Major vascular injuries during laparoscopic procedures.

BACKGROUND: Major vascular complications following laparoscopic procedures are rare, with only 20 cases reported in the literature. PATIENTS AND METHODS: The cases of 4 patients who sustained 5 vascular injuries during laparoscopic procedures between June 1991 and May 1994 are presented, and previously reported cases in the literature are reviewed. RESULTS: All injuries occurred during pelvic laparoscopy (2 diagnostic procedures, 1 tubal ligation, and 1 hernia repair). The vascular injury was recognized during laparoscopy in 3 patients. In only 1 patient was immediate vascular surgery consultation requested. The iliac artery was injured in 3 patients, the iliac vein in 1, and the inferior epigastric artery in 1. The mechanism of injury was by the trocar in 2 patients and by sharp dissection in 2 patients. Arterial repair was accomplished by polytetrafluoroethylene (PTFE) interposition, PTFE patch angioplasty, resection and primary anastomosis, and ligation in 1 patient each. The venous injury was repaired by lateral venorrhaphy. Three patients recovered without sequelae, and 1 patient had a stroke. A review of the literature revealed only 20 reported cases of major vascular injuries as a result of the pneumoperitoneum needle or trocar insertion. Characteristically, the terminal aorta, cava, iliac arteries, and veins were injured. Most injuries were treated by direct suture repair. With immediate recognition, recovery was the rule; however, 3 of the 8 patients with delayed recognition died. CONCLUSION: Laparoscopists must be aware of this rare, serious, and potentially lethal complication. Once recognized, immediate conversion to an open procedure and application of appropriate vascular surgical techniques are required to reestablish arterial and venous continuity and minimize morbidity and mortality.

Ruptured abdominal aortic aneurysm. The Tacoma experience.

The Tacoma, Washington surgical experience with 37 consecutive patients with ruptured abdominal aortic aneurysms seen over a 5 year period has been reported. The overall survival rate was 38 percent. The development of shock before initiation of surgery was a common finding and portended a poor prognosis. The presence of a known aneurysm before presentation with rupture had no influence on the delay required to make the diagnosis and institute surgery or on the proportion of patients in shock but it did negatively influence the survival rate. The need for improved community understanding of aneurysms, their natural history, and the necessity for prompt diagnosis and immediate surgical intervention combined with avoidance of shock when rupture occurs are stressed.

Contralateral limb and patient survival after leg amputation.

Fifty-three patients who required amputation for ischemic disease of the legs were evaluated actuarially. The incidence of subsequent contralateral amputation and the length of patient survival were found to be nearly identical to incidence rates reported during the 1960s. The diffuse end-stage nature of the atherosclerotic process which led to the initial amputation in both time periods accounted for the similarity. Operative mortality decreased from more than 10 percent to 1.5 percent, presumably because of improved cardiovascular support and early rehabilitation.

Ultrasonic arteriography: implications in patient management.

Forty-six consecutive studies of carotid bifurcations were done with a Hokanson Ultrasonic Arteriograph before contrast arteriography. Based on the Doppler signal and the oscilloscopic image, each internal carotid artery was sorted into one of four categories as an estimation of the percent diameter reduction: less than or equal to 10 percent, 10 percent to 49 percent, 50 percent to 99 percent, and total occlusion. These results were compared with the percent diameter reduction determined from contrast arteriograms by a vascular radiologist unaware of the noninvasive test results. Overall, 83 percent of the arteries were correctly categorized. Detection of stenosis in the 50 percent to 99 percent range was 89 percent accurate. The sensitivity and specificity in detecting a 50 percent or greater stenosis were both 96 percent.

Spectral analysis of Doppler velocity patterns in normals and patients with carotid artery stenosis.

A computerized pattern recognition program was utilized to assess the predictive ability of various parameters obtained from the spectra of ultrasonic pulsed Doppler signals from the carotid arteries. The most accurate features selected by linear regression analysis were the natural log (ln) of the ratio of the mean velocity in the internal carotid artery compared to that in the common carotid artery, and the ln of the maximum velocity, the ln of the maximum frequency, and the square of the fractional broadening term, all of which were measured at peak systole in the internal carotid artery. Using the combination of the velocity ratio and the fractional broadening term, the average difference in the estimated percentage stenosis, as compared to that obtained by arteriography, was 12.8%.

Noninvasive detection of internal carotid artery occlusion.

Flow in the common carotid artery is normally quasisteady with flow never approaching zero during diastole. With total occlusion of the internal carotid artery, flow in the common carotid assumes the pattern observed in the external carotid, which supplies a relatively high-resistance vascular bed. In 34 instances of total internal carotid obstruction, flow went to zero in diastole in 33 cases and also demonstrated flow reversal in 22. In addition, there was a significant reduction in peak systolic velocity when the low-resistance internal carotid was obstructed. These observations, which are simple to determine using an ultrasonic duplex scanner, are of value in suspecting total occlusion of the internal carotid artery, thus obviating the need for arteriography in some cases.

Limb hemodynamics after aortic aneurysm resection.

