- Email: [email protected]
Laparoscopic Management of External Iliac Artery Injury Using Yasargil Clamps and Intracorporeal Suture
Case Report
Laparoscopic Management of External Iliac Artery Injury Using Yasargil Clamps and Intracorporeal Suture Vito Chiantera, MD, Evrim Erdemoglu, MD*, Giuseppe Vercellino, MD, Magdalena Straube, MD, and Achim Schneider, MD, MPH From the Departments of Gynecology and Gynecologic Oncology, Charite University (Drs. Chiantera, Erdemoglu, Vercellino, Straube, and Schneider), Berlin, Germany, and S€ uleyman Demirel University (Dr. Erdemoglu), Isparta, Turkey.
ABSTRACT Presented is a case report of laparoscopic repair of an external iliac artery injury using titanium Yasargil clamps and intracorporeal suture during lymphadenectomy. Yasargil clamps were introduced and placed, 1 distal and 1 proximal to the lesion. The vascular injury site was identified and repaired using intracorporeal sutures. Laparoscopic staging was completed successfully. No sign of thrombosis or vascular occlusion was detected. The patient was discharged on postoperative day 4 to receive adjuvant therapy. Laparotomy is the accepted way of managing major vascular injuries during laparoscopy. However, in controlled circumstances, with availability of Yasargil clamps and a surgeon experienced with intracorporeal suturing, immediate laparoscopic repair of major vascular injury is feasible and is a safe alternative to open surgical repair. Journal of Minimally Invasive Gynecology (2011) 18, 516–519 Ó 2011 AAGL. All rights reserved. Keywords:
DISCUSS
Intracorporeal suture; Laparoscopy; Lymphadenectomy; Major vascular injury; Yasargil clamp
You can discuss this article with its authors and with other AAGL members at http:// www.AAGL.org/jmig-18-4-1655
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
Laparoscopic lymphadenectomy is generally considered a safe surgical procedure. Advanced laparoscopic techniques are used to stage and treat cervical, endometrial, and ovarian malignant diseases [1–3]. Laparoscopic lymphadenectomy is oncologically safe, and the technique is standardized [3]. Vascular injury is a rare but a potentially lethal complication that may occur during dissection of the large vessels in the pelvis [4]. Vascular trauma during retroperitoneal dissection is not a laparoscopy-associated complication; it is specific to the type of operation performed [1]. Vascular complications are usually managed using coagulation or vascular clips. If these measures fail, laparotomy is inevitable. Herein, we present a case report of laparoscopic The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Evrim Erdemoglu, MD, Departments of Gynecology and Gynecologic Oncology, Faculty of Medicine, S€uleyman Demirel University, Isparta, Turkey. E-mail: [email protected] Submitted November 18, 2010. Accepted for publication March 3, 2011. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2011 AAGL. All rights reserved. doi:10.1016/j.jmig.2011.03.005
repair of an external iliac artery injury using Yasargil clamps and intracorporeal suture during lymphadenectomy. To our knowledge, this is the first case report in the literature to demonstrate the feasibility of using Yasargil clamps and intracorporeal suture to treat major vascular injury during laparoscopic surgery. Case Report A 38-year-old woman, gravida 3, para 3, was referred to the Cervix Cancer Center, Charite University, with a diagnosis of cervical squamous epithelial cancer. Her body mass index was 18.7. According to FIGO staging, the patient had stage IIA cervical cancer. Magnetic resonance imaging revealed a tumor 3 cm in greatest diameter and a suspect lesion on the posterior cervix extending to the pelvis. Examination and radiologic workup verified a FIGO stage IIA lesion. Surgical staging was performed including diagnostic laparoscopy, pelvic and paraaortic lymphadenectomy, and biopsy of suspect lesions and the vesicouterine space. Individualized chemoradiation was planned after the staging operation.
Chiantera et al.
