Laparoscopic repair of aortic injury

Urology Department, Lakeshore Hospital, Kochi, Kerala, India.

Laparoscopic procedures may be complicated by injuries to the neighbouring organs or vasculature. Major vascular injuries sustained during laparoscopy demand immediate attention and herald conversion to incisional approach. We present a video on laparoscopic repair of aortic injury sustained during laparoscopic pyeloplasty and discuss the technical aspects of laparoscopic vascular suturing. The procedure achieved a good morbidity profile and on long term evaluation satisfactory vascular intergrity was attained. To the best of our knowledge it is the first report of laparoscopic repair of aortic injury.

Major vascular injuries are occasionally encountered during laparoscopic surgery.1,2 Although in most instances they are inflicted during initial access, injury may occur any time during the laparoscopic procedure. Haemorrhage is usually intraperitoneal, but may occasionally be concealed in the retroperitoneal space. Major vascular injuries result in haemodynamic compromise and demand immediate attention. The usual management of such scenarios dictates conversion to open approach. We report a case of aortic injury sustained during laparoscopic dismembered pyeloplasty. The repair was also performed by laparoscopic approach.

A 31 year old male presented with complaints of intermittent incapacitating left flank pain. Detailed workup revealed significant left pelviureteric junction obstruction. A transperitoneal laparoscopic dismembered pyeloplasty was contemplated. During the dissection of the left ureterogonadal pedicle an injury was sustained to a vascular structure medial to the ureter. Unaccustomed haemorrhage was encountered. Proximal and distal control was secured immediately using clips. The bleeding persisted and the structure was widely dissected. The injured structure was identified as the aorta. A 6 millimeter linear rent in the aorta was delineated. Decision was taken to suture the defect through a laparoscopic approach. Equipment necessary if incisional approach became necessary were kept ready. Laparoscopic suturing was undertaken with 6-0 polypropelene suture. The presence of clips helped in achieving vascular control proximally and distally. 3 sutures were employed in an interrupted fashion. Handling the suture with laparoscopic instruments was challenging but was successfully achieved. The clips were removed sequentially and the area inspected for any residual bleeding. A focus of persistent bleeding was identified and 2 additional interrupted sutures were applied. Satisfactory haemostasis was attained. The repair area was wrapped with a piece of surgicel. Dismembered pyeloplasty was completed via laparoscopic approach. The entire procedure spanned over 255 minutes and the blood loss recorded was 550 millilitres. The postoperative recovery was uneventful and the patient was ambulatory from the first postoperative day. He tolerated orals 18 hours post-procedure. Drain removal was undertaken 74 hours post-procedure. He was on close observation for 4 days and resumed routine activities after 1 week. The patient is well at 2 years follow-up with good pelvicaliceal drainage pattern and a normal CT angiogram.

Vascular injuries complicate 0.05-2% of laparoscopic procedures in various reported series.4,5 Injury to the abdominal aorta culminate in catastrophic consequences and herald conversion to incisional access to secure vascular control and reconstruction. This defeats the goal of minimally invasive access and delays recovery of the sufferer. In this case the vascular injury repair was attempted by laparoscopic approach. Throughout the procedure the necessities for incisional approach were kept ready. Handling of polypropelene suture with laparoscopic instruments was technically demanding, as any overtensioning leads to suture breakage. Also contrary to the practice of reconstruction of vascular defects with continuous suturing, interrupted suturing was employed in this scenario.

Laparoscopic attainment of vascular control demands wide mobilization sufficiently proximal and distal to the vascular defect. This mandates familiarity with laparoscopic anatomy and proficiency in laparoscopic dissection and suturing. Satisfactory haemostasis was achieved without any requirement of additional haemostatic agents. Additionally long-term follow-up CT angiogram confirmed preservation of vascular integrity without vascular leak or pseudoaneurysm. The greatest advantage obtained was the excellent morbidity profile and preservation of body image.

Laparoscopic repair of aortic injury has been hitherto unreported to our knowledge. Wide exposure of the defect, adequate vascular control proximal and distal to the defect and maintaining optimum tension during suturing are the key issues that needs to be addressed. The procedure requires technical expertise. The surgical team should be prepared for conversion to incisional approach if any difficulty is encountered.

1. Geers J, Holden C. Major vascular injury as a complication of laparoscopic surgery: a report of three cases and review of the literature. Am J Surg 1996; 62: 377–9.

2. Pring CM. Aortic Injury Using the Hasson Trocar: A Case Report and Review of the Literature. Ann R Coll Surg Engl. 2007; 89(2): 186.

3. Apelgren KN, Scheeres DN. Aortic injury. Surgical endoscopy 1994; 8: 689-91.

4. Lynn SC Jr, Katz AR, Ross PJ. Aortic perforation sustained at laparoscopy. J Reprod Med 1982; 27: 217–9.

5. Complications. In. Nezhat CR, Luciano AA, Siegler AM, et al., eds. Operative gynecologic laparoscopic: principles and techniques. New York: McGraw-Hill, 1995: 287–310.