© 2021 MJH Life Sciences and Contemporary Obstetricians and Gynecologists. all rights reserved.

© 2021 MJH Life Sciences™ and contemporary obstetricians and gynecologists. all rights reserved.

Although major complications are rare, the laparoscopic abdominal approach is the most dangerous part of any laparoscopic surgery.

In the United States, millions of laparoscopic surgeries are performed every year. 1 Although compared with abdominal surgery, the advantages of laparoscopic surgery have been fully affirmed, but it brings a unique life-threatening risk: laparoscopic abdominal surgery. 2

Although laparoscopic surgery is usually the shortest part of all laparoscopic surgery, laparoscopic surgery accounts for about 50% of serious laparoscopic complications and forensic litigation related to laparoscopy. 2,3

Pepin specializes in minimally invasive gynecological surgery at Weill Cornell Medicine in New York City. She is an assistant in the Department of Obstetrics and Gynecology at the New York Presbyterian Hospital and an assistant professor of clinical obstetrics and gynecology at the Weill Cornell School of Medicine at Cornell University.

Life-threatening complications of laparoscopic surgery are rare—estimated at 0.4 per 1000 cases of gastrointestinal injury, and 0.2 per 1000 cases of major vessel injury. 2 However, considering that nearly 5 million laparoscopic surgeries are performed in the United States each year, it is likely that at least one patient will experience severe complications every day or die from abdominal entry every day. 4

Regardless of the technique used, the risks associated with laparoscopic access include bowel or bladder perforation, vascular damage, solid organ damage, nerve damage, port site hernias, and surgical site infections. 5 Veres entry, main port entry may cause damage or secondary port entrance. However, this review will only discuss these risks, especially initial laparoscopic surgery. Serious complications have been reported for each type of laparoscopic surgery. 2

The incidence of venous or arterial injuries during laparoscopic surgery is rare, ranging from 0.1 to 6.4 injuries per 1,000 cases. 6 The consequences of vascular injury can be rapid and devastating, and it is estimated that 15% of such injuries are fatal. 7

Other sources report that 81% of trocar-related deaths are caused by vascular damage. 8 In an analysis of trocar-related injuries reported to the Food and Drug Administration (FDA) between 1997 and 2002, vascular injuries accounted for 25 of the 31 cases. Fatal injuries. 5 This includes 11 locations in the aorta, 3 locations in the vena cava, 5 locations in the iliac arteries or veins, 1 location in the gastric vessels, 1 location in the hepatic vessels, and 4 locations in unspecified locations. 5

An additional 261 cases of non-fatal vascular injury have also been reported. Unfortunately, device damage is often underestimated, and this study may only represent a small percentage of patients with trocar-related vascular damage.

Immediate recognition of major post-peritoneal vascular injuries (aorta, vena cava, iliac vessels) is essential to prevent bleeding. If not detected in time, the intravascular inflation caused by the pneumoperitoneum can cause air embolism, leading to ischemia, arrhythmia and death. 9

If retroperitoneal blood accumulation and hemodynamic instability may be the first sign, the judgment of major blood vessel damage can be delayed. 10 After identification, deal with such major vascular injuries through immediate compression, laparotomy, emergency vascular surgery consultation, and coordination with doctors. The anesthesia team quickly transfused blood.

Lesser vascular damage can also have serious effects and can be more difficult to diagnose. These blood vessels include the anterior abdominal wall, omentum, and organ-specific blood vessels. Mesenteric and omentum injuries are the most common damage to blood vessels during initial entry11,12, but the most common overall vascular damage during laparoscopic examination is the upper and lower abdominal vessels. 13 Trocar under direct view. 10

The second leading cause of major injuries and deaths caused by laparoscopic surgery is gastrointestinal injury. 7 Although the effects of intestinal injuries during laparoscopy are not as immediate as life-threatening as vascular injuries, they are fatal because they are not easily recognized. Delayed diagnosis of intestinal injury is an important cause of postoperative death after laparoscopic surgery. 6, 14

In the aforementioned trocar-related injuries reported to the FDA, 6 of the 31 fatal injuries involved intestinal injuries. 5 Of these deaths, 5 cases occurred outside of the immediate postoperative period. Another 69 non-fatal hollow organ injuries were reported from the 4th day to 21.5 after the operation, but it is also suspected that underreporting was underreported.

In a large retrospective study of gynecological surgery with intestinal injury, 33% of injuries occurred with the use of a Veres needle, 50% occurred with the placement of an umbilical cord trocar, and 17% occurred with the placement of an additional trocar. 15

In a study in the Journal of Urology, nearly half of intestinal injuries went undetected at the time of surgery. 14

If it is found during the operation, it can be repaired by two layers of preliminary repair or non-urgently through intestinal resection according to the size of the injury. 16 It is recommended to consult an intestinal surgeon. Very small injuries, such as those caused by Veres needles, can be treated as expected. 17

High suspicion and timely diagnosis are the key to preventing death and serious complications from intestinal injury. The reported clues that intestinal injury may occur include difficulty maintaining the peritoneum, viewing intestinal contents, and bubbling of irrigation fluid, but these signs are unlikely to appear in small injuries. 10,17

If the patient has fever, tachycardia, shortness of breath, worsening abdominal pain, abdominal distension, nausea/vomiting, insufficient oral intake, or intestinal obstruction, postoperative intestinal injury should be considered. 18 Intestinal injury can be detected by CT scan with oral contrast agent. 17 Treatment includes intravenous antibiotics and surgical exploration, as well as closing or resection of the injured area.

There are many ways to safely obtain abdominal access during laparoscopy (Table 1). Some theories have been proposed as to why certain sites and access technologies may be more secure than others. However, considering the rarity of catastrophic events during laparoscopic surgery, it is very difficult to design trials and have enough ability to observe differences between techniques. Meta analysis has been used as a tool to combat low event rates, but it may still not be able to capture accurate data on such rare events.

One such meta-analysis is the 2019 update of the Cochrane review of laparoscopic entry techniques. The review included 57 randomized trials involving 9,865 participants. 18 However, in most studies, the results are severely limited by the low event rate and high risk of bias.

Evidence on subjects is insufficient to show the difference in major injury (vascular, visceral, or other) between open and closed techniques, Veres entry and direct entry, or Veres and direct visual entry. In this study, like other previous studies, surgeons had little evidence-based guidance when choosing one entry technique over the other (Table 2).

Although there is almost no difference in entry techniques, there are some differences in the incidence of minor complications.

In terms of omentum injury and extraperitoneal inflation, the open technique is better than the closed technique. However, when lower-quality studies were deleted, the advantages of open technology for extraperitoneal inflation were no longer significant. In addition, in terms of entry failure, omentum injury, and extraperitoneal inflation, direct entry is better than Veres entry. 18

Due to the lack of data to guide which entry technique is best to use, we recommend the routine use of multiple entry techniques and entry sites. This will allow surgeons to easily rule out difficult items and patients with complicated surgical history.

Below, we review recommendations for safe abdominal entry at different entry sites and various entry techniques. Some are based on evidence, and some are based on expert opinions.

Laparoscopic abdominal access is the most dangerous part of any laparoscopic surgery, although serious complications are rare. No entry technique or location has been convincingly proven to be superior to any other entry technique or location in preventing serious complications.

Surgeons should be familiar with a range of access techniques and locations to allow safe access for patients with different body types and surgical histories.