Vascular and Bowel Injuries from Blind and Open Access Techniques in Laparoscopy

Transcription

1 Med. J. Cairo Univ., Vol. 77, No. 3, December: , Vascular and Bowel Injuries from Blind and Open Access Techniques in Laparoscopy TAMER M. NABIL, M.D.* and NADER SHABAAN, M.D.** The Department of Surgery, Faculties of Medicine, Beni Suif* and Fayom** Universities. Abstract Objective: This report evaluates access-related complications with both blind and open access techniques in a teaching hospital using standardized techniques for both methods with the aim is to alert to potential hazards and to suggest methods and practices to minimize these often catastrophic events while offering patients all the benefits of the minimal access approach. Methods: Two groups of patients at different times from a prospective database were compared. A retrospective analysis of 1,197 patients treated using blind access between Sep and Sep were compared with 352 patients treated using open step-by-step access between Dec and Sep regarding access-related complications. Results: In blind access group there were 4 cases of vascular injury (.33%); all cases were evaluated immediately and required laparotomy, provisional haemostasis and urgent attendance by a vascular surgeon in 3 cases. There was no further postoperative Complications in all cases and 1 case of bowel injury (.08%) from shielded trocar leading to perforation of sigmoid Colon repaired laparoscopically by sutures in 2 layers with no further postoperative complications. Open step-by-step access shows no vascular or bowel injuries (0%). Conclusion: Because no evidence exists to show that the blind access technique is superior in any aspect, the open technique is recommended for access to the abdominal cavity in laparoscopy. In cases when blind access technique is preferable (No cannula will be put around the umbilicus and/or Patient is morbidly obese), Blind Veress needle insertion in left subcostal area at point between left midclavicular and anterior axillary lines and insufflation followed by opticalaccess trocar insertion is the preferred method for first cannula insertion. Key Words: Laparoscopy Trocar vascular injuries Open access. Introduction THE establishment of pneumoperitoneum requires the introduction of a sharp insufflating needle or trocar. It is a purposeful stab wound which carries a very small but significant risk to the patient. It is during this beginning step that most vascular and bowel injuries in laparoscopy are encountered. When analyzing the factors that contribute to these complications, it is this first step in the operation that must be made as safe as possible. Although these catastrophic injuries are uncommon, they represent a major reason for mortality from laparoscopic procedures and a significant source of the morbidity associated with any laparoscopic procedure. Haemorrhage due to vessel injury and infection secondary to bowel injury, especially when diagnosis is delayed, are the most serious complications and the most likely to result in death. Most data suggest that the rate of trocar related complications is less than 3% [1]. Despite the rapid evolution of laparoscopic surgery in the past decade, the surgical community has failed to adequately report and study this tragic complication. As a result, most case reports and large series reporting these injuries are derived from older gynaecologic literature. It was largely believed that that newer instrumentation and knowledge would reduce the risk of these complications, reports from the general surgical literature, however, suggest this not to be the case. In fact, these injuries occur with greater frequency. Most disturbing, surgeons have been oblivious to the risk of trocar injury by failing to associate post operative complication with the possibility of trocar injury and thus failing to recognize bowel perforation until it is too late. Laparoscopic cases are scheduled in out patient clinics lacking blood, vascular operative instruments and expertise. Rarely does this complication addressed in the informed consent beyond the customary and conclusionary "bleeding and infection" [2]. 119

