- Email: [email protected]
Injuries to major blood vessels during endoscopy
May ]997, Vd. 4,No. 3
TheJournal of the American Association of GynecoJogic Laparoscopists
Injuries to Major Blood Vessels During Endoscopy Richard M. Soderstrom, M.D.
Abstract
Major blood vessel injury is a true emergency during endoscopic procedures. Too often, fear of litigation quashes the opportunity to assess the cause and learn from the experience of others. Frequently, only through a medicolegal review can such events be evaluated. A review of 47 such cases highlighted several key lessons. Proper technique for inserting the Veress needle, laparoscopic cannula, and open cannulas can prevent most accidents. If standard precautions during insertion are breached, safety shields on disposable cannula sleeves may not prevent or reduce the risk of major vessel injury. Distorted anatomy or steep Trendelenburg position may increase the risk. Retroperitoneal hematomas require exploratory laparotomy for proper assessment. Dissections around the great vessels of the pelvis require the same methods and precautions during laparoscopy as during laparotomy. (J Am Assoc Gynecol Laparosc 4(3):395-398, 1997.)
The first physician in the United States to review and report on laparoscopic injuries to the great blood vessels of the abdomen was Jefferson Penfield. 1 Through a national survey, he received 19 anecdotal case histories of such injuries and reported their location, his perceptions as to their probable cause, and his recommendations for preventing these serious injuries. As is the case today, he could access only the numerator of reported occurrence, without the denominator to calculate frequency. Still, based on results of similar annual surveys conducted by the American Association of Gynecologic Laparoscopists, it was assumed that the occurrence rate was low. Because of fear of litigation, when a vascular injury does occur during endoscopy, it is seldom discussed in open forum, morbidity and mortality conferences, or case history publications. Yet, because of the severity of such
an event and the high probability that a complication will ensue, the patient frequently searches for litigation. As a result, public records of legal investigations that question possible medical negligence are available to review an infrequent yet important complication of laparoscopy in search of medical lessons to be learned. Forty-seven cases of endoscopic injuries to major blood vessels in the abdomen were reviewed during medicolegal discovery. Ten of these cases occurred during general surgical procedures. This report should alert laparoscopic surgeons to the potential for injuries, the events that prompted the injuries, possible bad outcomes, and some methods of preventing them. Like Penfield's study, the data are biased by the medicolegal selection process, and the true frequency of these complications is unknown. Still, the fact that they occur deserves keen scrutiny.
From the Department of Obstetrics and Gynecology, University of Washington, Reproductive Health Specialists, Seattle, Washington. Address reprint requests to Richard M. Soderstrom, M.D., Reproductive Health Specialists, 1101 Madison, #580, Seattle, WA 98104; fax 206 622 1148.
395
Blood Vessel Injury During Endoscopy Soderstrom
Medicolegal Reviews
Nine Case Reports
I was consulted to render opinions about medicolegal questions regarding 47 cases of serious vascular injuries that occurred during endoscopic procedures. In some, prompt answers to questions resolved the legal issues either for the plaintiff or the defense; most are public record. Table 1 reveals the site of injuries and their frequency and Table 2 lists the instruments involved. All cannulas listed as disposable were produced with safety shields. It should be mentioned that in September 1996 the Food and Drug Administration notified all cannula manufactures that they could no longer describe their shielded cannulas with the word "safety"; instead, the term "shielded cannula" would be permitted.
Case 1 An achondroplastic dwarf with severe scoliosis and pelvic contracture requested tubal occlusion. Due to malrotation of the spine plus a contracture of the pelvic inlet, the fight common iliac artery was punctured. The injury was recognized when blood spurted from the Veress needle at the time of insertion. An immediate laparotomy was performed, the puncture wound was closed, and the patient recovered without sequelae. Case 2 During laparoscopy to assist at intraabdominal placement of a cerebral shunt for hydrocephalus, the left common iliac vein was lacerated with the primary cannula during insertion. Before the endoscopist arrived in the operating room, the patient was rolled onto her left side with a bolster placed under her fight back. This position aided the neurosurgeon in placing the shunt in the patient's right temple. The patient was fully draped when the endoscopist arrived, and he did not appreciate the change from the usual supine position. The injury was repaired and the patient recovered without sequelae.
