How to avoid major vessel injury during gynecologic laparoscopy

In the early days of laparoscopy, only one method of entry existed. Over time, however, several other techniques have been devised.

The initial method—still widely utilized—is known as the closed or blind technique. The surgeon creates a pneumoperitoneum with the use of a needle that is 18 gauge to 2.5 mm in diameter; the needle is placed through a subumbilical incision. Once intraperitoneal placement is confirmed, CO₂ gas is infused into the peritoneal cavity until the abdomen is tympanic to percussion (usually at pressures of 14 to 18 mm Hg).

Next, the surgeon aims the trocar toward the uterus at a 45° angle, maintaining the device in the midline. Entry is confirmed by opening the trocar’s trap-door valve and witnessing a rush of CO₂ gas.

Another entry technique—the open technique—is used almost universally by general surgeons. The procedure is a type of microlaparotomy. After making the subumbilical incision, the fascia of the abdominal wall is pierced and the peritoneum is grasped and opened bluntly or sharply. Once the edges of the peritoneum are secured, a blunt trocar (Hasson trocar) is inserted. Then the trocar is removed, leaving the sleeve in place to accept the laparoscope.

Another entry variation, called direct entry, employs no pneumoperitoneum. In this approach, the surgeon grabs the anterior abdominal wall, sharply elevating it, and directly thrusts the reusable or disposable trocar into the abdominal cavity.

An extensive review of entry techniques has been published elsewhere.¹

Many complications arise from entry techniques and devices

A survey of Australian gynecologists about entry techniques found that 73% of respondents used a Veress needle and pneumoperitoneum for entry and that 83% used a location other than the infraumbilical site when periumbilical adhesions were suspected. Twenty-one percent had experienced a major retroperitoneal vascular injury, but 33% lacked a plan to manage such injuries.²

In their review of entry techniques, Vilos and colleagues asserted that Veress-needle insertion should be accompanied by pneumoperitoneal pressures of 20 to 30 mm Hg rather than a predetermined volume of CO₂ gas.¹ They also recommended insertion in the left upper quadrant when periumbilical adhesions are suspected or when insufflation at the umbilicus fails three times.

Newer entry devices include the optical-view trocar and the radially expanding trocar. The first consists of a plastic, conically tipped instrument that is optically clear. At least hypothetically, this device permits the surgeon to view each layer of the abdominal wall as he or she thrusts the device under “direct vision” into the abdominal cavity.

The radially expanding trocar is inserted over a Veress needle into the abdominal cavity. Its initial diameter is only 3 mm; once the instrument is in place, however, a blunt plastic trocar and sleeve are pushed into the mesh-like, radially expanding tube until it reaches 11 to 12 mm in diameter. The blunt trocar is then removed, leaving the plastic sheath and mesh material in place to accept the laparoscope. One key advantage of this device is the mesh component, which resists slippage or movement as the laparoscope is moved in and out of the sheath.

Vilos and colleagues concluded that open entry was neither superior nor inferior to other entry techniques and that direct entry without pneumoperitoneum may be as safe as Veress-needle techniques and associated with a lower risk of gas embolism. They also reported that shielded trocars are not associated with fewer visceral or vascular injuries and that visual-entry trocars lack superiority, compared with other devices, for the prevention of visceral or vascular injuries.¹

Other review articles about entry techniques similarly found no objective evidence that any single technique is superior.³ However, data are conflicting on the safety of the optical trocar, compared with other trocars, with some data showing marginal advantages and others demonstrating no difference.^4-6

Follow a few key entry guidelines

In 1990, Yuzpe reported a mail-in survey of 800 practicing ObGyns in Canada on the topic of pneumoperitoneum and trocar injuries.⁷ Of the 407 physicians who responded, 16.7% reported that the pneumoperitoneum needle caused a visceral or major vessel injury, and 16.5% attributed the injury to the primary trocar. Among 109 vessel injuries, 31 were caused by the pneumoperitoneum needle, and 28 of 104 injuries were caused by the primary trocar.

To be safe, Veress needle and primary trocar entry require critical attention to the angle and direction of the thrust relative to the abdominal cavity (FIGURE, page 24). For example, if the Veress needle or the sharp tip of the trocar deviate to the right or left of the midline during entry into the abdomen, injury to the iliac vessels is a clear risk.