At our institution of higher learning, just had a laporscopic trochar in the aorta - the guy barely survived because of phenomenal anesthesia support.
The case was for a small umbilical hernia. (Parenthetically, I wonder if the patient was given informed consent about how doing the procedure open would hurt a little more, but it was unlikely he would get the the chance to almost DIE if done open.)
We have had about 4 in the last few years.
Is this happening elsewhere?
I should mention - good surgeon too.
That number is WAY too high, and reflects a need for root cause analysis, etc, which I'm sure is underway. The acceptable incidence of major vascular injury is less than 0.1%
In general, a small umbilical hernia is fixed using an open technique and consists of a tiny little incision. Laparoscopy for that is a bad idea in general (with some exceptions), as it opens the patient up to more complications (like death from aortic hole) and doesn't improve cosmesis, pain, or recurrence.
Hmmm, good surgeons simply don't have this happen to them.......Many of our non-gyn surgeons (and many of the gyns) have gone to an open laparoscopic technique with a Hasan. Just takes a couple minutes longer but FAR safer for the patient.
It's tough to say that good surgeons simply don't have this complication. If you do enough laparoscopy, you're going to have a catastrophic complication, but the
incidence should be very low.
Also, depending on the study, the Hassan technique does not decrease complications.
How are these guys hitting the Aorta. I'm trying to think whenever I watch these guys put in trochars, except the first one, they are all done under 'visualization'.
If there's no insufflation in the peritoneal cavity, the aorta can be very close to the anterior fascia (3-4 cm). The bowel will be flattened out and won't provide much resistance against a sharp trocar.
I think the main cause of unnecessary vascular injury is improper access. The worst approach is the
blind entry without pneumoperitoneum (just screwing it plus/minus someone holding up the belly wall). The second worst is use of
"optiview" without pneumoperitoneum, where you can use the laparoscope to watch yourself go through the belly wall (and right into the small bowel).
The acceptable techniques are 1)
veress needle to obtain pneumoperitoneum followed by blind or optiview-assisted trocar placement, or 2)
open "Hassan" technique. The literature has shown these to have equivalent major and minor complication rates.
The other thing, which is less important to anesthesia, is that the surgeon has to know when an alternative access site would be more suitable, e.g. a patient with a previous midline laparotomy.
