|Year : 2020 | Volume
| Issue : 1 | Page : 33-35
Veress needle injury in laparoscopy: A catastrophic complication
Atul Jain, Nabal Kumar Mishra, Sajid Makbul Nurbhai, Mansoor Banday, Gaurav Patel
Department of Surgery, ESI PGIMSR, Basaidarapur, New Delhi, India
|Date of Submission||28-Oct-2019|
|Date of Acceptance||29-Oct-2019|
|Date of Web Publication||3-Oct-2020|
Dr. Atul Jain
Department of Surgery, ESI PGIMSR, Basaidarapur, New Delhi
Source of Support: None, Conflict of Interest: None
Laparoscopy has become popular among surgeons and patients for surgery for various advantages it offers. Still, it has some complications and which can be lethal at times. Majority of injuries occur at the time of entry into the abdomen. Here, we report a case of major vascular injury by Veress needle and its sequelae.
Keywords: Aortic injury, complications, vascular injury, Veress needle
|How to cite this article:|
Jain A, Mishra NK, Nurbhai SM, Banday M, Patel G. Veress needle injury in laparoscopy: A catastrophic complication. Saudi J Laparosc 2020;5:33-5
|How to cite this URL:|
Jain A, Mishra NK, Nurbhai SM, Banday M, Patel G. Veress needle injury in laparoscopy: A catastrophic complication. Saudi J Laparosc [serial online] 2020 [cited 2021 Jan 24];5:33-5. Available from: https://www.saudijl.org/text.asp?2020/5/1/33/296780
| Introduction|| |
Laparoscopy is now widely used by surgeons in all fields for diagnostic and therapeutic purposes. Although it has various advantages, it is not risk-free. Majority (>50%) of complications during laparoscopic procedures occur at the time of entry into the peritoneal cavity. The first and critical step of laparoscopic procedure is the creation of pneumoperitoneum,, and it has a significant risk of vascular and bowel injury. Here, we report a case of major vascular injury during laparoscopic surgery by Veress needle.
| Case Report|| |
A 35-year-old female diagnosed with symptomatic cholelithiasis with American Society of Anesthesiologists Grade 1 was taken up for laparoscopic cholecystectomy. Intraoperative finding – flimsy adhesions were present around Calot's triangle. Throughout the procedure, the patient was stable, and laparoscopic cholecystectomy was done in 60-min duration. After thorough inspection, ports were removed; pneumoperitoneum was deflated and closure was done.
At the time of extubation, the patient had transient episode of hypotension (blood pressure [BP] – 90/60 mmHg). She was hemodynamically stable for the next 2 h. After 2 h, there was sudden drop in BP with tachycardia. The patient was conscious, the abdomen was distended, and marked pallor was present. Needle aspiration was done, which showed blood as content (5 ml). She was taken for emergency exploratory laparotomy immediately.
Intraoperatively, a large hematoma was noted in entire retroperitoneum. Hemoperitoneum of about 600 ml was present in the pelvic cavity. There was a breach present in the posterior peritoneum – overlying abdominal aorta and inferior vena cava with a leakage of blood into peritoneal cavity. A tear around 0.5 cm was present along the anterior wall of aorta, just proximal to the aortic bifurcation with active bleeding. Furthermore, there was a rent in the mesentery with a small tangential serosal tear in bowel 70–80 cm proximal to ileocecal junction. Aortic tear was repaired using prolene 4-0 suture. Closure was done after assuring repair and drain placement. Post procedure, the patient was shifted to intensive care unit, kept on assisted ventilation with inotropic support. The patient was discharged on postoperative day 26. After 3-month follow-up, the patient is healthy and doing well. The cardinal events in the postoperative period are summarized in [Table 1], [Figure 1], [Figure 2]. The consent for reporting this case was taken from the patient.
|Figure 2: Computed tomography - angiography showing intact arterial system post repair|
Click here to view
| Results|| |
The injury incurred during entry into peritoneum led to serious morbidity, but timely intervention and management saved the life of the patient.
| Discussion|| |
Access into the abdomen is the one challenge of laparoscopy that is particular to the insertion of surgical instruments through small incisions. Although there is no consensus regarding the best method of gaining access to the peritoneal cavity to create a pneumoperitoneum, the Veress needle insertion is the most frequently used technique, popularized by Raoul Palmer of France in 1947.,,, Complication rates are reported to be higher with repeated attempts to gain access – with 85%–100% rate on more than three attempts.
The risk factors for injury during creating pneumoperitoneum are surgeon's inexperience, failure to elevate the abdominal wall, forceful entry, wrong direction at insertion, thin and lean patient, skeletal deformities, and previous abdominal surgery. The risk factors present in our case were- thin built patient, inexperienced surgeon and multiple attempts for veress insertion.
Major vascular injury is a rare but serious complication that occurs in 0.11%–2% of cases, most frequently involving the aorta and common iliac vessels. They present with sudden hypotension/tachycardia and accumulation of blood in the abdominal cavity, a mesenteric hematoma, or an expanding retroperitoneal hematoma.
However, studies have suggested that 13%–50% of vascular injuries are undiagnosed at the time of surgery. This is probably because, bleeding is confined to the retroperitoneum. As in our case after transient episode of hypotension, the patient remained stable for the next 2 h as the bleeding was contained in retroperitoneal space, and hence, diagnosis was delayed.
Transient hypotension at the time-deflating pneumoperitoneum may be the earliest presentation of major vascular injury, and the surgeon must relook the abdominal cavity even if the patient has been extubated and requires reintubation.
| Conclusion|| |
Detailed information regarding the procedure and potential complications associated with laparoscopic surgery should be explained to the patient before the surgery. When performing laparoscopy:
- We should not forget that injury to major vascular structures is a reality
- A relook is must, if patients have transient episode of hypotension during reversal from anesthesia
- Beginners should preferably create pneumoperitoneum with open technique.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jiang X, Anderson C, Schnatz PF. The safety of direct trocar versus veress needle for laparoscopic entry: A meta-analysis of randomized clinical trials. J Laparoendosc Adv Surg Tech A 2012;22:362-70.
Mouret PH. Laparoscopic surgery: An evolution of philosophy surgical? In: Mineiro M, Melotti G, Mouret PH, editors. Surgery Laparosco´Pica. Madrid: Pan American; 1996. p. 112.
Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy: A prospective multicentre observational study. Br J Obstet Gynaecol 1997;104:595-600.
Molloy D, Kaloo PD, Cooper M, Nguyen TV. Laparoscopic entry: A literature review and analysis of techniques and complications of primary port entry. Aust N
Z J Obstet Gynaecol 2002;42:246-54.
Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonjer HJ, Cuschieri A, et al.
The European association for endoscopic surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 2002;16:1121-43.
Veress J. Neues instument zur asfuhrung von brust-oder bauchpunktionen and pneumothoraxbehandlung. Dtsch Med Wochenshr 1938;41:1480-1.
Perissat J, Vitale GC. Laparoscopic cholecystectomy: Gateway to the future. Am J Surg 1991;161:408.
Palmer R. Safety in laparoscopy. J Reprod Med 1974;13:1-5.
Richardson RF, Sutton CJ. Complications of first entry: A prospective laparoscopic audit. Gynaecol Endosc 1999;8:327-34.
Corson SL, Chandler JG, Way LW. Survey of laparoscopic entry injuries provoking litigation. J Am Assoc Gynecol Laparosc 2001;8:341-7.
Schäfer M, Lauper M, Krähenbühl L. Trocar and veress needle injuries during laparoscopy. Surg Endosc 2001;15:275-80.
[Figure 1], [Figure 2]