AORTIC LACERATION DURING VERESS NEEDLE INSERTION: A LAPAROSCOPIC DISASTER

Abstract

Introduction: Over 50% of complications related to laparoscopy occur during the entry phase for pneumoperitoneum and trocar insertion. Major vascular injuries, although infrequent (0.04–0.1% of laparoscopic procedures), can lead to significant morbidity and mortality, with 13%–50% going undetected immediately during surgery. Major vascular injuries rank as the second most common cause of death during laparoscopy, following anesthesia-related deaths, with a mortality rate of 6.37%. Immediate response to vascular injuries should prioritize assessment and potential control rather than immediate conversion to laparotomy. Recognized risk factors for entry phase injuries during laparoscopy include obesity, prior abdominal surgeries, surgical experience, inflammatory bowel disease, and pelvic inflammatory disease.
Clinical case: A 47-year-old woman with a BMI of 42.2 kg/m2, no prior abdominal surgeries, and two recent episodes of diverticulitis within six months, was scheduled for an elective left hemicolectomy at a secondary hospital. During Veress needle insertion, blood was observed. Subsequently, upon placing the first trocar, a median retroperitoneal inframesogastric hematoma was identified, and attempts to control bleeding were unsuccessful, leading to conversion due to hemodynamic instability. An infrarenal aortic laceration was revealed, requiring clamping to halt bleeding. The patient was then transferred to a tertiary hospital for vascular surgery intervention, involving aortoplasty with a patch of the great saphenous vein and thrombectomy of the ilio-distal arteries. The time from injury to the start of vascular surgery was 2 hours. The patient was admitted to an Intensive Care Unit, receiving 15 red blood cell units (initial 2 without compatibility testing), 12 plasma units, 3 grams of fibrinogen, and 1 platelet pool. During the intensive care stay, the patient developed leg compartment syndrome, necessitating fasciectomy, and moderate ARDS, complicating disease management.
Conclusion: While major vascular lesions in laparoscopic surgery are rare, they are linked to significant morbidity and mortality. A collaborative effort involving laparoscopic surgeons, anesthesiologists, vascular surgeons, and intensivists is essential to minimize damage and improve vascular repair outcomes. Strict action protocols are crucial to reducing morbidity and mortality associated with major vascular injuries during laparoscopic procedures.