Surgical Techniques
How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy
By arming yourself with knowledge of the most common complications—and their causes—and employing well-chosen surgical strategies, you can lower...
RELEVANT NERVES OF THE ANTERIOR ABDOMINAL WALL
The iliohypogastric and ilioinguinal nerves are also at risk for injury with laterally placed trocars through direct trauma or nerve entrapment. These nerves emerge from the T12 to L1 and L1 to L2 regions, respectively, and course through the muscles of the anterior abdominal wall. Specifically, the iliohypogastric nerve penetrates the fascia of the internal oblique muscle, and the ilioinguinal nerve penetrates the fascia of the transverse abdominus muscle.22 Fascial closure at lateral port sites can also increase the risk of injury to those nerves (FIGURE 4).23
CASE CONTINUED
As you continue your case, you have had to replace your right lower quadrant port several times. During the last insertion, you notice that you have an enlarging abdominal wall hematoma. You suspect that you have injured the inferior epigastric vessel.
How should it be repaired?
HOW TO PREVENT AND REPAIR INJURED DEEP INFERIOR EPIGASTRIC VESSELS
A thorough knowledge of anatomy is the most effective way to prevent these types of injuries. The use of bladeless radially expanding trocars and smooth conical-tip trocars that push the vessels away may result in fewer port-site bleeding complications and injuries than large pyramidal or cutting trocars.24–26 It is important to inspect all ports sites at the end of any laparoscopic procedure because the port itself can tamponade an injured anterior abdominal wall vessel and obscure an injury.
If an injury occurs, leave the trocars in place until a plan for repair is devised. First, start by compressing the bleeding point by moving the cannula against it. Because there are two bleeding ends, the vessels must be sutured cephalad and caudad to the site of injury. The use of electrosurgical desiccation is usually less successful.25 In obese patients we prefer to suture-ligate the bleeder intracorporeally or use a laparoscopic port closure device. In thin and pediatric patients, percutaneous suture ligation can be done easily.
Another option to control bleeding at the cannula site is placement of a Foley catheter to tamponade the vessel using a large balloon placed on tension.27 If abdominal loop sutures are used to control bleeding, the sutures typically are left intact for 8 hours prior to removal.25 If identification of the bleeding point is difficult, percutaneous placement of a suture ligature over a roll of gauze or using a Foley catheter to tamponade the bleeder can be helpful.
CASE RESOLVED
A laparoscopic port closure device is used to suture ligate the bleeding vessel. Hemostasis is achieved and the laparoscopic hysterectomy is completed without further complications.
Tell us what you think!
Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Share your thoughts by sending a letter to obg@frontlinemedcom.com. Please include the city and state in which you practice. Stay in touch! Your feedback is important to us!