Vascular Injury during Laparoscopy
Transperitoneal laparoscopic surgical staging was performed according to a technique described previously [3]. Four laparoscopic ports were used including a 10-mm umbilical port and three 5-mm ancillary ports, 1 in the suprapubic area and 1 in each iliac fossa. After completing right-sided parametric and pelvic lymphadenectomy, lymph nodes in the lumbosacral fossa were removed. The external iliac artery and vein were completely mobilized from the psoas muscle. The lateral wall of the external iliac artery was lacerated during mobilization of a lymph node via sharp dissection.
517
Fig. 2 One Yasargil clamp is placed distal and 1 is placed proximal to the lesion.
Technique of Vascular Repair: Control of Hemorrhage and Preparation Immediately, hemorrhaging was stopped by pressing the back side of the scissors on the artery, followed by gentle grasping of the lacerated site with a Schneider alligator grasper, thus averting pooling of blood. The lymph node was removed to obtain optimal exposure. The optic was moved away from site of injury to obtain an overview and clear image. An immediate decision was made to perform laparoscopic repair. The suprapubic 5-mm trocar was exchanged for a 10-mm trocar, and Yasargil clamps (FT 292T; Aesculap AG & Co. KG, Tuttlingen, Germany) (Fig. 1) were introduced. One clamp was placed distal and 1 proximal to the lesion (Fig. 2). The vascular injury site was identified by slightly releasing the tension of the proximal clamp.
Technique of Vascular Repair: Restoration Laparoscopy provided adequate magnification for suturing of the external iliac artery. The laceration was repaired using 2 interrupted intracorporeal polypropylene sutures (Prolene 6/0; Ethicon Endo-Surgery GmbH, Norderstedt, Germany). The suture was passed smoothly through the vessel wall (adventitia), causing minimal disruption. The duration of total occlusion of the external iliac artery using the clamps was 13 minutes. The tension on the Yasargil clamps was slowly decreased to evaluate hemostasis, and the clamps were removed. Patency was checked. The external iliac artery was patent, and the pulse of the dorsalis pedis artery was normal. The patient received heparin therapy, and the pelvic and paraaortic lymphadenectomy was completed.
Fig. 1 For vascular clamping, titan made Yasargil vessel clips can be used in laparoscopic surgery.
Follow-up and Results Color duplex ultrasonography demonstrated good flow to the right leg. Antithrombotic prophylaxis with lowmolecular-weight heparin (Dalteparin, 0.25 mg subcutaneously once daily) was administered. The patient was discharged on postoperative day 4. No sign of thrombosis or vascular occlusion was detected. Pathologic examination revealed no metastasis to either the pelvic or paraaortic lymph nodes (0 of 30) or in the biopsy specimen from the vesicocervical septum. External pelvic radiotherapy (45 Gy) sparing the para-aortic region, followed by brachytherapy (21 Gy), was delivered along with weekly platin-based chemotherapy. The patient has been followed up for 6 months, and no complication has been observed. Discussion The technique of laparoscopic lymphadenectomy has been standardized [3]; however, laparoscopic techniques for controlling hemorrhage from a major vascular injury are not well described. Injury to a major retroperitoneal vessel occurs in 0.3% to 1.0% of laparoscopic procedures [4,5]. Laparotomy is the preferred technique to control bleeding
518
Journal of Minimally Invasive Gynecology, Vol 18, No 4, July/August 2011
and repair vascular injury. Nezhat et al [6] reported 8 patients with major vascular trauma not related to Veress needle or trocar insertion. In 3 of these patients, vascular trauma was managed using surgical clips; one case was managed using bipolar coagulation; and in the other 4 patients, laparotomy was necessary. To our knowledge, the present case is the first report of laparoscopic management of vascular injury using Yasargil clamps and suture. Pelvic abscesses, high body mass index, and previous operations may increase the risk of major retroperitoneal vascular injury. Sharp dissection, unbalanced traction, or erroneous use of laser and electricity may cause vascular lacerations [6]. Laparoscopy has multiple advantages in patients with cancer, including image magnification, improved dissection, early ambulation, and rapid recovery [7]. Postoperative chemotherapy or radiation can be initiated earlier, and complications from bowel adhesions are minimized [7]. However, compared with laparotomy, laparoscopic lymphadenectomy has the disadvantages of losing tactile sensation and of working in the third dimension. Surgeons should use energy sources carefully during lymphadenectomy and should apply precise traction and countertraction on vessels, in particular in older patients. The vessel walls are more fragile in