Preoperative ankle/arm indices were determined in 104 lower extremities from 53 patients who underwent prosthetic graft placement for abdominal aortic aneurysms. Sixty-nine percent of the limbs (group 1) had a normal index; 31% of the limbs (group 2) had indices indicative of arterial occlusive disease. Early postoperative ankle/arm indices were determined in 87 limbs (57 in group 1 and 30 in group 2). Twelve group 1 limbs exhibited a postoperative decrease in the index. In group 2, four of the five decreases were seen when the distal anastomosis was placed above the inguinal ligament, while all 17 group 2 limbs in which the index increased had the distal anastomoses performed at the common femoral level. In 1.8% of the group 1 limbs and 6.7% of the group 2 limbs, a subsequent arterial procedure below the inguinal ligament was required. An additional 1.8% of group 1 limbs and 6.7% of group 2 limbs had undergone a distal arterial procedure prior to aneurysm resection.

Arterial injuries of the extremities following blunt trauma.

Thirty-three peripheral arterial injuries were observed in 29 patients following blunt trauma. Motor vehicle accidents were the most common initiating event. The mechanism of injury was fracture or dislocation in 21 patients, acute traction on the extremity in five patients, and contusion in three patients. Pulses were absent distal to the site of arterial injury in all patients. Complete arterial disruption was documented in 19 arteries; intimal or intimal and medial tears were observed in 10 arteries. Four arteries not surgically explored. If possible, debridement and primary anastomosis was the preferred method of revascularization. Saphenous vein interposition grafts were the second choice. Five amputations, four major and one minor, were required. Although patient vascular reconstructions may be uniformly achieved, long-term functional results are frequently affected by the duration of limb ischemia before revascularization, and concomitant injuries to bone, nerve, and soft tissue.

Flow disturbances following carotid endarterectomy.

Noninvasive flow dynamics in 69 carotid arteries following endarterectomy were studied. By using three parameters which measure either changes in velocity or disturbed flow, 49 per cent of the arteries demonstrated flow abnormalities consistent with a 50 per cent, or greater, reduction in diameter in at least two of the three measured parameters. Of the 31 arteries which underwent more than one postoperative study, progression of the flow abnormality was suggested by changes in the velocity ratio in 20 arteries, maximum velocity in 15 arteries and the fractional broadening term in 25 arteries.

Ultrasonic demonstration of external and internal carotid patency with common carotid occlusion: a preliminary report.

Non-invasive ultrasonic imaging of the carotid bifurcation by duplex scanning and ultrasonic arteriography combined with pulsed Doppler spectrum analysis demonstrated patency of the external and internal carotid arteries distal to a common carotid occlusion in 3 patients. Common carotid occlusion is not invariably associated with thrombosis of the ipsilateral internal carotid artery. Identification of internal carotid patency by the use of ultrasonic techniques will permit surgical treatment in selected cases.

The influence of limb elevation, examination technique, and outflow system design on venous plethysmography.

The effect of limb elevation and the design of the thigh cuff outflow system on venous capacitance and venous outflow, as determined by strain gauge plethysmography, was reviewed in a group of normal limbs without evidence of deep venous thrombosis. We improved the reliability of plethysmography in evaluating venous outflow, particularly in the early period after cuff deflation, by using uniform leg elevation, large diameter outflow tubing, and single rather than simultaneous limb examinations. Based on this experience, an optimum technique of examination emphasizing precise limb elevation, sequential limb examination and proper design of the cuff outflow system was used to evaluate 21 patients with acute venous thrombosis. The results obtained were compared with previously reported results of strain gauge plethysmography in patients with acute venous thrombosis. This technique significantly reduced the incidence of false-positive results.

The physiology of venous claudication.

The hemodynamic features of venous claudication are presented in a patient with chronic occlusion of the iliac vein. Exercise results in a marked venous volume overload, particularly in the thigh, which leads to pain. The syndrome develops in patients with isolated iliac vein occlusion and patent, competent veins distal to the inguinal ligament.

Venous capacitance and outflow in the postoperative patient.

Venous capacitance and outflow were measured in a series of 50 unselected patients undergoing a variety of general surgical procedures. Studies done prior to operation and the morning after demonstrated a fall in capacitance and outflow that was related to the degree of ambulation. Fully ambulatory patients demonstrated no changes. Males under the age of 40 were unchanged regardless of the type of operation or degree of ambulation. It is likely that the observed changes reflected a reduction in arterial flow but alterations in venous tone cannot be ruled out.

Ruptured thoracic aorta: evolving radiological concepts.

The chest roentgenograms of 18 patients with ruptured aortas were studied and the radiographic features tabulated. Fifteen patients survived to undergo angiography, and 14 aortograms were available for review. Distortion of the normal aortic contour and blurring of the aortic outline occurred on the initial chest film in each of the 18 cases. Obliteration of the medial left upper lung field and displacement of the superior vena cava to the right were observed in 16 and 15 films, respectively. Increased mediastinal width was not the most common noted abnormality. The mean mediastinal width on 100 cm anteroposterior supine chest film was 8.8 cm. One patient exhibited a mediastinal width within the normal range. Other frequently occurring abnormalities included opacification of the clear space between the aorta and pulmonary artery, obliteration of the distal aortic shadow, and tracheal shift to the right. At aortography nine patients demonstrated both linear radiolucent defects across the aorta and pseudoaneurysm formations, three patients showed only pseudoaneurysms, and two exhibited only linear radiolucent defects.

Multiple gastric polyps and parathyroid adenomas. Report of two cases.

Two cases of multiple gastric polyps associated with parathyroid adenomas are presented. A review of the literature revealed four patients with multiple gastric polyps and multiple endocrine adenomatosis. The possiblity of multiple gastric polyps as a variant of the MEA syndrome complex is explored. Emphasis is placed on the need for thorough endocrine evaluation in patients with multiple gastric polyps.