TABLE 1. Sites of Injury and Frequency Site of Injury
Number
Aorta Vena cava Right common iliac artery Left common iliac artery Mesenteric vessel Right hypogastric artery Left hypogastric artery Right external iliac artery Left external iliac artery Several vessels Total
6 5 16 5 4 1 1 5 2 2 47
Case 3 While the surgeon was scrubbing for surgery, a woman was anesthetized, prepared, and draped. Since the anesthesiologist anticipated the need for Trendelenburg position after insuffiation, he placed the woman in steep Trendelenburg position. The surgeon assumed the patient was in the supine position when he inserted the insuffiation needle, followed by the primary cannula, into the abdomen at a 45-degree angle. The operative note stated that more pressure than usual was necessary to insert the dull trocar. The surgeon requested a sharper trocar but was told none was available. The bifurcation of the inferior vena cava was impaled, resulting in a retroperitoneal hematoma that was not recognized at first. Shock ensued, and once seeing the hematoma, the surgeon opened the abdomen and repaired what was consistent with a trocar injury. The patient recovered without sequelae.
TABLE 2. Instruments Involved in Creating Injuries Instrument Needle Primary cannula Reusable Disposable Blunt open cannula Secondary cannula Reusable Disposable Hysteroscope Scissors Staples Knife Electrode
Number 4 24 10 11 3 4 2 2 1 4 2 3 5
Case 4 Two surgeons spent a weekend taking a hands-on postgraduate course in basic laparoscopy and laparoscopic cholecystectomy. After they completed two cholecystectomies on laboratory pigs, they returned
396
May 1997, Vol. 4, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
home and scheduled their first human case. Although an accomplished gynecologic endoscopist was on staff, it was the sales representative for the instrument company that helped underwrite the expenses of the course who was invited into the operating room to give advice. During insertion of the disposable cannula, the protective shield deployed and became locked in the properitoneal space. Because the sharp tip of the trocar had pierced the peritoneum, gas began to leak through the open side port of the cannula sleeve. The surgeon quickly rearmed the retractable shield and plunged the trocar and sleeve through the inferior mesenteric artery, the aorta, and the inferior vena cava. In a few minutes the patient was in shock and died on the operating table. Nine days later the hospital issued laparoscopic cholecystectomy privileges to both surgeons.
Case 8 The right hypogastric artery was impaled with the secondary trocar/cannula, creating a through-andthrough perforation. The cannula was placed in the midline about 3 cm above the pubis. The surgeon stated he never looked through the laparoscope when he inserted the secondary trocar/cannula. The patient underwent exploratory laparotomy and repair, and received several units of blood. Later, she developed progressive hepatitis caused by infected blood. Case 9 Using the direct insertion approach with a disposable primary trocar/cannula, the surgeon attempted repeatedly to perforate the abdominal wall. The scrub nurse testified that the angle of insertion varied at least 30 degrees off midline. When the last attempt did perforate into the abdominal cavity, the left external iliac artery was lacerated, requiring a replacement graft; the graft later clotted off and required a second operation. This was the only case of vessel injury associated with direct insertion.
Case 5 After the primary cannula was inserted during laparoscopic cholecystectomy, cardiac arrest led to the patient being sent to recovery without exploration. Because of hypotension, the woman was returned to the operating room for exploration. A through-andthrough trocar perforation of aorta was repaired by graft replacement. Days later the patient died of sepsis.
Discussion
The first two cases reveal a gross alteration in anatomic orientation from normal. Here, vascular injury can occur despite proper surgical techniques. The third case introduces the problem of ancillary staff or other physicians who may not be aware of the nuances of a specific surgical technique. The fourth case can only be called dumb. The arrogant surgeon is any plaintiff attorney's dream come true. Each hospital has a fiduciary responsibility to have a reasonable credentialing process in place for advanced surgical procedures, and is so mandated by the Joint Commission on Hospital Accreditation. Case 5 reveals a major flaw in technique and lack of appreciation for what might have led to cardiac arrest. Knowing what complications might occur and how to handle them is part of the surgeon's specialty. Case 6 exposes the need for prompt management of a complication specific to laparoscopy. Cases 7, 8, and 9 expose flaws and omissions in basic technique, a logical approach to what might be going wrong, and how to deal with the complication in an expedient manner.