elderly women. In case of a bleeder smaller than 2 mm, coagulation can be used. If the bleeder is larger than 2 mm, compression may not be sufficient. Thus endocorporeal clips can be used; however, it is difficult to place the endoclips tangential to the vessel with currently available instruments. The angle between the clip applicator and vessel results in partial obliteration of the vessel wall. If these measures fail, the surgeon can decide to repair the laceration or to sacrifice the vessel via occlusion. In this setting, consultation with a vascular surgeon should be a part of the decision-making process. The first principle of repair is to control bleeding by grasping the vessel with atraumatic clamps and to identify the laceration site. These measures will enable a clear unobstructed view. The first assistant should also immediately react in accord with the surgeon, moving the optic away from the operation site. This maneuver keeps the optic clean of blood and provides an overview of the operation site (Video 1, online only). The duration of total occlusion of the external iliac artery was 13 minutes. The duration of occlusion can be extended if necessary. It has been reported that the supramesenteric, suprarenal, and infrarenal aortae can be safely clamped for 20 and 40 minutes and even longer than 3 hours, respectively [8–10]. The major complication of temporary vessel occlusion is thromboembolism [9]. Therefore, patients should receive heparin during repair of a lacerated vessel. Gas embolism is another possible fatal complication, in particular in venous lacerations during laparoscopy. For vascular clamping, we used titanium Yasargil vessel clips (Fig. 1), named for Prof. Gazi Yasargil, a neurosurgeon who in the late 1960s invented the clips to treat cerebral aneurysms. These clips have a jaw length of 17.5 mm, a maxi-
mum opening of 10.6 mm, and a clamp force of 90 g. Since 2008, we have been using these clamps to temporarily occlude the uterine artery during laparoscopic myomectomy. The closing force required to occlude any vessel is determined by the vessel diameter, blood pressure, clip blade contact area, and vessel elasticity [11]. Vascular surgical clips with low closing forces that are designed for temporary use are delicate instruments that, if improperly used, can produce irreversible complications [12]. If a vascular clip exerts more force than necessary to occlude a blood vessel, the vessel could be damaged, collagen would then be exposed to the circulating elements, and mural thrombi could develop [12]. The closing force of Yasargil clamps is comparable to that of micro bulldog clamps and lower than that of conventional instruments such as the SatinskyDeBakey vascular clamp. When a major vessel injury occurs during laparoscopy and a surgeon experienced in intracorporeal suturing and retroperitoneal surgery is not available, temporary control of blood loss while awaiting the arrival of a vascular surgeon is recommended [5]. Temporary control of blood loss can be achieved by maintaining pressure at the injury site. Only surgeons with vascular surgical experience should attempt surgical repair of the injury because blood loss will increase in the absence of adequate exposure and appropriate vascular instruments [5]. Surgeons with experience in retroperitoneal dissection can manage the process of repairing the injured vessel using appropriate vascular instruments if additional blood loss is kept to a minimum [5]. The present case report demonstrates the feasibility of Yasargil clamps in major retroperitoneal vessel injuries during laparoscopic surgery. Presence of these clamps in the operating room will enable the surgical team to react immediately. Because of the controlled circumstances, the availability of Yasargil clamps and surgeons experienced in intracorporeal suturing, immediate laparoscopic repair was feasible in this patient. Supplementary Data Supplementary data associated with this article can be found in the online version at doi: 10.1016/j.jmig.2011.03.005. References 1. Kehoe SM, Ramirez PT, Abu-Rustum NR. Innovative laparoscopic surgery in gynecologic oncology. Curr Oncol Rep. 2007;9:472–477. 2. Panici PB, Plotti F, Zullo MA, et al. Pelvic lymphadenectomy for cervical carcinoma: laparotomy extraperitoneal, transperitoneal or laparoscopic approach? a randomized study. Gynecol Oncol. 2006;103:859–864. 3. K€ohler C, Klemm P, Schau A, Possover M, Kraus N, Schneider A. Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and paraaortic transperitoneal lymphadenectomies. Gynecol Oncol. 2004;95:52–61. 4. Nordestgaard AG, Bodily KC, Osborne RW Jr, Buttorff JD. Major vascular injuries during laparoscopic procedures. Am J Surg. 1995;169: 543–545. 5. Sandadi S, Johannigman JA, Wong VL, Blebea J, Altose MD, Hurd WW. Recognition and management of major vessel injury during
Chiantera et al.
