it is thought that the rate of vascular injury may increase as the complexity of laparoscopic surgery increases . to our knowledge , this is the first report of laparoscopic management of a leaking inferior mesenteric artery caused by trauma . vascular complications during diagnostic and operative laparoscopy have been reported at rates of 2.6 to 11 per 1000 . it is thought that the rate of vascular injury may increase as the complexity of laparoscopic surgery increases . eight cases of large retroperitoneal vascular injuries that resulted from intraoperative manipulations have been reported of which 4 were managed laparoscopically . we have had past success with laparoscopic management of a preoperatively diagnosed leaking inferior mesenteric artery in a patient with a vascular graft . ( c. nezhat , oral communication ) herewith , we report laparoscopic management of a leaking inferior mesenteric artery secondary to trocar insertion . to our knowledge , this is the first report of laparoscopic management of a leaking inferior mesenteric artery caused by trauma . the patient is a thin , 32-year - old woman with a history of endometriosis and 2 prior laparoscopies for gynecological indications who was admitted to the hospital for a tubal ligation . she had no history of past upper abdominal surgeries and no past medical history of coagulopathy or recent aspirin use . after general anesthesia and endotracheal intubation , the patient was placed in the dorsal lithotomy position , prepped and draped in the usual sterile fashion . a 5-mm intraumbilical skin incision was made with a scalpel , and the underlying subcutaneous tissue was separated with a mayo clamp . the primary surgeon and assistant then elevated the anterior abdominal wall using their hands , and 2 attempts at direct trocar entry using a 5-mm - ridged bladed trocar ( ethicon , new jersey ) were unsuccessful . towel clips were then used to elevate the anterior abdominal wall approximately 3 cm lateral to the umbilicus bilaterally , and direct trocar placement into the abdominal cavity was performed when presumed atraumatic and intraperitoneal placement of the trocar and sleeve was confirmed with the laparoscope . the abdominal cavity was then insufflated with co2 gas to a pressure of 15 mm hg . an evaluation of the upper abdomen and pelvis was then performed followed by tubal ligation , which proceeded in a routine fashion with bipolar electrocautery . at completion of the procedure , re - evaluation of the upper abdomen revealed a retroperitoneal hematoma with 2 peritoneal lacerations : 1 at the level of the inferior mesenteric artery and a second near the sacral promontory . the anesthesiologist was notified . a decision was made to proceed with laparoscopic exploration because the patient was hemodynamically stable and the bleeding appeared minimal . peritoneal borders of the hematoma were marked with bipolar electrocautery as a way of objectively reevaluating the hematoma for expansion . arterial and central venous catheters were placed , and 6 units of blood were made available . after identification of the paths of the ureters , the peritoneal edges at the level of the mesenteric artery were thoroughly cauterized with bipolar electrosurgery . then , the hematoma was cautiously opened and explored . the retroperitoneal space overlying the inferior mesenteric artery was exposed both superiorly and inferiorly to the site of oozing approximately 4 cm from the aorta . the areas were observed for 15 minutes at 4 mm hg and found to be hemostatic . preoperatively , the patient 's hemoglobin was 13.1 g / dl . her estimated blood loss was 500 cc , and she required no intraoperative or postoperative blood products . a 1-hour postoperative hemoglobin was 9.0 g / dl , with a range of 8.6 to 9.3 g / dl during her hospitalization . she was observed overnight in the intensive care unit where she was hemodynamically stable and was discharged on the second postoperative day . vascular injury is the most urgent type of trauma at laparoscopy . out of 56 536 laparoscopies , hulka et al found that significant hemorrhage occurred in 6.8 per 1000 cases and unintended laparotomy was performed in 8.9 of 1000 cases . eleven were the result of veress needle injuries , and 3 were due to trocar placement . bateman et al reported on 2324 laparoscopies spanning 5 years by the same surgical team . the 3 major injuries involved the inferior epigastric and deep circumflex iliac vessels , and all required laparotomy . jansen et al performed a prospective , observational study of 25 764 cases of laparoscopy and reported that most complications occurred during creation of pneumoperitoneum , and the most frequent injury was vascular . the other 6 cases involved epigastric vessel injury and were managed with suture ligatures and electrosurgery . risk of vascular injury may be reduced by proper abdominal entry with the veress needle or trocar . recognition that very thin and very obese patients are at increased risk of organ injury should alert the surgeon to take extra precautions . this occurred in a patient who had an abdominal aortic aneurysm repair with a stent graft with several postoperative imaging studies showing an endo leak from a patent inferior mesenteric artery . ( c. nezhat , oral communication ) early intraoperative diagnosis of retroperitoneal bleeding may limit mortality and morbidity from vascular injury , such as laparotomy , transfusion , and even death . immediate laparoscopic confirmation of atraumatic intraabdominal entry is essential . evaluation of operative sites and ancillary trocar ports under low intraabdominal pressures at the end of procedures may detect leaking vessels , which had been tamponaded by higher intraabdominal pressures or trocar sleeves . major retroperitoneal vascular injury is the most serious complication of laparoscopy and usually occurs at the time of veress needle or initial trocar placement . these should be managed immediately by ( 1 ) consulting a vascular surgeon or equivalent ; ( 2 ) placing immediate pressure on the bleeding vessel , preferably , with vascular clamps ; ( 3 ) hemodynamically stabilizing the patient ; and ( 4 ) achieving permanent hemostasis and repair of injury . this patient , who was hemodynamically stable , was properly evaluated during surgery and was prepared for immediate laparotomy , if necessary . patients who are hemodynamically unstable , or have rapidly expanding hematomas or intraperitoneal bleeding that obscures adequate visualization , may require emergency laparotomy . fortunately , we were able to manage this patient conservatively without having her undergo any undue risk and avoiding a laparotomy with a large midline incision .
background : vascular injury is the most urgent type of trauma at laparoscopy . it is thought that the rate of vascular injury may increase as the complexity of laparoscopic surgery increases . to our knowledge , this is the first report of laparoscopic management of a leaking inferior mesenteric artery caused by trauma.method:case report.results:successful laparoscopic management of a leaking inferior mesenteric artery secondary to trocar insertion.conclusion:laparoscopic management of a vascular injury in a hemodynamically stable patient is possible .