1) Verres needle and Trocar injuries:
Most complications from laparoscopic surgery have been reported to
occur at the time of Verres needle or Trocar placement.
The primary concern of the surgeon when entering these tools is the
possibility of inadvertent laceration of a major blood vessel that may
not be recognized immediately since the tools are entered blindly into
the abdomen. Several procedural techniques minimize this risk, which
actually occurs very rarely in the hands of an experienced laparoscopist.
A high index of suspicion also allows for a more rapid identification
of injury to a major vessel.
If the Verres needle is placed directly into a major vessel and this
is not recognized then insufflation of the vessel with CO2 gas may result
in a massive pulmonary (gas) embolism and cardiovascular compromise
Trocar injuries may involve the major vessels. More commonly the trocar
injures the bowel during the blind insertion. To minimize either of
these events, I always invert the umbilicus, hold the abdominal wall
up (to maximize distance from the deep structures such as bowel and
vessels), and enter the instruments into the abdomen just past the inner
lining of the abdominal wall. I have not had any such injuries using
2) Vascular injury in abdominal wall and great vessels of the pelvis
Vascular injuries appear to account for about 30-50% of laparoscopic
trauma, but injury to the major vessels is very uncommon (less than
1 in 1000). Injury to the vessels in the abdominal wall may involve
- deep epigastric vessels (inferior or superior epigastric vessels).
The epigastric artery originates from the external iliac artery near
its transition to the femoral artery and the deep inferior epigastric
artery then lies adjacent (lateral) to the obliterated umbilical ligaments
(usually easy to see on direct laparoscopic inspection of the inner
abdominal wall) beneath the lateral margin of the rectus abdominus
muscle. Entry of additional trocars lateral to these vessels reduces
vascular injury to these vessels within the abdominal wall.
- the superficial epigastric vessels. These vessels course "on
top" of the rectus abdominus muscle and are usually able to be
visualized with transillumination using the laparoscope as the source
of light within the pelvis.
- the deep and superficial circumflex iliac vessels. These vessels
course lateral to the epigastric vessels, usually lateral to any typical
placement site for a trocar.
If there is an injury to one of these deep abdominal wall vessels
with significant bleeding seen from the site of the trocar the exact
location of the bleeding site should be identified (if possible) by
carefully moving or rotating the trocar so as to identify the precise
site of the injury. Then bipolar cautery can be used to try to immediately
control the bleeding. The epigastric artery should be coagulated above
and below the site of injury. This is not always possible and a second
manipulation that can be useful is tamponade (using a Foley catheter
that is passed through the 5 mm port, inflation of the balloon, pulling
the balloon tightly against the inner abdominal wall and holding it
in place with a (Kelly) clamp. After a few minutes (about 10-15 minutes)
the balloon may be released and the bipolar used once again if the bleeding
has significantly decreased. If this fails to control bleeding, a figure
of eight suture may be placed through and through the abdominal wall
to control the bleeding (with tying on the outer skin of the abdominal
wall). If all of these techniques fail then a cut down for exploration
and tying off the vessels may be required.
If there is injury to one of the superficial vessels of the abdominal
wall then pressure on the skin usually controls the flow. If external
pressure is not successful then ligature is required. At the end of
the case the sites should be reevaluated after removal of the trocars
since the release of tamponade from the trocar may allow reactivation
Injury to the aorta, inferior vena cava or common iliac vessels can
be life threatening. Immediate laparotomy with the assistance of a vascular
surgeon is usually indicated.
2) Urinary tract injury:
Injury to the urinary tract (bladder or ureters) is uncommon in laparoscopic
surgery involving the pelvis, however, endometriosis or infection can
certainly involve these structures intimately and the possibility of
injury is important to recognize.
Bladder perforation with a Verres needle or the midline lower abdominal
trocar is possible. This risk is dramatically reduced if a foley catheter
is placed into the bladder at the onset of the case (with confirmation
of urine flow since occasionally the lubricating gel plugs the catheter).
Treatment may be a double layer closure (water tight) with a low reactive
long half life suture like Vicryl or PDS, placement of a foley catheter
for 7 days and antibiotics.
Bladder injury during resection of endometriosis or adhesiolysis (especially
if there is a history of prior bladder surgery or cesarean section)
is not common and depends on the extent of pathology being resected
and the experience of the surgeon.
Ureteral injury is not common, most often involving the ureters as
they course near the uterosacral ligaments. The most common cause is
the use of cautery (either unipolar or bipolar) in the area and either
direct or lateral thermal damage. If not immediately recognized, the
diagnosis is suggested by development of flank pain, (unilateral) pelvic
pain, fever, leukocytosis and peritonitis. If there is an intraoperative
concern about ureteral injury, 5 cc of indigo carmine can be injected
IV by the anesthesiologist and this should appear in the Foley bag within
about 10 minutes. Postoperative diagnosis is usually guided with intravenous
3) Gastrointestinal injury:
Injury to the bowel is most often caused by the Verres needle or Trocar
when blindly inserted. A Verres needle injury may be quite small and
remain unrecognized. These injuries may involve the small bowel, large
bowel or stomach. Electrosurgical or laser injury is relatively uncommon.
Extensive enterolysis for small bowel adhesions may result in injury
in as many as 25% of the cases. These injuries often are not recognized.
If recognized, the repair of small bowel injuries consists of a surgical
consultation, repair with 3-0 or 4-0 silk (or PDS) suture (tapered SH
needle), and nasogastric tube.
Large bowel injury is probably most often caused by the Verres needle
and may go undiagnosed a large percentage of the time. Foul smelling
gas is a characteristic sign. If the hole is small (needle size), expectant
management is usually recommended.
Trocar injury to the large bowel usually occurs when there are dense
adhesions from the large bowel to the inner anterior abdominal wall.
Occasionally, these injuries are only identified when the trocar is
removed under direct observation since they may be through and through
the walls of the bowel. Laparotomy and repair by a general surgeon is
indicated, leaving the trocar in situ for identification of the site
Most large bowel injuries are due to mechanical trauma as adhesions
from the rectosigmoid bowel are freed from the cul de sac in the presence
of dense endometriosis or chronic inflammation. Superficial injury may
be able to be managed expectantly but deep injury requires surgical
Stomach injuries may be more common following difficult endotracheal
intubation since the stomach may be filled with gas. These injuries
usually occur with subsequent (blind) entry of the Verres needle or
Trocar into the inflated stomach. Placement of a nasogastric tube may
reduce this possibility.
Reactivation of a dormant infection during laparoscopic surgery is
possible but uncommon. Whenever surgery is performed in the presence
of an active infection or is to repair the pelvis that has been damaged
through a chronic infection antibiotics should be used liberally.