Vascular injury during laparoscopic gynaecological surgery

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

Vascular Injury During Laparoscopic Gynaecological Surgery Brierley G et al. Vascular injury during laparoscopic gynaecological surgery: a methodological approach for prevention and management. TOG 2020;22:191–198. doi:10.1111/tog.12664

0.1–1.1% 8–23% 75% VASCULAR INJURY INCIDENCE, ALL MORTALITY RISK, MAJOR VASCULAR INJURY INJURIES OCCURRING AT ENTRY LAPAROSCOPIES (VERESS/PRIMARY TROCAR)

DO N' T-M IS S FA C TS

  1. 75% of vascular injuries occur at Veress/primary trocar entry; major injury mortality 8–23%

  2. Safety-shield/direct-view trocars do not prevent serious injury – 87% of vascular deaths involved a safety-shield trocar

  3. Veress entry pressure <8 mmHg confirms peritoneal entry; switch technique after 2 failed attempts (RCOG)

  4. Raise pneumoperitoneum to ≥20 mmHg before trocar insertion (distance to vessels 0.6→5.6 cm), then reduce to 10– 15 mmHg

  5. Insert Veress/primary trocar supine (not Trendelenburg) – bifurcation caudal to umbilicus in 33% Trendelenburg vs 11% supine

  6. Palmer’s point = 3 cm below left subcostal margin, mid-clavicular line – alternative site in low BMI/previous surgery

  7. Haemodynamic compromise + suspected major injury → immediate midline laparotomy, leave causative trocar in place

  8. Emergency drill: declare → direct pressure → SBAR communication → resuscitate → monitor/bloods → equipment/family → documentation/incident form

VESSELS AT RISK (BOX 2)

Anterior wall: IEA, superficial circumflex iliac a. Posterior wall: aorta, common/external/internal iliac vessels, IVC, corona mortis

ABBREVIATION KEY

BMI — body mass index CT — computed tomography

RCOG — Royal College of Obstetricians and Gynaecologists SBAR — situation, background, assessment, recommendation

FDA — US Food and Drug Administration ICU/HDU — intensive care unit/high dependency unit

IEA — inferior epigastric artery VTE — venous thromboembolism

IVC — inferior vena cava PTFE — polytetrafluoroethylene

ASIS — anterior superior iliac spine

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — management. TOG 2020;22:191–198. doi:10.1111/tog.12664

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