6.
7. 8. 9.
Vascular Injury during Laparoscopy
laparoscopy [published online ahead of print July 24, 2010]. J Minim Invasive Gynecol. 2010;17:692–702. Nezhat C, Chielders J, Nezhat F, Nezhat CH, Seidman DS. Major retroperitoneal vascular injury during laparoscopic surgery. Human Reprod. 1997;12:480–483. Cho JE, Liu C, Gossner G, Nezhat FR. Laparoscopy and gynecologic oncology. Clin Obstet Gynecol. 2009;52:313–326. Gabrielli L, Martelli M, Baudo A, Belletti S. The approach to the infradiaphramatic and adrenal aorta. Ann Ital Chir. 2004;75:151–156. Chou MM, Ke YM, Wu HC, Tsai CP, Ho ES, Ismail H. Temporary cross-clamping of the infrarenal abdominal aorta during cesarean hys-
519 terectomy to control operative blood loss in placenta previa increta/ percreta. Taiwan J Obstet Gynecol. 2010;49:72–76. 10. Wise RA. Control of the common iliac artery during sacro-iliac disarticulation (hemipelvectomy). Ann Surg. 1948;128:993–998. 11. Otawara Y, Ogasawara K, Kubo Y, Kashimura H, Ogawa A, Watanabe K. Mechanical and surface properties of Yasargil phynox aneurysm clips after long-term implantation in a patient with cerebral aneurysm. Neurosurg Rev. 2009;32:193–196. 12. Dujovny M, Kossovsky N, Kossowsky R, et al. Mechanical and metallurgical properties of vascular clips designed for temporary use. Microsurgery. 1983;4:124–133.
Laparoscopic Management of External Iliac Artery Injury Using Yasargil Clamps and Intracorporeal Suture Vito Chiantera, MD, Evrim Erdemoglu, MD*, Giuseppe Vercellino, MD, Magdalena Straube, MD, and Achim Schneider, MD, MPH From the Departments of Gynecology and Gynecologic Oncology, Charite University (Drs. Chiantera, Erdemoglu, Vercellino, Straube, and Schneider), Berlin, Germany, and S€ uleyman Demirel University (Dr. Erdemoglu), Isparta, Turkey.
ABSTRACT Presented is a case report of laparoscopic repair of an external iliac artery injury using titanium Yasargil clamps and intracorporeal suture during lymphadenectomy. Yasargil clamps were introduced and placed, 1 distal and 1 proximal to the lesion. The vascular injury site was identified and repaired using intracorporeal sutures. Laparoscopic staging was completed successfully. No sign of thrombosis or vascular occlusion was detected. The patient was discharged on postoperative day 4 to receive adjuvant therapy. Laparotomy is the accepted way of managing major vascular injuries during laparoscopy. However, in controlled circumstances, with availability of Yasargil clamps and a surgeon experienced with intracorporeal suturing, immediate laparoscopic repair of major vascular injury is feasible and is a safe alternative to open surgical repair. Journal of Minimally Invasive Gynecology (2011) 18, 516–519 Ó 2011 AAGL. All rights reserved. Keywords:
DISCUSS
Intracorporeal suture; Laparoscopy; Lymphadenectomy; Major vascular injury; Yasargil clamp
You can discuss this article with its authors and with other AAGL members at http:// www.AAGL.org/jmig-18-4-1655
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
Laparoscopic lymphadenectomy is generally considered a safe surgical procedure. Advanced laparoscopic techniques are used to stage and treat cervical, endometrial, and ovarian malignant diseases [1–3]. Laparoscopic lymphadenectomy is oncologically safe, and the technique is standardized [3]. Vascular injury is a rare but a potentially lethal complication that may occur during dissection of the large vessels in the pelvis [4]. Vascular trauma during retroperitoneal dissection is not a laparoscopy-associated complication; it is specific to the type of operation performed [1]. Vascular complications are usually managed using coagulation or vascular clips. If these measures fail, laparotomy is inevitable. Herein, we present a case report of laparoscopic The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Evrim Erdemoglu, MD, Departments of Gynecology and Gynecologic Oncology, Faculty of Medicine, S€uleyman Demirel University, Isparta, Turkey. E-mail: [email protected] Submitted November 18, 2010. Accepted for publication March 3, 2011. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2011 AAGL. All rights reserved. doi:10.1016/j.jmig.2011.03.005
