Major vascular injury incurred at laparoscopy

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A 39-year-old G2P1102 presented to her gynecologist with a complaint of pelvic pressure. She had regular menses and no loss of urine. Her history was significant only for a postpartum bilateral tubal ligation 2 years earlier.

The woman’s examination revealed prolapse of the uterus, with the cervix visible at the introitus. An ultrasound performed by the physician 1 week after her initial presentation revealed a 4.8 4.5 6.8-cm left ovarian cyst. The physician recommended a laparoscopically assisted vaginal hysterectomy (LAVH) and left salpingo-oophorectomy (SP).

The woman was presented with several options for management, including a total abdominal hysterectomy and left salpingo-oophorectomy. The gynecologist reviewed the risks of surgery and potential complications. All the patient’s questions were answered and operative permissions were signed.

The surgery was scheduled for 1 week later.

During surgery, insertion of the Veress needle was without incident. However, upon insertion of the umbilical trocar, profuse bleeding was noted and the patient became bradycardic and hypotensive and experienced cardiac arrest.

She was resuscitated, following which, the gynecologist made a midline vertical incision and noted a laceration in the area of the aorta. A general surgeon was consulted, who could not fully control the bleeding. Thus, pressure was applied to the aorta and the patient was transferred to a tertiary hospital 40 minutes away that had a vascular surgeon.

Upon arrival at the tertiary hospital, the patient was taken immediately to surgery. The vascular surgeon noted transaction of the anterior wall of the common iliac artery encompassing almost half the diameter of the artery. Also noted was a duodenal serosal tear, presumably from the pressure held during transport.

 

The vascular surgeon also noted thrombi of the common iliac artery, and the right and left iliac arteries. The surgeon repaired the vascular injury with an end-to-end anastomosis, and performed right and left iliofemoral thrombectomies, as well as from the common iliac artery, restoring flow to the right and left common iliac arteries. He then noted that both the patient’s feet had good capillary refill.

The duodenal laceration was repaired without consequence. The patient had a relatively uncomplicated recovery, with the exception of residual neuropathy in her right leg and hip, with foot drop that persisted despite months of occupational and physical therapy.

Approximately 9 months after the attempted LAVH, the patient sought the care of another gynecologist, who noted that her uterus was protruding to the introitus with valsalva.

An ultrasound was obtained, which was interpreted as normal, with no pelvic or ovarian masses or cysts. The physician recommended a total vaginal hysterectomy. Despite being “scared to death,” the patient elected to go forward with the procedure, which was performed without incident. Surgical findings stated that “both tubes and ovaries appeared normal.”

Ultimately, the patient filed suit against the original gynecologist, alleging inadequate and inappropriate preoperative evaluation, improperly performed surgery, with resultant complications, long-term physical deficits, pain and suffering, and loss of life’s enjoyment.

Media Contact
John Mathews
Journal Manager
Journal of Phlebology and Lymphology
Email: phlebology@eclinicalsci.com