2 120 Injuries from Blind & Open Access Techniques in Laparoscopy Minimally invasive surgery typically involves use of multiple trocars and cannulas. The first trocar inserted, or primary trocar, is used to place a cannula through which a laparoscope is inserted to view internal structures. Other, secondary, trocars provide for insertion of other instruments such as biopsy forceps, etc. The primary trocar is typically inserted using either a "blind" puncture or a Hasson "cut-down or open method" [3]. Before inserting the primary trocar many surgeons introduce carbon dioxide gas into the abdominal cavity (creating pneumoperitoneum) through a Veress needle - a process called insufflation. Insufflation elevates and holds the abdominal wall away from internal structures. Blind Veress needle insertion and insufflation followed by blind trocar insertion is the technique most widely used. One-third to one-half of major intra-abdominal vascular and intestinal injuries occurs from the Veress needle itself [4]. The Veress needle consists of a blunt-tipped, spring loaded inner stylet and a sharp outer needle. The stylet retracts during passage of the needle through the abdominal layers, to allow penetration. Once the peritoneum is entered, the lack of tissue resistance allows the blunt stylet to protrude. Theoretically, this should prevent perforation of intraabdominal structures. But it is important to note that the stylet does not lock once it protrudes. It can penetrate an intra-abdominal structure because the stylet will again retract on contact with an intra-abdominal structure [5]. Important procedural steps during insertion of the Veress needle are: Trendelenburg position, elevation of the abdominal wall and direction of the needle at 45 to the spine and aimed toward the pelvis in the midline. The following tests should be done to confirm the presence of the needle in the peritoneum and not in a visceral organ. 1- Manometer test-involves connecting the gas tubing to the Veress needle and raising the abdominal wall to create negative pressure. 2- Hissing sound test-involves turning the valve to the off position after it has been properly positioned. The abdomen is elevated and the valve opened, creating a hissing sound. 3- Aspiration test-involves attaching a syringe filled with saline to the Veress needle and attempting to aspirate any material. If material is aspirated, such as bowel contents or urine, the Veress needle should be removed. If blood is aspirated, the needle is left in place and preparation for exploratory laparotomy is made for a presumed vascular injury. 4- If no material is aspirated, 5mL of saline is inserted and a reattempt to aspirate is made. If no fluid is aspirated, entry into the peritoneal cavity is confirmed. If the saline is aspirated, an enclosed space was probably entered, that is, preperitoneal space and the needle should be repositioned. 5- Hanging drop test-involves placing a drop of water on the open end of the Veress needle. The abdominal wall is elevated; if the needle is correctly positioned, the water should disappear down the shaft. Until confirmation of proper position of the needle, insufflation should be low at a rate of 1L/minute. 6- Finally, the needle is attached to an insufflator that measures the pressure at the tip. The pressure will be low (5mmHg), if it is appropriately placed. Insufflation to 12 to 15mmHg with carbon dioxide gas follows. Once this pressure is achieved, a 10-mm trocar with or without a safety shield is placed blindly into the abdomen. It must be emphasized that a full pneumoperitoneum should be established prior to insertion of the blind umbilical trocar. Once again, care must be taken to elevate and stabilize the abdominal wall and to ensure that the trocar is inserted in the midline at 45 degrees to the spine aimed towards the pelvis [6]. Injuries related to the blind Veress needle insertion led to studies on alternative methods. Some suggest it is safer to skip the Veress needle step altogether and use a direct trocar insertion technique [7]. Others Reich et al. [8] recommended high pressure insufflation during the primary trocar insertion in order to create more space between the abdominal wall and internal structures. Trocar design: Early trocars were simple devices used for paracentesis. More complex designs were developed as laparoscopic surgery was introduced. Trocar tips are designed for either sharp or blunt penetration (Fig. 1). In 1984, a trocar was introduced with a retractable shield that covers the tip before and after insertion (Fig. 2).

