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Implications for port placement of deep circumflex iliac artery damage at laparoscopy
May 1999, Vd. 6, No. 2
TheJournal of the American Associationof Gynecologic Laparoscopists
Implications for Port Placement of Deep Circumflex Iliac Artery Damage at Laparoscopy Geoff D. Reid, FRACOG, Michael J. W. Cooper, FRACOG, and Jim Parker, FRANZCOG
Abstract
A cannula injury to the deep circumflex iliac vessels led to substantial morbidity and required surgical repair. Surgeons must increase their awareness of the anatomy of these vessels and place laparoscopic ports to minimize the risk of injury. (l Am Assoc Gynecol Laparosc 6(2)'.221-223, 1999)
Injury to abdominal wall vessels is reported to occur in approximately 2% of patients during operative laparoscopy.1 Most reports describe damage to the inferior epigastric vessels, which laparoscopic surgeons aim to identify before placing secondary ports and thus lessen the risk of injury. The anatomy of deep circumflex iliac vessels is less well known, and these vessels are more difficult to identify but are similarly prone to injury.
ports for instruments, one placed suprapubically in the midline and the other two on each side 2 cm superior to the anterior superior iliac spine (ASIS) lateral to the inferior epigastric artery, which was carefully visualized at initial laparoscopic inspection. At the completion of surgery, because a small amount of discharge was emanating from the left lateral port site, the area was oversewn with two deep polypropylene sutures. The evening of surgery a small hematoma was noted surrounding the left lateral port site. As it was only a few centimeters in diameter and not increasing in size, management was limited to observation. By 48 hours, extensive bruising was present in the abdominal wall, centered on that port site. By 72 hours the bruising had extended laterally to the level of the left
Case Report A routine laparoscopic-assisted vaginal hysterectomy was performed in a 36-year-old woman with dysfunctional uterine bleeding. 2 We had a 10-mm umbilical port for the laparoscope and three 5-mm
From the Departments of Gynaecological Endoscopy and Pelvic Surgery (Drs. Reid and Parker), Liverpool Hospital, Liverpool, Australia; and Department of Gynaecological Endoscopy, King George V Hospital, Newtown, Australia (Dr. Cooper). Address reprint requests to Geoff D. Reid, Liverpool Hospital, P.O. Box 103, Liverpool NSW 2170, Australia; fax 61 2 9828 5672. Presented as a brief abstract at the annual scientific meeting of the Australian Gynaecological Endoscopy Society, Melbourne, Australia, June 1998. Accepted for publication February 3, 1999.
221
Deep Circumflex IJiac Artery Damage at Laparoscopy Reid et al
The vascular supply of the abdominal wall is shown in Figure 1.3 The deep circumflex iliac artery arises from the external iliac artery opposite the inferior epigastric artery. It ascends lateral to the ASIS and posterior to the inguinal ligament. It pierces the transversalis fascia and passes along the inner lip of the iliac crest to about its middle, where it pierces the transverses abdominis muscle. It then courses posteriorly between this muscle and the internal oblique muscles. At the level of the ASIS it gives off a large ascending branch that runs superiorly between the transverses abdominis and the internal oblique muscles. It is likely that the lateral port in our patient damaged this ascending branch. The location of this vessel between two muscle groups makes it difficult to view it laparoscopically, causing a potential for substantial deep hematoma formation. It cannot be reliably identified by either
scapula. The patient's hemoglobin had fallen from 13.5 to 9.6 g/dl. On postoperative day 6, because the woman had increasing pain and redness over the persisting hematoma and a spiking fever, surgical drainage was performed. About 50 ml of blood and clot was drained from the site, after which the fever dissipated. Discussion
Traditional teaching of secondary port placement for laparoscopic surgery emphasized avoiding injury to inferior epigastric vessels. This is achieved by placing central secondary ports within the safety triangle bounded laterally by the medial umbilical ligaments (obliterated umbilical arteries), or by viewing the vessels directly and placing secondary ports lateral to them.
I
10 mm Abdominal I Trocar
Right, Lt UmbiliQ
Umbilicus
/ J ]]/ .11]
Median Umbilical Ligament
II//
Deep Circumflex Iliac Vessels
/AlL
II
Inferior . . . . . . . .