repair of an external iliac artery injury using Yasargil clamps and intracorporeal suture during lymphadenectomy. To our knowledge, this is the first case report in the literature to demonstrate the feasibility of using Yasargil clamps and intracorporeal suture to treat major vascular injury during laparoscopic surgery. Case Report A 38-year-old woman, gravida 3, para 3, was referred to the Cervix Cancer Center, Charite University, with a diagnosis of cervical squamous epithelial cancer. Her body mass index was 18.7. According to FIGO staging, the patient had stage IIA cervical cancer. Magnetic resonance imaging revealed a tumor 3 cm in greatest diameter and a suspect lesion on the posterior cervix extending to the pelvis. Examination and radiologic workup verified a FIGO stage IIA lesion. Surgical staging was performed including diagnostic laparoscopy, pelvic and paraaortic lymphadenectomy, and biopsy of suspect lesions and the vesicouterine space. Individualized chemoradiation was planned after the staging operation.
Chiantera et al.
Vascular Injury during Laparoscopy
Transperitoneal laparoscopic surgical staging was performed according to a technique described previously [3]. Four laparoscopic ports were used including a 10-mm umbilical port and three 5-mm ancillary ports, 1 in the suprapubic area and 1 in each iliac fossa. After completing right-sided parametric and pelvic lymphadenectomy, lymph nodes in the lumbosacral fossa were removed. The external iliac artery and vein were completely mobilized from the psoas muscle. The lateral wall of the external iliac artery was lacerated during mobilization of a lymph node via sharp dissection.
517
Fig. 2 One Yasargil clamp is placed distal and 1 is placed proximal to the lesion.
Technique of Vascular Repair: Control of Hemorrhage and Preparation Immediately, hemorrhaging was stopped by pressing the back side of the scissors on the artery, followed by gentle grasping of the lacerated site with a Schneider alligator grasper, thus averting pooling of blood. The lymph node was removed to obtain optimal exposure. The optic was moved away from site of injury to obtain an overview and clear image. An immediate decision was made to perform laparoscopic repair. The suprapubic 5-mm trocar was exchanged for a 10-mm trocar, and Yasargil clamps (FT 292T; Aesculap AG & Co. KG, Tuttlingen, Germany) (Fig. 1) were introduced. One clamp was placed distal and 1 proximal to the lesion (Fig. 2). The vascular injury site was identified by slightly releasing the tension of the proximal clamp.
Technique of Vascular Repair: Restoration Laparoscopy provided adequate magnification for suturing of the external iliac artery. The laceration was repaired using 2 interrupted intracorporeal polypropylene sutures (Prolene 6/0; Ethicon Endo-Surgery GmbH, Norderstedt, Germany). The suture was passed smoothly through the vessel wall (adventitia), causing minimal disruption. The duration of total occlusion of the external iliac artery using the clamps was 13 minutes. The tension on the Yasargil clamps was slowly decreased to evaluate hemostasis, and the clamps were removed. Patency was checked. The external iliac artery was patent, and the pulse of the dorsalis pedis artery was normal. The patient received heparin therapy, and the pelvic and paraaortic lymphadenectomy was completed.
Fig. 1 For vascular clamping, titan made Yasargil vessel clips can be used in laparoscopic surgery.
