When minimally invasive surgery becomes a catastrophe

Abstract text (incl. references and figure legends)

Introdution:

Major vascular injuries are the second most common cause of death during laparoscopy, after death from anesthesia, with a mortality rate of 6.37 %.

Obesity, previous abdominal surgeries, surgical experience, inflammatory bowel disease and pelvic inflammatory disease are known risk factors to injuries during the entry phase in laparoscopy.

Clinical report:

A 47 years old woman, BMI 42.2 kg/m2, was proposed to an elective left hemicolectomy after 2 diverticulitis episodes in a 6 months period, at a secondary hospital.

As soon as the Veress needle was inserted, blood was seen.

After the first trocar was placed, an median retroperitoneal inframesogastric hematoma was seen and the surgeon did an unsuccessful attempt to control the bleeding. Since there was hemodynamic instability, a conversion was made.

An infrarrenal aortic laceration was seen and clamps were put in place to stop the bleeding. The patient was then transferred to a tertiary hospital to be intervened by vascular surgery.

An aortoplasty with patch of the great safenous vein and trombectomy of the ilio-distal arteries was performed.

The time occurred between the injury and the beginning of the vascular surgery was 2hours.

A total of 15 red blood cells pool, 12 plasma units, 3grams of fibrinogen and 1 pool of plaquelets were transfused.

During the intensive care stay, the patient developed leg compartment syndrome, with the need of fasciectomy and a moderate ARDS, making it harder to manage the disease

The patient was discharged after 73 days to a continued care unit.

Conclusion:

Major vascular injuries require rapid and effective hemostasis. Major vascular entry injuries are infrequent but should be studied and strict protocols put in place, since it has high morbimortality and a small period were measures can be taken.

A close cooperation between general surgeons, vascular surgeons, intensivists and imunohemoterapists is essential to achieve a positive outcome.

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