,I II
I
S mm Lateral Trocar 12 mm L AIxlomii TrorJr
Inguinal Ligament
Ext~ liia~ Ves
Symphysis Bladder FIGURE 1. Vessels of the lower abdominal wall and suggested locations of operative laparoscopy cannuias. (Reprinted from reference 3 with permission.)
222
May 1999, Vol. 6, No. 2
TheJournal of the American Association of Gynecologic Laparoscopists
transillumination or direct visualization. We therefore urge surgeons to avoid placing secondary ports too far laterally. A relatively safe site would seem to be midway between a line drawn superiorly from the ASIS and inferior epigastric vessels. It is also important that the degree of vascular injury may not be immediately apparent from the amount of revealed bleeding. Delayed recognition led to laparotomy to control bleeding from this vessel. 4 Generally, however, the vessel is little recognized and this can cause operative complications. If injury to this vessel is suspected in the future, we would place full-thickness sutures both above and below the port site, tied securely over a folded gauze swab to distribute pressure on the skin. These could be removed after 24 hours. Other methods of hemostatic control have been described, such as Foley catheter tamponade. 5 We recommend that operative laparoscopists consider this potential complication, reappraise secondary port placement, and take action to prevent delayed morbidity when injury is suspected.
223
References
1. Vilos GA: Extracorporeal suturing of trocar-induced defects and vascular injuries in the abdominal wall during laparoscopy using a modified Veress needle. Obstet Gynecol 85:638-640, 1995 2. Cooper MJW, Carlo G, Lam A, et al: Complications of t74 laparoscopic hysterectomies. Aust NZ J Obstet Gynaecol 36:44-48, 1996 3. Saidi MH, Vancaille TG, White AJ, et al: Complications and cost of multipuncture laparoscopy: A review of 264 cases. Gynaecol Endosc 3:85-90, 1994 4. Bateman BG, Kolp LA, Hoeger K: Complications of laparoscopy--Operative and diagnostic. Fertil Steril 66(1):33-35, 1996 5. Aharoni A, Condea A, Leibovitz Z, et al: A comparative study of Foley catheter and suturing to control trocarinduced abdominal wall hemorrhage. Gynaecol Endosc 6:31-32, 1997
TheJournal of the American Associationof Gynecologic Laparoscopists
Implications for Port Placement of Deep Circumflex Iliac Artery Damage at Laparoscopy Geoff D. Reid, FRACOG, Michael J. W. Cooper, FRACOG, and Jim Parker, FRANZCOG
Abstract
A cannula injury to the deep circumflex iliac vessels led to substantial morbidity and required surgical repair. Surgeons must increase their awareness of the anatomy of these vessels and place laparoscopic ports to minimize the risk of injury. (l Am Assoc Gynecol Laparosc 6(2)'.221-223, 1999)
Injury to abdominal wall vessels is reported to occur in approximately 2% of patients during operative laparoscopy.1 Most reports describe damage to the inferior epigastric vessels, which laparoscopic surgeons aim to identify before placing secondary ports and thus lessen the risk of injury. The anatomy of deep circumflex iliac vessels is less well known, and these vessels are more difficult to identify but are similarly prone to injury.
ports for instruments, one placed suprapubically in the midline and the other two on each side 2 cm superior to the anterior superior iliac spine (ASIS) lateral to the inferior epigastric artery, which was carefully visualized at initial laparoscopic inspection. At the completion of surgery, because a small amount of discharge was emanating from the left lateral port site, the area was oversewn with two deep polypropylene sutures. The evening of surgery a small hematoma was noted surrounding the left lateral port site. As it was only a few centimeters in diameter and not increasing in size, management was limited to observation. By 48 hours, extensive bruising was present in the abdominal wall, centered on that port site. By 72 hours the bruising had extended laterally to the level of the left
Case Report A routine laparoscopic-assisted vaginal hysterectomy was performed in a 36-year-old woman with dysfunctional uterine bleeding. 2 We had a 10-mm umbilical port for the laparoscope and three 5-mm
From the Departments of Gynaecological Endoscopy and Pelvic Surgery (Drs. Reid and Parker), Liverpool Hospital, Liverpool, Australia; and Department of Gynaecological Endoscopy, King George V Hospital, Newtown, Australia (Dr. Cooper). Address reprint requests to Geoff D. Reid, Liverpool Hospital, P.O. Box 103, Liverpool NSW 2170, Australia; fax 61 2 9828 5672. Presented as a brief abstract at the annual scientific meeting of the Australian Gynaecological Endoscopy Society, Melbourne, Australia, June 1998. Accepted for publication February 3, 1999.
