The more serious injuries are those to the deep inferior epigastric vessels, which are branches of the external iliac artery and vein that course cephalad but are deep to the rectus fascia and often deep to the muscles (Fig. 23.3). More laterally located are the deep circumﬂex iliac vessels, which are not often encountered in laparoscopic surgery. Laceration of these vessels may cause profound blood loss, particularly when the trauma is unrecognized and causes extraperitoneal bleeding.
Signs of injury, in addition to blood dripping down the cannula, include the postoperative appearance of shock and abdominal wall discolorization or hematoma located near the incision. In some instances, the blood may track to a more distant site, presenting as a pararectal or vulvar mass. Delayed diagnosis may be prevented by laparoscopic evaluation of each peritoneal incision after removal of the cannula.
Superficial inferior epigastric vessel trauma usually stops bleeding spontaneously; therefore, expectant management is appropriate. A straight ligature carrier can be used to repair lacerated deep inferior epigastric vessels. Alternatively, a Foley catheter may be inserted through the cannula, inﬂated, put on traction, and held in place with a clamp for up to 24 hours. If a postoperative hematoma develops, local compression should be used initially. Open removal or aspiration of the hematoma should not be undertaken because it may inhibit the tamponade effect and increase the risk of abscess. If the mass continues to enlarge or if signs of hypovolemia develop, the wound must be explored.
Hemorrhage may result from inadvertent entry into a vessel or failure of a specific occlusive technique. In addition to delayed hemorrhage, there may be a further delay in diagnosis at laparoscopy as a result of the restricted visual field and the temporary occlusive pressure exerted by CO2 in the peritoneal cavity.
Inadvertent division of an artery or vein is usually evident immediately. Transected arteries may go into spasm and bleed minutes to hours later, going unnoticed temporarily because of the limited visual field of the laparoscope. Therefore, at the end of the procedure, all areas of dissection must be carefully examined. Carbon dioxide should be vented, which decreases the intraperitoneal pressure so that blood vessels temporarily occluded by higher pressure can be recognized.
The stomach, the small bowel, and the colon can be injured during laparoscopy. Mechanical entry into the large or small bowel can occur 10 times more often when laparoscopy is performed in patients who have had prior intraperitoneal inﬂammation or abdominal surgery. Loops of intestine can adhere to the abdominal wall under the insertion site and be injured (117,118).
Needle entry into the gastrointestinal tract may be more common than reported because it may go unnoticed and without further complication. Gastric entry may be identified by the increased filling pressure, asymmetric distention of the peritoneal cavity, or aspiration of gastric particulate matter through the lumen of the needle. Initially, the hollow, capacious stomach may allow the insufﬂation pressure to remain normal. Signs of bowel entry are the same as those for gastric injury, with the addition of feculent odor.
If particulate debris is identified, the needle should be left in place, and an alternate insertion site should be identified, such as the left upper quadrant. Immediately after successful entry into the peritoneal cavity, the site of injury can be identified. Defects must be repaired immediately by laparoscopy or laparotomy.