Follow-up and Results Color duplex ultrasonography demonstrated good flow to the right leg. Antithrombotic prophylaxis with lowmolecular-weight heparin (Dalteparin, 0.25 mg subcutaneously once daily) was administered. The patient was discharged on postoperative day 4. No sign of thrombosis or vascular occlusion was detected. Pathologic examination revealed no metastasis to either the pelvic or paraaortic lymph nodes (0 of 30) or in the biopsy specimen from the vesicocervical septum. External pelvic radiotherapy (45 Gy) sparing the para-aortic region, followed by brachytherapy (21 Gy), was delivered along with weekly platin-based chemotherapy. The patient has been followed up for 6 months, and no complication has been observed. Discussion The technique of laparoscopic lymphadenectomy has been standardized [3]; however, laparoscopic techniques for controlling hemorrhage from a major vascular injury are not well described. Injury to a major retroperitoneal vessel occurs in 0.3% to 1.0% of laparoscopic procedures [4,5]. Laparotomy is the preferred technique to control bleeding
518
Journal of Minimally Invasive Gynecology, Vol 18, No 4, July/August 2011
and repair vascular injury. Nezhat et al [6] reported 8 patients with major vascular trauma not related to Veress needle or trocar insertion. In 3 of these patients, vascular trauma was managed using surgical clips; one case was managed using bipolar coagulation; and in the other 4 patients, laparotomy was necessary. To our knowledge, the present case is the first report of laparoscopic management of vascular injury using Yasargil clamps and suture. Pelvic abscesses, high body mass index, and previous operations may increase the risk of major retroperitoneal vascular injury. Sharp dissection, unbalanced traction, or erroneous use of laser and electricity may cause vascular lacerations [6]. Laparoscopy has multiple advantages in patients with cancer, including image magnification, improved dissection, early ambulation, and rapid recovery [7]. Postoperative chemotherapy or radiation can be initiated earlier, and complications from bowel adhesions are minimized [7]. However, compared with laparotomy, laparoscopic lymphadenectomy has the disadvantages of losing tactile sensation and of working in the third dimension. Surgeons should use energy sources carefully during lymphadenectomy and should apply precise traction and countertraction on vessels, in particular in older patients. The vessel walls are more fragile in elderly women. In case of a bleeder smaller than 2 mm, coagulation can be used. If the bleeder is larger than 2 mm, compression may not be sufficient. Thus endocorporeal clips can be used; however, it is difficult to place the endoclips tangential to the vessel with currently available instruments. The angle between the clip applicator and vessel results in partial obliteration of the vessel wall. If these measures fail, the surgeon can decide to repair the laceration or to sacrifice the vessel via occlusion. In this setting, consultation with a vascular surgeon should be a part of the decision-making process. The first principle of repair is to control bleeding by grasping the vessel with atraumatic clamps and to identify the laceration site. These measures will enable a clear unobstructed view. The first assistant should also immediately react in accord with the surgeon, moving the optic away from the operation site. This maneuver keeps the optic clean of blood and provides an overview of the operation site (Video 1, online only). The duration of total occlusion of the external iliac artery was 13 minutes. The duration of occlusion can be extended if necessary. It has been reported that the supramesenteric, suprarenal, and infrarenal aortae can be safely clamped for 20 and 40 minutes and even longer than 3 hours, respectively [8–10]. The major complication of temporary vessel occlusion is thromboembolism [9]. Therefore, patients should receive heparin during repair of a lacerated vessel. Gas embolism is another possible fatal complication, in particular in venous lacerations during laparoscopy. For vascular clamping, we used titanium Yasargil vessel clips (Fig. 1), named for Prof. Gazi Yasargil, a neurosurgeon who in the late 1960s invented the clips to treat cerebral aneurysms. These clips have a jaw length of 17.5 mm, a maxi-
