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Spill All on Great Vessel Injury Risk in Laparoscopy.

MONTREAL -- Laparoscopic injury of the great vessels, while rare, carries up to a 20% mortality rate and a high rate of malpractice, Dr. George Vilos warned at the joint annual meeting of the Society of Obstetricians and Gynaecologists of Canada and the Association of Obstetricians and Gynaecologists of Quebec.

Physicians should outline the risk of this type of great vessel wall injury during the informed consent process, explaining that such events can occur, even if only among 0.2 per 1,000 patients, said Dr. Vilos, who has served as an expert witness on several such cases.

"Judges have said that at this level of frequency, we don't have to mention it to patients, but think it's prudent, especially given the consequences that this kind of injury can have," Dr. Vilos further advised in an interview.

Regular laparoscopy, open laparoscopy, and the direct trochar incision method have all been shown to have a similar frequency of complications.

"You can cause great vessel injuries with blades, Veress needles, and trochars, so I recommend simply choosing the laparoscopic method that you are most comfortable with," said Dr. Vilos of the department of ob.gyn. at the University of Western Ontario and St. Joseph's Health Center in London.

Most vascular injuries are entry related. With the regular laparoscopy method, both the Veress needle, used to insufflate gas, and the trochar are inserted blindly which increases the odds of injury, he commented.

Likewise, direct trochar insertion also involves blind placement.

But the blade used for incision in open laparoscopy has also been known to cause great vessel injury.

Independent of the surgery's complexity, the patient's body type is an underlying risk factor, with thin patients more at risk, he explained.

"Entering at a 45-degree angle should make it easier to avoid the great vessels in a patient less than 160 pounds, but in someone over 220 pounds, the angle should be more like 90 degrees, and between 160 and 220 pounds you need to use your judgment," he said at the conference.

Because the angle of entry is so important, Dr. Vilos strongly advised against tilting the patient into the Trendelenburg position, emphasizing that this should be done only after insertion.

"If she is already tilted, it will be very hard to estimate the right angle, and once you're into the abdomen you should inspect the organs before tilting the bowel and organs," he said.

As with any surgical injury, prompt recognition and repair are key to avoiding major morbidity or mortality, he explained.

And even if the injury is repaired without consequence, the patient should be informed on the incidence, he said.
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Publication:OB GYN News
Date:Aug 15, 2000
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