Case 6 During laparoscopic cholecystectomy, a bleeding mesenteric artery was identified and coagulated. Twenty minutes later a retroperitoneal hematoma was noted and "watched" through the rest of the operation. In the recovery room, the patient went into cardiac arrest and died. At postmortem, the cause of death was declared to be exsanguination from a laceration consistent with a trocar injury to the inferior vena cava. Case 7 During open laparoscopy the surgeon described technical difficulties with the incision (no. 15 blade) and placement of the cannula. After a brief period of insuffiation, the patient had cardiac arrest with elevated partial pressure of carbon dioxide. The cannula was removed without inserting the laparoscope, and fascial sutures were approximated. The patient died in the recovery room. At postmortem, a puncture wound of the fight iliac artery was found. The cause of death was exsanguination.
397
Blood Vessel Injury During Endoscopy Soderstrom
Major endoscopy textbooks that address these types of injuries state that, for the most part, injuries to the major vessels of the abdomen during endoscopy are preventable.l~ They emphasize rigid requirements in basic technique that must be practiced to eliminate these complications. A search of the literature revealed numerous articles, most from Europe, containing anecdotal incidents of endoscopic injuries to the great vessel of the abdomen. 7q4 Each author emphasizes that not all endoscopies are see one, do one, teach one procedures. As with most surgical procedures, didactic education should come first, followed by a structured program of hands-on education and experience with a qualified preceptor. The level of experience should be determined by an evaluation that follows a reasonable template of progress and achievement.
References
1. Penfield, AJ: Trocar and needle injuries. In Laparoscopy. Edited by JM Phillips. Baltimore, Williams & Wilkins, 1977, pp 236-241 2. Munro MG: Complications of laparoscopy. In Gynecologic Endoscopy; Principles in Practice. Edited by MJ Sammarco, TG Stovall, JF Steege. Baltimore, Williams & Wilkins, 1996, pp 245-27& 3. Hulka JF, Reich H: Textbook of Laparoscopy, 2nd ed. Philadelphia, WB Saunders, 1994 4. Corfman RS, Diamond MR, DeChemey AH: Complications of Laparoscopy and Hysteroscopy, 1st ed. Boston, Blackwell Science, 1993 5. Soderstrom RM: Operative Laparoscopy: The Masters' Techniques, 1st ed. New York, Raven Press, 1993
Once the endoscopist's skills have met expectations of peers, the cornerstone of continued success lies in strict attention to basic standards of laparoscopic techniques. Despite the emotional comfort one might have with disposable trocar/cannulas with safety shields, their presence does not soften established surgical principles.
6. Borton M: Laparoscopic Complications, 1st ed. Philadelphia, BC Becker, 1986 7. Oza KN, O'Donnell N, Fisher JB: Aortic laceration: A rare complication of laparoscopy. J Laparoendosc Surg 2(5):235-237, 1992 8. Bacourt E Mercier F: Injuries to the abdominal aorta during laparoscopy. Chirurgie 119(8):457-461, 1994 9. Baadsgaard SE, Bille S, Egeblad K: Major vascular injury during gynecologic laparoscopy; report of a case and review of published cases. Acta Obstet Gynecol Scand 68(3):283-285, 1989
Summary Despite the warnings and surgical protocols regarding techniques of laparoscopic procedures, injuries to the great vessels of the abdomen continue to occur. This series of cases exposes medical and surgical lessons that should reduce the frequency of these serious events. It is unfortunate that most of the lessons learned from the complications must reach the medical community through the process of litigation.
10. Soutoul JH, Pierre F: Medicolegal risks of celioscopy: Analysis of 32 cases of complications. J Gynecol Obstet Biol Reprod 17(4):439-451, 1988 11. Zweigel D, Thiele H, Schworm HD: Injuries of the large vessels caused by laparoscopy. Zentralbl Gynakol 109(10):673-678, 1987 12. McDonald PT, Rich NM, Collins GJ, et al: Vascular trauma secondary to diagnostic and therapeutic procedures during laparoscopy. Am J Surg 135(5):651-655, 1978
Most of the 47 cases had a similar theme--basic steps were omitted during insertion of needles and cannulas. Reliance on protective shields does not permit departure from standard insertion techniques. As advanced procedures, especially those that require several cannulas, become more common, the risk of major vessel injury will increase if these principles are ignored. We should learn from the mistakes of others, as we do not have enough time to make all of them ourselves.
13. Bisler H, Sinde J, Alemany J, et al: Injuries of blood vessels due to gynaecologic laparoscopy. Geburtshilfe Frauenheilkd 40(6):553-556, 1980 14. Thiele H, Alstaedt F, Ruckert U: Iatrogenic vascular injuries. Zentralbl Chit 104(16): 1061-1068, 1979
398
TheJournal of the American Association of GynecoJogic Laparoscopists
Injuries to Major Blood Vessels During Endoscopy Richard M. Soderstrom, M.D.
