V1029: Intraoperative vascular injuries: Inadvertent and preventable!

Video

Introduction and Objectives
Intraoperative vascular injuries are reported in approximately 1.5% of major urological laparoscopic procedures and may need conversion. Although some of these are accidental, others happen due to improper or poor knowledge of instrumentation and technique, and are thus preventable. We present two such vascular injuries.

Methods
In the first instance, during left renal hilar dissection for a partial nephrectomy, the surgeon tried to dissect behind the renal vein by holding and retracting an already applied Weck® clip on a lumbar vein. The pull on the clip resulted in avulsion of the lumbar vein from renal vein. The resulting hole was difficult to hold due to its posterior location. An additional port was used to temporarily clamp an accessory and main renal artery. The defect in thus collapsed renal vein could then be grasped and repaired with prolene 5-0 suture. The procedure could be completed without the need for conversion. In the second procedure, the surgeon created a hole at the junction of the renal artery and aorta during laparoscopic donor nephrectomy while trying to cut a flimsy attachment of the renal vein with the harmonic scalpel (HS). He was trying to release the broad renal vein to enable its rotation to reach a lumbar vein coursing posteriorly across renal artery. Harmonic ACE® was used at a setting of 5 for five seconds. With bleeding kept in control under vision with a surgicel pack and pressure, the procedure was converted to open for safe completion.

Results
Self locking ligature clip from Weck (Hem-o-lock) holds the vessel firmly with its teeth and is unlikely to slip. Any attempt at holding an applied clip to retract may result in avulsion of the held vessel . HS, with its ability to coagulate and dissect close to vital organs, is extensively used without the risk of electrical injury. It has been described to achieve its surgical effect by providing temperatures below 100°. However, heat generation depends on many factors, like power setting and application time, apart from the amount of tissue held between blades. Little or no tissue between blades may generate very high blade temperatures (called the abuse mode). Continuing to fire HS while little or no tissue between distal part of the blades, despite a small amount of tissue still held by the proximal end, may also result in abuse mode. Temperatures >200°C have been recorded using harmonic ACE, high enough to cause injury to organs in direct touch of the tip.

Conclusions
Ligature clips and HS are safe and commonly used. One needs to know the proper technique and basics of technologies to enable their safe use.

Funding: none