October 2004 · Vol. 16, No. 10Avoiding vascular injury at laparoscopy
An expert traces distances between trocar entry and vascular landmarks, describes the safest insertion techniques, and outlines decisive action in case of injuries.
Michael
Baggish,
MDChairman, Ob/Gyn Department Good Samaritan Hospital,
Cincinnati.
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Fast Track
Adequate pneumoperitoneum lessens the force required to drive in the trocar.
Distance between the primary trocar and iliac vessels and urinary bladder increases with the patient’s height.
The Touhy epidural needle is 8.5 cm long, making it less hazardous than the 12.5-cm Verres needle.
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KEY POINTS
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Distances between the entry trocar and the aorta bifurcation increase directly with body mass index, mainly because of the commensurate increase in abdominal wall thickness.
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The mean thrusting force for insertion of a disposable trocar is 10.2 lb versus 17.53 lb for a reusable device, and the time to penetrate is shorter for the disposable trocar: mean of 3.54 seconds versus 11.64 seconds. Thus, greater caution is warranted when inserting a disposable trocar.
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Thrust the primary trocar into the midline of the abdomen at a 45° to 60° angle relative to the plane of the abdominal wall, with the trocar pointing toward the uterus, to avoid injuring the iliac vessels.
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When injury occurs, call for a vascular surgeon immediately, perform a laparotomy using a vertical incision, and get accurate inputs, outputs, and blood-loss estimates.
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Major vessel injury is a two-sided coin: It can occur with alarming speed, but it is preventable.
Fortunately, the laparoscopic surgeon can avoid the problem by following simple precautions and steering clear of scenarios that increase the risk of injury. This article tells how to accomplish both objectives.
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