Abstract
Major blood vessel injury is a true emergency during endoscopic procedures. Too often, fear of litigation quashes the opportunity to assess the cause and learn from the experience of others. Frequently, only through a medicolegal review can such events be evaluated. A review of 47 such cases highlighted several key lessons. Proper technique for inserting the Veress needle, laparoscopic cannula, and open cannulas can prevent most accidents. If standard precautions during insertion are breached, safety shields on disposable cannula sleeves may not prevent or reduce the risk of major vessel injury. Distorted anatomy or steep Trendelenburg position may increase the risk. Retroperitoneal hematomas require exploratory laparotomy for proper assessment. Dissections around the great vessels of the pelvis require the same methods and precautions during laparoscopy as during laparotomy. (J Am Assoc Gynecol Laparosc 4(3):395-398, 1997.)
The first physician in the United States to review and report on laparoscopic injuries to the great blood vessels of the abdomen was Jefferson Penfield. 1 Through a national survey, he received 19 anecdotal case histories of such injuries and reported their location, his perceptions as to their probable cause, and his recommendations for preventing these serious injuries. As is the case today, he could access only the numerator of reported occurrence, without the denominator to calculate frequency. Still, based on results of similar annual surveys conducted by the American Association of Gynecologic Laparoscopists, it was assumed that the occurrence rate was low. Because of fear of litigation, when a vascular injury does occur during endoscopy, it is seldom discussed in open forum, morbidity and mortality conferences, or case history publications. Yet, because of the severity of such
an event and the high probability that a complication will ensue, the patient frequently searches for litigation. As a result, public records of legal investigations that question possible medical negligence are available to review an infrequent yet important complication of laparoscopy in search of medical lessons to be learned. Forty-seven cases of endoscopic injuries to major blood vessels in the abdomen were reviewed during medicolegal discovery. Ten of these cases occurred during general surgical procedures. This report should alert laparoscopic surgeons to the potential for injuries, the events that prompted the injuries, possible bad outcomes, and some methods of preventing them. Like Penfield's study, the data are biased by the medicolegal selection process, and the true frequency of these complications is unknown. Still, the fact that they occur deserves keen scrutiny.
From the Department of Obstetrics and Gynecology, University of Washington, Reproductive Health Specialists, Seattle, Washington. Address reprint requests to Richard M. Soderstrom, M.D., Reproductive Health Specialists, 1101 Madison, #580, Seattle, WA 98104; fax 206 622 1148.
395
Blood Vessel Injury During Endoscopy Soderstrom
Medicolegal Reviews
Nine Case Reports
I was consulted to render opinions about medicolegal questions regarding 47 cases of serious vascular injuries that occurred during endoscopic procedures. In some, prompt answers to questions resolved the legal issues either for the plaintiff or the defense; most are public record. Table 1 reveals the site of injuries and their frequency and Table 2 lists the instruments involved. All cannulas listed as disposable were produced with safety shields. It should be mentioned that in September 1996 the Food and Drug Administration notified all cannula manufactures that they could no longer describe their shielded cannulas with the word "safety"; instead, the term "shielded cannula" would be permitted.
Case 1 An achondroplastic dwarf with severe scoliosis and pelvic contracture requested tubal occlusion. Due to malrotation of the spine plus a contracture of the pelvic inlet, the fight common iliac artery was punctured. The injury was recognized when blood spurted from the Veress needle at the time of insertion. An immediate laparotomy was performed, the puncture wound was closed, and the patient recovered without sequelae. Case 2 During laparoscopy to assist at intraabdominal placement of a cerebral shunt for hydrocephalus, the left common iliac vein was lacerated with the primary cannula during insertion. Before the endoscopist arrived in the operating room, the patient was rolled onto her left side with a bolster placed under her fight back. This position aided the neurosurgeon in placing the shunt in the patient's right temple. The patient was fully draped when the endoscopist arrived, and he did not appreciate the change from the usual supine position. The injury was repaired and the patient recovered without sequelae.