3 Tamer M. Nabil & Nader Shabaan 121 In 1994, Optical-access trocars (Fig. 3) were introduced as an alternative to the blind insertion. These allow laparoscopists to view the cutting tip as it penetrates the tissues. Studies suggest that optical-access trocars may provide some protection over blind insertion [11,12]. Even with use of optical trocars, some injuries are reported in the literature and direct placement of an optical-access trocar into the desufflated abdomen carries the potential for significant injury [13]. Pyramidal Conical (Sharp) Conical (Blunt) Blunt (Hasson) C958HN8A-04 Fig. (1) The purpose of the shield is to protect abdominal and pelvic organs from inadvertent puncture. Whether shielded trocars offer protection against injuries is the subject of debate. A study of 103,852 operations involving the use of 386,784 trocars found that ten out of the 26 (39%) serious injuries and two out of the seven (29%) deaths involved shielded trocars [1]. In a 1995 retrospective study of 3,591 laparoscopic procedures, Saville and Woods [9] found four major retroperitoneal vessel injuries all of which involved shielded trocars [10]. In 2000, ECRI reported that the laparoscopists it consulted disagreed about the benefit of shielded trocars. Laparoscopists attitudes about shielded trocars appear to be influenced by the laparoscopists training and experience with the various trocar designs. ECRI s report concluded that when used properly, shielded trocars may provide a margin of safety, but that the shield may create a false sense of security and lead to undue reliance upon it. Trocar Handle Shield Release Cannula Handle Trocar Shaft Trocar Cannula Fig. (2) Shield Cannula Sleeve C958HN8A-02 Fig. (3) The amount of force required may correlate with the risk of injury. Injuries may occur twice as often when associated with difficult trocar insertion [15]. Corson et al. [14] reported that the force required to insert reusable trocars was twice that for disposable trocars. This is due to the fact manufacturers use different alloys (that are compatible with autoclaving) for reusable trocars than for disposable trocars. The alloys used for reusable trocars are difficult to sharpen and do not allow for as sharp cutting edges as are found on the disposable trocars. Hence the force necessary for insertion is greater for reusable trocars. Vascular injuries: Major vascular injury during the initiation of pneumoperitoneum is a much-feared complication of laparoscopic procedures. The frequency of vascular complications has been reported to occur in 5 to 12/10,000 cases. Vascular injury is a major cause of death from laparoscopy, with a reported mortality rate of 15% [2]. Major vascular injury can occur when the Veress needle is inserted prior to insufflation, or when a trocar is inserted after insufflation.

4 122 Injuries from Blind & Open Access Techniques in Laparoscopy The reason for these injuries is the close proximity of the anterior abdominal wall to the retroperitoneal vascular structures. In thin people, this distance can be as little as 2cm. The distal aorta and right common iliac artery are particularly prone to injury. This is not surprising, given the fact that the take off of the right common iliac artery lies directly below the umbilicus [16]. Minor vascular injuries are so named because they are injuries to vessels of lesser importance than the aorta, inferior vena cava and iliac vessels. It is not because these injuries are minor in nature. By far the most common minor vascular injury is to the inferior epigastric vessels. Injury to these vessels is reported to occur in up to 2.5% of laparoscopic hernia repairs. There were 76 cases of minor vascular injuries involving principally the epigastric vessels identified in a review of 10,837 patients undergoing hernia operation [17]. Injuries of the epigastric vessels can be related to carelessness during the operative procedure. These injuries invariably occur during placement of secondary cannulas, which should be placed under direct vision and with prior transillumination of the abdominal wall. Although injury of the epigastric vessels is still possible if these measures are taken, the incidence should be dramatically reduced. Fig. (4): Transverse and sagittal sections, showing the considerable sagittal plane misdirection and excessive penetration, but minimal transverse deviation involved in combined right common iliac artery-left common iliac vein injuries. Table (1): Factors responsible for large vessel injury. Inexperienced or unskilled surgeon Failure to sharpen the trocar Failure to place the patient in trendelenburg position Failure to elevate or stabilize the abdominal wall Perpendicular insertion of the needle or trocar Lateral deviation of the needle or trocar Inadequate pneumoperitoneum Forceful thrust Failure to note anatomic land marks Inadequate incision size Bowel injuries: Bowel injury is the third cause of death from a laparoscopic procedure after major vascular injury and anaesthesia. The frequency of bowel injuries has been reported to occur in 9 to 18/10,000 cases. The small intestine was most frequently injured (55.8 per cent), followed by the large intestine (38.6 per cent). Unlike major vascular injuries where the risk and presentation are immediate, many bowel injuries go unrecognized at the time of the procedure. Consequently, patients present postoperatively, often after discharge, with peritonitis. This delay makes it a significant cause of morbidity and mortality [18]. 