Laparoscopic repair of a vascular injury during the treatment of a patient with endometriosis

The laparoscopic vascular injury is an uncommon but serious complication in laparoscopy. In this video, we show a left external iliac vein injury during the dissection of the physiological attachments of the sigmoid colon in a 30-year-old woman with severe endometriosis.

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Laparoscopic repair of a vascular injury during the treatment of a patient with endometriosis

Authors

A Wattiez, I Miranda-Mendoza, J Nassif, E Kovoor

Abstract

The laparoscopic vascular injury is an uncommon but serious complication in laparoscopy. In this video, we show a left external iliac vein injury during the dissection of the physiological attachments of the sigmoid colon in a 30-year-old woman with severe endometriosis.

Classification

tips and tricks

Keywords

Laparoscopic repair, vascular injury, treatment, endometriosis

Media type

Surgical video

Duration

08'42''

Publication

2009-06

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E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2660.htm

Laparoscopic repair of a vascular injury during the treatment of a patient with endometriosis

1. Exploration and exposure 00'09''

This is the case of a 30-year-old woman presenting with severe endometriosis. She has had a previous history of an appendectomy and two laparoscopic surgeries for the treatment of endometriosis. The patient’s symptoms were dysmenorrhea (score of 8 out of 10), dyspareunia (score of 8 out of 10), dyschezia and catamenial diarrhea. The procedure starts as usual. We can observe a frozen pelvis due to the severe endometriosis: the pelvic tissues are very inflammatory and bleed when the implants are touched. We found tight adhesions between the bowel and the posterior wall of the uterus.

2. Dissection of the physiologic sigmoid attachment 01'00''

We started with the dissection of the physiological attachments of the sigmoid colon. Through this, we can see the left ureter and start the left pararectal fossa dissection. The dissection is uneasy because of the inflammatory tissue and the adhesions due to the endometriotic implants.

3. Vascular injury 02'14''

As soon as the dissection is achieved, we can see the psoas muscle, the left external iliac artery and vein. During the dissection, the left iliac external vein is opened. With a very fast move, the vein is clamped with the bipolar forceps. It is critical to quickly respond in such a situation. Once the bleeding has been controlled, you can analyze the repair procedure.

4. Introduction of an accessory left port 03'17''

As the left iliac fossa port is used for clamping the vein, we introduce an accessory left superior port in the left abdominal flank. With this, we can put the aspiration and identify the lesion. Then we can begin with the dissection of the vein for the repair.

5. Iliac vein dissection and vascular clamp introduction 04'17''

The isolation of the vascular injury is carried out. We can see the hole in the vein very clearly. We now change the forceps that was used to clamp the vein in the left iliac fossa. Now, through this port, we can introduce the vascular clamp for the suturing. We can see how the vein has been clamped and the hole is clearly visible.

6. Stitching 05'20''

Now that the situation is under control, we can start the repair process. We use a 5/0 Prolene suture for the stitching. We put 2 stitches in the inferior and superior angles of the hole to approximate the edges. Five knots are performed due to the thread memory of this material. We cut the thread long enough so that we can identify the lesion during surgery.

7. Removal of vascular clamp and final view 07'57''

We can see that the repair has been completed. Now we can remove the vascular clamp and observe the results. The vein has been repaired. We aspirate fluids and re-check it to make sure that the suture is fine. The intervention can be continued. The patient’s postoperative outcome is uneventful. We think that a fast response during a vascular complication is extremely important. Once control has been achieved, we can figure out what is the best way to get round the complication.