TABLE 1. Sites of Injury and Frequency Site of Injury
Number
Aorta Vena cava Right common iliac artery Left common iliac artery Mesenteric vessel Right hypogastric artery Left hypogastric artery Right external iliac artery Left external iliac artery Several vessels Total
6 5 16 5 4 1 1 5 2 2 47
Case 3 While the surgeon was scrubbing for surgery, a woman was anesthetized, prepared, and draped. Since the anesthesiologist anticipated the need for Trendelenburg position after insuffiation, he placed the woman in steep Trendelenburg position. The surgeon assumed the patient was in the supine position when he inserted the insuffiation needle, followed by the primary cannula, into the abdomen at a 45-degree angle. The operative note stated that more pressure than usual was necessary to insert the dull trocar. The surgeon requested a sharper trocar but was told none was available. The bifurcation of the inferior vena cava was impaled, resulting in a retroperitoneal hematoma that was not recognized at first. Shock ensued, and once seeing the hematoma, the surgeon opened the abdomen and repaired what was consistent with a trocar injury. The patient recovered without sequelae.
TABLE 2. Instruments Involved in Creating Injuries Instrument Needle Primary cannula Reusable Disposable Blunt open cannula Secondary cannula Reusable Disposable Hysteroscope Scissors Staples Knife Electrode
Number 4 24 10 11 3 4 2 2 1 4 2 3 5
Case 4 Two surgeons spent a weekend taking a hands-on postgraduate course in basic laparoscopy and laparoscopic cholecystectomy. After they completed two cholecystectomies on laboratory pigs, they returned
396
May 1997, Vol. 4, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
home and scheduled their first human case. Although an accomplished gynecologic endoscopist was on staff, it was the sales representative for the instrument company that helped underwrite the expenses of the course who was invited into the operating room to give advice. During insertion of the disposable cannula, the protective shield deployed and became locked in the properitoneal space. Because the sharp tip of the trocar had pierced the peritoneum, gas began to leak through the open side port of the cannula sleeve. The surgeon quickly rearmed the retractable shield and plunged the trocar and sleeve through the inferior mesenteric artery, the aorta, and the inferior vena cava. In a few minutes the patient was in shock and died on the operating table. Nine days later the hospital issued laparoscopic cholecystectomy privileges to both surgeons.
Case 8 The right hypogastric artery was impaled with the secondary trocar/cannula, creating a through-andthrough perforation. The cannula was placed in the midline about 3 cm above the pubis. The surgeon stated he never looked through the laparoscope when he inserted the secondary trocar/cannula. The patient underwent exploratory laparotomy and repair, and received several units of blood. Later, she developed progressive hepatitis caused by infected blood. Case 9 Using the direct insertion approach with a disposable primary trocar/cannula, the surgeon attempted repeatedly to perforate the abdominal wall. The scrub nurse testified that the angle of insertion varied at least 30 degrees off midline. When the last attempt did perforate into the abdominal cavity, the left external iliac artery was lacerated, requiring a replacement graft; the graft later clotted off and required a second operation. This was the only case of vessel injury associated with direct insertion.
Case 5 After the primary cannula was inserted during laparoscopic cholecystectomy, cardiac arrest led to the patient being sent to recovery without exploration. Because of hypotension, the woman was returned to the operating room for exploration. A through-andthrough trocar perforation of aorta was repaired by graft replacement. Days later the patient died of sepsis.
Discussion
The first two cases reveal a gross alteration in anatomic orientation from normal. Here, vascular injury can occur despite proper surgical techniques. The third case introduces the problem of ancillary staff or other physicians who may not be aware of the nuances of a specific surgical technique. The fourth case can only be called dumb. The arrogant surgeon is any plaintiff attorney's dream come true. Each hospital has a fiduciary responsibility to have a reasonable credentialing process in place for advanced surgical procedures, and is so mandated by the Joint Commission on Hospital Accreditation. Case 5 reveals a major flaw in technique and lack of appreciation for what might have led to cardiac arrest. Knowing what complications might occur and how to handle them is part of the surgeon's specialty. Case 6 exposes the need for prompt management of a complication specific to laparoscopy. Cases 7, 8, and 9 expose flaws and omissions in basic technique, a logical approach to what might be going wrong, and how to deal with the complication in an expedient manner.