mum opening of 10.6 mm, and a clamp force of 90 g. Since 2008, we have been using these clamps to temporarily occlude the uterine artery during laparoscopic myomectomy. The closing force required to occlude any vessel is determined by the vessel diameter, blood pressure, clip blade contact area, and vessel elasticity [11]. Vascular surgical clips with low closing forces that are designed for temporary use are delicate instruments that, if improperly used, can produce irreversible complications [12]. If a vascular clip exerts more force than necessary to occlude a blood vessel, the vessel could be damaged, collagen would then be exposed to the circulating elements, and mural thrombi could develop [12]. The closing force of Yasargil clamps is comparable to that of micro bulldog clamps and lower than that of conventional instruments such as the SatinskyDeBakey vascular clamp. When a major vessel injury occurs during laparoscopy and a surgeon experienced in intracorporeal suturing and retroperitoneal surgery is not available, temporary control of blood loss while awaiting the arrival of a vascular surgeon is recommended [5]. Temporary control of blood loss can be achieved by maintaining pressure at the injury site. Only surgeons with vascular surgical experience should attempt surgical repair of the injury because blood loss will increase in the absence of adequate exposure and appropriate vascular instruments [5]. Surgeons with experience in retroperitoneal dissection can manage the process of repairing the injured vessel using appropriate vascular instruments if additional blood loss is kept to a minimum [5]. The present case report demonstrates the feasibility of Yasargil clamps in major retroperitoneal vessel injuries during laparoscopic surgery. Presence of these clamps in the operating room will enable the surgical team to react immediately. Because of the controlled circumstances, the availability of Yasargil clamps and surgeons experienced in intracorporeal suturing, immediate laparoscopic repair was feasible in this patient. Supplementary Data Supplementary data associated with this article can be found in the online version at doi: 10.1016/j.jmig.2011.03.005. References 1. Kehoe SM, Ramirez PT, Abu-Rustum NR. Innovative laparoscopic surgery in gynecologic oncology. Curr Oncol Rep. 2007;9:472–477. 2. Panici PB, Plotti F, Zullo MA, et al. Pelvic lymphadenectomy for cervical carcinoma: laparotomy extraperitoneal, transperitoneal or laparoscopic approach? a randomized study. Gynecol Oncol. 2006;103:859–864. 3. K€ohler C, Klemm P, Schau A, Possover M, Kraus N, Schneider A. Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and paraaortic transperitoneal lymphadenectomies. Gynecol Oncol. 2004;95:52–61. 4. Nordestgaard AG, Bodily KC, Osborne RW Jr, Buttorff JD. Major vascular injuries during laparoscopic procedures. Am J Surg. 1995;169: 543–545. 5. Sandadi S, Johannigman JA, Wong VL, Blebea J, Altose MD, Hurd WW. Recognition and management of major vessel injury during
Chiantera et al.
6.
7. 8. 9.
Vascular Injury during Laparoscopy
laparoscopy [published online ahead of print July 24, 2010]. J Minim Invasive Gynecol. 2010;17:692–702. Nezhat C, Chielders J, Nezhat F, Nezhat CH, Seidman DS. Major retroperitoneal vascular injury during laparoscopic surgery. Human Reprod. 1997;12:480–483. Cho JE, Liu C, Gossner G, Nezhat FR. Laparoscopy and gynecologic oncology. Clin Obstet Gynecol. 2009;52:313–326. Gabrielli L, Martelli M, Baudo A, Belletti S. The approach to the infradiaphramatic and adrenal aorta. Ann Ital Chir. 2004;75:151–156. Chou MM, Ke YM, Wu HC, Tsai CP, Ho ES, Ismail H. Temporary cross-clamping of the infrarenal abdominal aorta during cesarean hys-
519 terectomy to control operative blood loss in placenta previa increta/ percreta. Taiwan J Obstet Gynecol. 2010;49:72–76. 10. Wise RA. Control of the common iliac artery during sacro-iliac disarticulation (hemipelvectomy). Ann Surg. 1948;128:993–998. 11. Otawara Y, Ogasawara K, Kubo Y, Kashimura H, Ogawa A, Watanabe K. Mechanical and surface properties of Yasargil phynox aneurysm clips after long-term implantation in a patient with cerebral aneurysm. Neurosurg Rev. 2009;32:193–196. 12. Dujovny M, Kossovsky N, Kossowsky R, et al. Mechanical and metallurgical properties of vascular clips designed for temporary use. Microsurgery. 1983;4:124–133.