39.8% of vascular and intestinal injuries were caused by the Veress needle, 37.9% by insertion of the primary trocar and 22% by the secondary trocar. The remaining gastrointestinal injuries resulted during dissection, electrocoagulation, or grasping [19]. Importantly, these investigators noted the experience of the surgeons was an important factor in the overall complication rate and in the incidence of intestinal injury. Previous abdominal surgery: Autopsy studies have found adhesions in 75% to 90% of patients with previous abdominal surgery, typically localized to the previous surgical site but often involving other areas. Interestingly 10% of patients with no previous abdominal surgery had adhesions in areas at risk for injury. Clearly, a midline incision presents a high risk for bowel adhesions under a planned umbilical trocar site; however, even scars away from the umbilicus can lead to adhesions at the umbilical site. A blind-access technique (i.e., Veress needle insertion followed by trocar insertion) has resulted in a high rate of complications, even in patients without abdominal surgical scars. Most vascular injuries are associated with a blind-insertion technique of the first port, whereas more than half of all bowel injuries are associated with this technique. The risks for bowel injury or vascular injury are even higher if the needle or trocar is blindly placed through a previous incision [18]. Safer alternatives include placement of the needle at a site far from previous scars, such as the right upper quadrant in patients with pelvic surgery. An attempt should be made to place the

5 Tamer M. Nabil & Nader Shabaan 123 needle and initial trocar in a site to be used for surgery, but occasionally access must be in a remote quadrant, such as the left subcostal region for laparoscopic cholecystectomy. The chosen site should be away from scars and should avoid the inferior epigastric vessels. Placement in the midclavicular line is safest in the upper quadrants. In the lower abdomen, the trocars are best placed lateral to the epigastric vessels but sufficiently medial to prevent colonic injury [20]. Another alternative is the use of an open technique. These injuries are not completely eliminated by this technique, but their prevalence is decreased with its use. In addition to decreasing the rate of bowel injury, the open technique allows surgeons to promptly identify and repair any injury that may occur, thus decreasing morbidity and mortality rates [21]. The open access technique (Hasson method) has been introduced with the aim to reduce these injuries. The concept in the open technique is to create a tiny incision, directly incise the layers of the abdominal wall, directly cut the peritoneum and enter the abdomen. Since gas can escape around the incision, sutures are placed on the abdominal fascia and attached to the cannula or Allis forceps grasps wound edges tightly. Proposed advantages for the open technique are avoidance of blind puncture with a needle and subsequent trocar, certainty of establishing a pneumoperitoneum and correct anatomical repair of the abdominal wall incision. In general, widespread use of this technique has been limited to patients with previous lower abdominal surgery, pregnant patients, children and very thin patients where little space exists between the abdominal wall and the spine. Reasons for limiting the use of the open technique include greater time needed for performance, difficulty with the technique, obesity of the patient, difficulty maintaining the pneumoperitoneum and no port will be put in periumbilical region. There are considerably fewer reports of bowel and major vascular injury in the literature using this technique than the Veress needle technique. Penfield [22] noted a 0.06% incidence of bowel injury but the injuries were mostly partial and were recognized immediately because of the proximity of the bowel to the wound. Hasson presented his review of 5284 patients who had open laparoscopies developed complica- tions related to primary access. Twenty-one had minor wound infections, four had minor haematomas, one developed an umbilical hernia that required reoperation and one had an inadvertent injury to the small bowel that was repaired intraoperatively without adverse outcome. Access to the abdominal cavity was generally secured in 3-10 minutes. In a review of 15,279 laparoscopic cases in Japan, a 1.02% incidence of needle and trocar insertion-related complications was noted; The Japanese researchers concluded in their paper that complications related to needle and trocar insertion are preventable by placement under direct vision [23]. Proponents of the open technique often cite a lack of major vascular injuries reported in the literature. But a recent report notes two cases of aortic injury using open laparoscopy. In this regard, it is important to note that the injuries resulted from a faulty cannula and not from the technique itself. Bowel injuries reported have been minor and were recognized immediately as they were in the immediate proximity to the cannula. Nonetheless, injuries can and do occur [24]. In 1998 ECRI estimated that 50% of surgeons used Veress needle insufflation prior to primary trocar insertion, while 30% used a direct (no insufflation) trocar insertion method and 20% used the Hasson method. The literature does not indicate a difference in complication rates for direct entry versus a preliminary pneumoperitomeum. Patients and Methods Two groups of patients at different times from a prospective database were compared. A retrospective analysis of 1,197 patients treated using blind access between Sep and Sep were compared with 352 patients treated using open step-by-step access between Dec and Sep regarding access-related complications. Blind access via one of the following methods: 1- Blind Veress needle insertion around the umbilicus and insufflation followed by blind trocar insertion. 2- Blind Veress needle insertion in left subcostal area at point between left mid clavicular and anterior axillary lines and insufflation followed by blind trocar insertion. This method was adopted since Dec when no cannula will be put around the umbilicus and/or the patient was morbidly obese.

