Insertion of Veress needle with 45° angulation through the umbilicus
Tip: In obese patients, the introduction angle of the Veress must be changed from 45 to 90°; this maneuver could avoid vascular injury.
The Veress needle should be carefully examined to ensure that the spring snap mechanism is performing properly. Following the insertion of the Veress needle into the abdomen, the tip of the needle should move freely. An injury should be suspected if intestinal contents, stomach contents or blood are aspirated and if the intra-abdominal pressure with a low gas flow exceeds 15 mmHg. Bleeding from blood vessels in the abdominal wall resulting from the insertion of the Veress needle or optic trocar could typically be controlled successfully following the insertion of a second trocar by endoscopic coagulation or a circular suture pattern that encloses the bleeding blood vessel .
A method for gaining access is with the Veress connected to the pneumoperitoneum equipment; this connection allows for the visualization of increasing pressure while the needle is slowly introduced through the abdominal wall. If the Veress needle is in the correct position, the pressure falls below 5 mmHg, and a click of the needle is simultaneously heard; the introduction of the needle must be stopped, and then the pressure rises. If there are fluctuations in the pressure or if there is doubt regarding the position of the Veress needle, the needle must be aspirated; if blood or intestinal contents are aspirated, the needle should be left in place, and new access should be obtained using an open technique, inspecting the area for damage. The majority of complications caused by the Veress needle could be recognized by direct visualization, including free blood in the abdominal cavity, or more frequently, a retroperitoneal hematoma. If vascular injury caused by the Veress needle is present, the management should be tailored to the specific situation:
Small, no expanding hematoma:
Control with clips.
Verify the placement and continue with surgery.
At the end of the surgery, re-check the placement.
Insert additional trocars.
Improve the exposure site.
Open the hematoma.
If the hematoma is difficult to repair laparoscopically, apply compression and perform a laparotomy.
The insertion of the first trocar is typically performed blindly through the incision of the Veress needle in the umbilical region. For this purpose, a shielded trocar is routinely used to minimize the risk of injury. Additional working trocars are inserted through the abdominal wall under laparoscopic vision with the assistance of transillumination. Theoretically, the risk of injury is greatest when inserting the first trocar ; for this reason, the surgeon should ensure that the pneumoperitoneum is between 16 and 20 mmHg before inserting the first trocar, and the skin incision should be long enough to allow the trocar to pass without resistance. The active hand that is inserting the trocar should always be prevented from accidentally slipping or protruding too deeply into the abdomen by the contralateral hand on the abdomen of the patient.
All surgeons are familiar with the problem of injuries to the epigastric artery that could be avoided by carefully identifying the vessels using transillumination, which is sometimes difficult in obese patients ; competent attention to an injured blood vessel (in this case, an epigastric artery) using clips or sutures is always preferable to extensive endoscopic coagulation . For persistent bleeding, suturing with a straight needle through the abdominal wall encaging the bleeding vessel is very useful. The suture is released 2 days after the initial operative procedure.
Intraoperative Vascular Injuries
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 .
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 .
Posterior hematoma due to abdominal hemorrhage
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 .
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  (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 . 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 . 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 .