221
Deep Circumflex IJiac Artery Damage at Laparoscopy Reid et al
The vascular supply of the abdominal wall is shown in Figure 1.3 The deep circumflex iliac artery arises from the external iliac artery opposite the inferior epigastric artery. It ascends lateral to the ASIS and posterior to the inguinal ligament. It pierces the transversalis fascia and passes along the inner lip of the iliac crest to about its middle, where it pierces the transverses abdominis muscle. It then courses posteriorly between this muscle and the internal oblique muscles. At the level of the ASIS it gives off a large ascending branch that runs superiorly between the transverses abdominis and the internal oblique muscles. It is likely that the lateral port in our patient damaged this ascending branch. The location of this vessel between two muscle groups makes it difficult to view it laparoscopically, causing a potential for substantial deep hematoma formation. It cannot be reliably identified by either
scapula. The patient's hemoglobin had fallen from 13.5 to 9.6 g/dl. On postoperative day 6, because the woman had increasing pain and redness over the persisting hematoma and a spiking fever, surgical drainage was performed. About 50 ml of blood and clot was drained from the site, after which the fever dissipated. Discussion
Traditional teaching of secondary port placement for laparoscopic surgery emphasized avoiding injury to inferior epigastric vessels. This is achieved by placing central secondary ports within the safety triangle bounded laterally by the medial umbilical ligaments (obliterated umbilical arteries), or by viewing the vessels directly and placing secondary ports lateral to them.
I
10 mm Abdominal I Trocar
Right, Lt UmbiliQ
Umbilicus
/ J ]]/ .11]
Median Umbilical Ligament
II//
Deep Circumflex Iliac Vessels
/AlL
II
Inferior . . . . . . . .
,I II
I
S mm Lateral Trocar 12 mm L AIxlomii TrorJr
Inguinal Ligament
Ext~ liia~ Ves
Symphysis Bladder FIGURE 1. Vessels of the lower abdominal wall and suggested locations of operative laparoscopy cannuias. (Reprinted from reference 3 with permission.)
222
May 1999, Vol. 6, No. 2
TheJournal of the American Association of Gynecologic Laparoscopists
transillumination or direct visualization. We therefore urge surgeons to avoid placing secondary ports too far laterally. A relatively safe site would seem to be midway between a line drawn superiorly from the ASIS and inferior epigastric vessels. It is also important that the degree of vascular injury may not be immediately apparent from the amount of revealed bleeding. Delayed recognition led to laparotomy to control bleeding from this vessel. 4 Generally, however, the vessel is little recognized and this can cause operative complications. If injury to this vessel is suspected in the future, we would place full-thickness sutures both above and below the port site, tied securely over a folded gauze swab to distribute pressure on the skin. These could be removed after 24 hours. Other methods of hemostatic control have been described, such as Foley catheter tamponade. 5 We recommend that operative laparoscopists consider this potential complication, reappraise secondary port placement, and take action to prevent delayed morbidity when injury is suspected.
223
References
1. Vilos GA: Extracorporeal suturing of trocar-induced defects and vascular injuries in the abdominal wall during laparoscopy using a modified Veress needle. Obstet Gynecol 85:638-640, 1995 2. Cooper MJW, Carlo G, Lam A, et al: Complications of t74 laparoscopic hysterectomies. Aust NZ J Obstet Gynaecol 36:44-48, 1996 3. Saidi MH, Vancaille TG, White AJ, et al: Complications and cost of multipuncture laparoscopy: A review of 264 cases. Gynaecol Endosc 3:85-90, 1994 4. Bateman BG, Kolp LA, Hoeger K: Complications of laparoscopy--Operative and diagnostic. Fertil Steril 66(1):33-35, 1996 5. Aharoni A, Condea A, Leibovitz Z, et al: A comparative study of Foley catheter and suturing to control trocarinduced abdominal wall hemorrhage. Gynaecol Endosc 6:31-32, 1997