The overall risk of intraoperative vascular injuries is 2.3–3 % [4, 22]. The major causes of vascular injuries during surgery are associated with abrupt laparoscopic maneuvers, movements outside of the viewing area, unsuitable identification of the anatomy and instrument failure. Colombo et al. did not identify an association between age, body mass index, ASA (American Society of Anesthesiologists) score, the Charlson Comorbidity Index, the European Scoring System and previous abdominal/pelvic surgery and the development of perioperative complications. Those authors determined that the complication rate tended to decrease as surgical experience increased [4].

Injuries of the large abdominal vessels cause extensive hemorrhaging (Fig. 60.2). In the majority of cases, the only method for controlling this problem is to perform an immediate laparotomy, which is most likely the major reason that every laparoscopic procedure should be performed in an operating room that is fully equipped to handle all aspects of open surgery, including vascular suturing [7].

Major venous injuries have a greater potential for laparoscopic repair. Insufflation pressure is increased to 20–25 mmHg, and additional trocars are inserted if needed; pressure should be applied with a sponge or gauze, and the site of the injury should be widely exposed. The site should be clamped above or below the lesion and repaired; atraumatic graspers could hold the edges together while closure is performed with a running suture requiring skilled assistance [13].

A large needle with a multifilament suture is easier to tie than monofilament, ensuring that it is easier for the rapid control of bleeding. This issue is controversial because vascular surgeons assert that vessels should not be repaired with multifilament; however, in an emergency, it is easier to tie sutures without memory, and a large needle is easier to visualize in the midst of bleeding. Thus, the ¨rescue stitch¨ is very useful; this stitch uses a CT-1 needle and 6-in. long 0-polyglactin with a Hem-o-lok tied to the end [6] (Fig. 60.3).

Laparoscopic suturing, vascular clip application or the use of an Endo-GIA stapler might be warranted to control bleeding from larger vessels. However, stapler malfunctions have been reported in 1.7–10 % of cases [8, 12]. Hsi et al. found 352 reported failures using laparoscopic hemostatic devices [8]. Of these, 63 % occurred with the use of an endovascular stapling device, 33 % occurred with titanium clips, and 5 % occurred with the use of locking clips. The leading causes of failure were staple-line malformation and clip dislodgment. As a general recommendation, when using locking clips to secure the vessels, it is commonly accepted that at least two clips should be placed on the patient side of the vessels [15]. Additionally, the vessels should be meticulously dissected and isolated to prevent the lymphatics and tissues and the perivessel fat from interfering with the correct clip placement. This latter recommendation does not generally apply to endovascular stapler use. However, if the vessels are transected with an endovascular stapler, particular attention should be taken not to include in the staple line metallic clips that might have been placed close to the vessels. Some authors have shown this problem to be one of the most frequent causes of staple misfire. The cartridge of the endovascular stapler should be carefully inspected before use because the absence of staples in the cartridge has been reported [3, 8, 12].

If bleeding is major and cannot be controlled with an instrument for adequate visualization, hand-assisted device insertion or immediate open exploration is indicated. Maintaining compression with an instrument at the site of an injured vessel would reduce further blood loss and facilitate the rapid identification of the bleeding site upon opening the abdomen [6].