6 124 Injuries from Blind & Open Access Techniques in Laparoscopy 3- Blind Veress needle insertion in left subcostal area at point between left mid clavicular and anterior axillary lines and insufflation followed by optical-access trocar insertion. This method is adopted from 2006 when no cannula will be put around the umbilicus and/or the patient is morbidly obese. Open step-by-step access is adopted in all cases starting from Dec with the following exceptions. No cannula will be put around the umbilicus. Patient is morbidly obese. Results In blind access group: 4 cases of vascular injury (.33%); all cases were evaluated immediately and required laparotomy, provisional haemostasis and urgent attendance by a vascular surgeon in 3 cases. There was no further postoperative Complications in all cases. 3 major vascular injuries (.25%) via first method. Left common iliac artery repaired via direct suture by vascular surgeon. Left common iliac vein repaired via direct sutures by vascular surgeon. Left common iliac artery repaired via venous patch from long saphenous vein by vascular surgeon. - In the 3 cases the original pathology was dealt with, open Cholecestectomy in one case and open hernioplasty in 2 cases. 1 vascular injury via second method from Blind Veress needle insertion in left subcostal area associated with large amount of blood intraperitonially and systolic pressure 85 on exploration no source was found and bleeding stopped spontaneously with correction of shock most probably it was an omental vessel. Open Nissan fundoplication was done for management of GERD which was the original disease. 1 case of bowel injury (.08%) via second method from shielded trocar Entered midway between xiphoid process and umbilicus for management of achalasia of cardia leading to perforation of sigmoid Colon repaired laparoscopically by sutures in 2 layers. Laparoscopic Hiller cardiomyotomy was done in this case with no further postoperative complications. Open step-by-step access: No vascular or bowel injuries (0%). Gas leakage was not a problem in open access and in the few cases in which it was occurred approximation of skin wound edges by Allis forceps or towel clip was more than enough. In last 20 cases of open laparoscopy after some experience in the procedure, the time from starting the procedure till entering the scope ranges from minutes average 4 minutes which is more or less near that of blind procedure. Post operative port hernia was identified in 4 cases in open procedure (1.14%). Post operative port hernia was identified in 5 cases in open procedure (.4 1 %). This is statistically significant difference (p=0.335). The third method of blind access technique in which Blind Veress needle insertion in left subcostal area at point between left midclavicular and anterior axillary lines and insufflation followed by opticalaccess trocar insertion was used in 47 cases since January 2006 without vascular or bowel injuries. Discussion This report evaluates access-related complications with both blind and open access techniques in a teaching hospital using standardized techniques for both methods with the aim is to alert to potential hazards and to suggest methods and practices to minimize these often catastrophic events while offering patients all the benefits of the minimal access approach. Our educational efforts to make techniques as safe as possible were successful, as evidenced by a minimum of access-related complications in last year in which 258 cases were done. Gas leakage is not a problem in open technique and if present it is well controlled by easy manoeuvres. Expected time delay in open technique till scope introduction was not present as average time taken from 1 st scalpel inscion till scope introduction is equal or lower than that in closed technique and this time was shortened after some experience in the procedure. Regarding the higher incidence of port hernia, this can be accepted in order to avoid major vascular and bowel injuries. This higher incidence should