Case 6 During laparoscopic cholecystectomy, a bleeding mesenteric artery was identified and coagulated. Twenty minutes later a retroperitoneal hematoma was noted and "watched" through the rest of the operation. In the recovery room, the patient went into cardiac arrest and died. At postmortem, the cause of death was declared to be exsanguination from a laceration consistent with a trocar injury to the inferior vena cava. Case 7 During open laparoscopy the surgeon described technical difficulties with the incision (no. 15 blade) and placement of the cannula. After a brief period of insuffiation, the patient had cardiac arrest with elevated partial pressure of carbon dioxide. The cannula was removed without inserting the laparoscope, and fascial sutures were approximated. The patient died in the recovery room. At postmortem, a puncture wound of the fight iliac artery was found. The cause of death was exsanguination.
397
Blood Vessel Injury During Endoscopy Soderstrom
Major endoscopy textbooks that address these types of injuries state that, for the most part, injuries to the major vessels of the abdomen during endoscopy are preventable.l~ They emphasize rigid requirements in basic technique that must be practiced to eliminate these complications. A search of the literature revealed numerous articles, most from Europe, containing anecdotal incidents of endoscopic injuries to the great vessel of the abdomen. 7q4 Each author emphasizes that not all endoscopies are see one, do one, teach one procedures. As with most surgical procedures, didactic education should come first, followed by a structured program of hands-on education and experience with a qualified preceptor. The level of experience should be determined by an evaluation that follows a reasonable template of progress and achievement.
References
1. Penfield, AJ: Trocar and needle injuries. In Laparoscopy. Edited by JM Phillips. Baltimore, Williams & Wilkins, 1977, pp 236-241 2. Munro MG: Complications of laparoscopy. In Gynecologic Endoscopy; Principles in Practice. Edited by MJ Sammarco, TG Stovall, JF Steege. Baltimore, Williams & Wilkins, 1996, pp 245-27& 3. Hulka JF, Reich H: Textbook of Laparoscopy, 2nd ed. Philadelphia, WB Saunders, 1994 4. Corfman RS, Diamond MR, DeChemey AH: Complications of Laparoscopy and Hysteroscopy, 1st ed. Boston, Blackwell Science, 1993 5. Soderstrom RM: Operative Laparoscopy: The Masters' Techniques, 1st ed. New York, Raven Press, 1993
Once the endoscopist's skills have met expectations of peers, the cornerstone of continued success lies in strict attention to basic standards of laparoscopic techniques. Despite the emotional comfort one might have with disposable trocar/cannulas with safety shields, their presence does not soften established surgical principles.
6. Borton M: Laparoscopic Complications, 1st ed. Philadelphia, BC Becker, 1986 7. Oza KN, O'Donnell N, Fisher JB: Aortic laceration: A rare complication of laparoscopy. J Laparoendosc Surg 2(5):235-237, 1992 8. Bacourt E Mercier F: Injuries to the abdominal aorta during laparoscopy. Chirurgie 119(8):457-461, 1994 9. Baadsgaard SE, Bille S, Egeblad K: Major vascular injury during gynecologic laparoscopy; report of a case and review of published cases. Acta Obstet Gynecol Scand 68(3):283-285, 1989
Summary Despite the warnings and surgical protocols regarding techniques of laparoscopic procedures, injuries to the great vessels of the abdomen continue to occur. This series of cases exposes medical and surgical lessons that should reduce the frequency of these serious events. It is unfortunate that most of the lessons learned from the complications must reach the medical community through the process of litigation.
10. Soutoul JH, Pierre F: Medicolegal risks of celioscopy: Analysis of 32 cases of complications. J Gynecol Obstet Biol Reprod 17(4):439-451, 1988 11. Zweigel D, Thiele H, Schworm HD: Injuries of the large vessels caused by laparoscopy. Zentralbl Gynakol 109(10):673-678, 1987 12. McDonald PT, Rich NM, Collins GJ, et al: Vascular trauma secondary to diagnostic and therapeutic procedures during laparoscopy. Am J Surg 135(5):651-655, 1978
Most of the 47 cases had a similar theme--basic steps were omitted during insertion of needles and cannulas. Reliance on protective shields does not permit departure from standard insertion techniques. As advanced procedures, especially those that require several cannulas, become more common, the risk of major vessel injury will increase if these principles are ignored. We should learn from the mistakes of others, as we do not have enough time to make all of them ourselves.
13. Bisler H, Sinde J, Alemany J, et al: Injuries of blood vessels due to gynaecologic laparoscopy. Geburtshilfe Frauenheilkd 40(6):553-556, 1980 14. Thiele H, Alstaedt F, Ruckert U: Iatrogenic vascular injuries. Zentralbl Chit 104(16): 1061-1068, 1979
398