Non-trocar related major retroperitoneal bleeding during laparoscopic appendectomy
© Kaafarani et al; licensee BioMed Central Ltd. 2011
Received: 5 January 2011
Accepted: 22 March 2011
Published: 22 March 2011
Most of the reported vascular injuries in laparoscopic appendectomies occur during trocar or Veress needle insertions. As laparoscopy continues to evolve, it is essential that surgeons report unusual complications in an effort to raise awareness and guide management of any iatrogenic injury incurred during minimally-invasive procedures. We report the case of a patient who sustained a major non-trocar related retroperitoneal vascular injury during a routine LA.
Laparoscopic appendectomy (LA) has gained widespread acceptance in the last 2 decades. Multiple trials and meta-analyses have suggested that the laparoscopic approach offers patients a lower risk of surgical site infection, less postoperative pain, a shorter length of stay and earlier return to work when compared to open appendectomy (OA) [1–6]. Nonetheless, the same studies found higher rates of intra-abdominal abscesses and vascular injuries with LA. Most of the reported vascular injuries in laparoscopy occur during trocar or Veress needle insertions . For patients over the age of 65, population-based studies have even suggested a lower mortality with LA . As laparoscopy continues to evolve, it is essential that surgeons report unusual complications in an effort to raise awareness and guide management of any iatrogenic injury incurred during minimally-invasive procedures. We report the case of a patient who sustained a major non-trocar related retroperitoneal vascular injury during a routine LA.
After almost two centuries of performing appendectomies, surgeons started resecting the inflamed appendix laparoscopically in the late 1980's. Whether the laparoscopic approach is superior, equivalent or inferior to the open approach in terms of outcomes remains controversial. Several trials have consistently showed that LA, despite being associated with a longer operative time, provides patients with a faster recovery and earlier return to routine activities when compared to OA [1–6]. In a systematic review of randomized trials conducted by Sauerland et al, the rate of superficial surgical site infection was decreased by half, but the rate of deep surgical site infections (intra-abdominal abscesses) was three times higher in LA as compared to OA . On the other hand, a more recent study that used the Nationwide Inpatient Sample database from 2000 to 2005 suggested that the overall rate of complications is 7% higher with LA . This same study of more than 132,000 appendectomies also found that the cost of LA was 22% higher than OA in uncomplicated appendicitis and 9% higher in complicated appendicitis. More importantly, laparoscopy has been associated with a 0.1 to 1% risk of intra-abdominal or retroperitoneal injuries, including major vessel injury [10–12]. Most of these injuries have been reported to occur during the initial trocar or Veress needle insertion, and many resulted in major morbidity to the patient. Whether LA or OA is the "standard" treatment for acute appendicitis remains controversial, and resolving that matter will probably require rigorous valuation (assigning "values" to the severity of specific complications) and severity weighting of the complication profile of each approach in the setting of a randomized trial .
The appendix is reported to be "hidden" in a retroperitoneal, retroileal, retrocecal or retrocolic location in up to 30% of cases . The terms retrocecal, retroperitoneal and retrocolic have been and continue to be used in literature interchangeably. However, in a 1938 report, William B. Marbury defined retrocecal as being limited by the caput cecum and retrocolic as extending superiorly posterior to the ascending colon . Most retrocolic appendices are also retroperitoneal, while most retrocecal appendices are intraperitoneal.
The patient we report in this paper had a major vascular retroperitoneal injury resulting in significant hemorrhage. The injury likely resulted from avulsion of the retroperitoneal gonadal vessel during dissection of the inflamed retrocolic appendix rather than from a trocar or Veress needle insertion. Marbury, in his landmark 1938 paper, reported on one patient with a retrocolic appendix who suffered "troublesome" bleeding subsequent to injury to a branch of the ileocecal artery . To the best of our knowledge and following review of the literature, major bleeding during routine blunt dissection of the appendix is very rare but poses potentially significant harm to patients. We recommend that surgeons continue with meticulous dissection of any suspected retroperitoneal or retrocolic appendix. The use of advanced bipolar devices (e.g. Ligasure ™) or ultrasonic desiccation instruments (e.g. harmonic scalpel ™) might be of assistance if the appendix is severely inflamed. In addition, conversion to OA should be seriously considered when the patient shows signs of hemodynamic instability or when laparoscopic hemostatic methods fail to adequately expose and control the hemorrhage.
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