7 Tamer M. Nabil & Nader Shabaan 125 be expected to become lower and lower with more experience in technique. Because no evidence exists to show that the blind access technique is superior in any aspect, the open technique is recommended for access to the abdominal cavity in laparoscopy. In cases when blind access technique is preferable (No cannula will be put around the umbilicus and/or Patient is morbidly obese), Blind Veress needle insertion in left subcostal area at point between left midclavicular and anterior axillary lines and insufflation followed by optical-access trocar insertion is the preferred method for first cannula insertion and proved to be more safer. References 1- CHAMPAULT G., CAZACU F. and TAFFINDER N.: Serious trocar accidents in laparoscopic surgery: A French survey of 103,852 operations. Surg. Laparosc. Endosc., 6: , BHOYRUL S., VIERRA M.A., NEZHAT C.R., KRUMMEL T.M. and WAY L.W.: Trocar injuries in laparoscopic surgery Journal of the American College of Surgeons-June (Vol. 192, Issue 6), HASSON H.M.: Open laparoscopy: A report of 150 cases. J. Repro. Med., 12 (6): , SCHALLER G., KUENKEL M. and MANEGOLD B.C.: The optical "Veress needle" initial puncture with a minioptic. End. Surg. All. Tech., 3: 55-57, PHILIPS P.A. and AMARAL J.F.: Abdominal access complications in laparoscopic surgery Journal of the American College of Surgeons-April (Vol. 192, Issue 4), MYRIAM J.: Curet MD Special Problems in Laparoscopic Surgery Surgical Clinics of North America Volume 80 Number 4 August, YERDEL M.A., KARAYLCIN K., KOYUNCU A., AKIN B., KOKSOY C., TURKCAPAR A.G., ERVERDI N., et al.: Direct trocar insertion versus Veress needle insertion in laparoscopic cholecystectomy. Am. J. Surg., 177: 247-9, REICH H., RIBEIRO S.C., RASMUSSEN C., ROSEN- BURG J. and VIDALI A.: High-pressure trocar insertion technique. J. Soc. Laparoendos Surg., 3 (1): 45-48, SAVILLE L.E. & WOODS M.S.: Laparoscopy and major retroperitoneal vascular injuries (MRVI). Surg. Endosc., 9 (10): , Trocars: New data on safety and selection. Health Devices, 29 (2-3): 67-71, SHARPE H.T., DODSON M.K., DRAPER M.L., WATTS D.A., DOUCETTE R.C. and HURD W.W.: Complications associated with optical-access laparoscopic trocars. Obstet. Gynecol., 99: 553-5, SCHULAM P.G., HEDICAN S.P. and DOCIMO S.G.: Radially dilating trocar system for open laparoscopic access. Urology, 54: , CORSON S.L., CHANDLER J.G. and WAY L.W.: Survey of laparoscopic entry injuries provoking litigation. J. Am. Assoc. Gynecol. Laparosc., 8: , CORSON S.L., BATZER F.R., GOCIAL B. and MAISLIN G.: Measurement of the force necessary for laparoscopic trocar entry. J. Reprod. Med., 34: 282-4, YUZPE A.A.: Pneumoperitoneum needle and trocar injuries in laparoscopy: A survey on possible contributing factors and prevention. J. Reprod. Med., 35: , BARBOSA BARROS M., LOZANO F.S. and QUERAL L.: Sao. Paulo. Med. J., Jan 2; 123 (1): 38-41, Epub 2005 Mar 31. Vascular injuries during gynecological laparoscopy-the vascular surgeon's advice. 17- PAUL LIN MD DANIEL R.: Grow MD Complications of Laparoscopy Obstetrics and Gynecology Clinics Volume 26 Number 1 March, AUDEBERT A.J. and GOMEL V.: Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion. Fertil Steril, 73: , SCHÄFER M., LAUPER M. and KRÄHENBÜHL L.: Trocar and Veress needle injuries during laparoscopy. Surg. Endosc., 15 (3): , 2001 (ISSN: ). 20- CHANG F.H., LEE C.L. and SOONG Y.K.: Use of Palmer's point for insertion of the operative laparoscope in patients with severe pelvic adhesions: Experience of seventeen cases. J. Am. Assoc. Gynecol. Laparosc., 1: S7, HASSON H.M.: A modified instrument and method for laparoscopy. Am. J. Obstet. Gynecol., 110: , PENFIELD A.L.: How to prevent complications of open laparoscopy. J. Reprod. Med., 30: , HESHIZUME M. and SUGIMACHI K.: Needle and trocar injury during laparoscopic surgery in Japan. Surg. Endosc., 11: , HANNEY R.M., CARMALT H.L., MERRETT N. and TAIT N.: Vascular injuries during laparoscopy associated with the Hasson technique. Letter to the editor: J. Am. Coll. Surg., 188 (3): 337, 1999.