal iliac arteries and SMAs were explored and ligated.

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FIG. 3.

Computed tomography angiography reveals contrast medium extravasation at the branch of the right internal iliac artery (arrow).

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FIG. 4.

Computed tomography angiography reveals contrast medium extravasation at the superior mesenteric artery (bold arrow) branches and right internal iliac artery (broken arrow).

Results

The patient's postlaparotomy course was unremarkable, and she was discharged later in stable condition.

Discussion

Major vascular injury is the most serious and life-threatening complication of surgery, with a 9%–17% mortality rate. Some researchers have reported that this complication was as rare as 0.004%–0.05% and that there was an 0.009% incidence of major vascular injuries.^4,5 There are many laparoscopic entry techniques—such as the open entry technique, Veress needle entry technique, direct trocar entry technique, and direct vision technique—but there is no evidence of benefit in terms of safety of one technique over the others. ⁶

Most vascular injuries occur during insertion of the Veress needle or primary trocar, ⁷ and the most commonly injured sites are the distal abdominal aorta, right common iliac vessels, distal inferior vena cava, left common iliac vessels, and the internal and external iliac vessels. ⁸ These sites are near or at the pelvic brim area, which is the direction of Veress needle or trocar insertion. However, in the current case, the cause of the injury was the scalpel incision at the umbilicus for the primary port and the injured vessel was the SMA, which is an unusual site of injury because of the SMA's higher location than the common sites. Factors that might have contributed to this type of complication include the surgeon's skill, the volume of the pneumoperitoneum, and even the patient's body habitus. The current patient had a BMI of 21, with minimal fat deposits in the anterior abdominal wall. Body habitus may be a contributing factor for this type of complication because thin patients have thin abdominal walls; thus, the scalpel can easily get through the abdominal wall, causing injury to underlying major organs and vessels, especially if deep pressure is applied during the incision.

The skill of the surgeon is an important factor. A skilled surgeon must be careful and put adequate pressure on the scalpel while making an abdominal incision to avoid injury. An adequate volume of pneumoperitoneum will increase the abdominal cavity and the distance between the umbilicus from the retroperitoneal bed, where major organs and vessels are located. If the pneumoperitoneum is not adequate, the organs and vessels can be injured easily during an umbilical incision. In this case, injury to the major vessel might have occurred due to the patient's thin abdominal wall and the deep umbilical incision.

Management of a vascular injury requires a prompt, direct, and coordinated response. The operations for more than half of major vascular injuries are converted to laparotomy, but laparoscopic surgery could be continued if a patient is hemodynamically stable, the bleeding is temporarily controlled, the hematoma is not expanding, and the surgeon is experienced in handling such a complication.

The reasons for not converting the surgery to laparotomy in the current case were due to the patient's stable vital signs, minimal bleeding from the puncture site, and a nonexpanding hematoma, even after releasing the pneumoperitoneum.

CT angiography is a rapid, accurate noninvasive method of vascular-injury examination, with accurate differentiation between arterial and venous injuries, which have a significant impact on a patient's treatment plan. Venous vascular injury mostly requires observation and supportive measures, while arterial vascular injury requires immediate conversion to laparotomy for prompt exploration and repair of the injured artery. Retroperitoneal arteries—including the abdominal aorta, renal artery, proximal celiac axis, and SMA—are easy to assess with CT angiography of the abdomen. ⁹ In the current case, the result showed an extravasation at the level of the SMA and right internal iliac artery.

Conclusions

Although less likely to happen, injury to the SMA via an umbilical incision can occur. Surgeons should practice extreme vigilance and be precise in all steps of laparoscopic surgeries. Extreme care should be practiced when making umbilical incisions, especially in thin patients. Prompt identification of the complication and treatment are important for successful management of laparoscopic injuries.

Finally, adequate training and experience is required for performing difficult procedures so that a surgeon can learn necessary skills and gain the confidence to deal with complications.