21. Trocar- and Port-Related Bleeding

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21. Trocar- and Port-Related Bleeding

Daniel J. Deziel, M.D.

A. Clinical Signiﬁcance

Some abdominal wall bleeding from trocar or port sites is common during laparoscopic operations. This type of bleeding, while irritating to the surgeon, is usually not a serious problem. However, bleeding from the abdominal wall is a significant complication for 1%–2% of patients undergoing therapeutic laparoscopic procedures in general surgery. In addition, port site hemorrhage accounts for 10%–15% of intraoperative bleeding complications and for more than one-half of postoperative bleeding events. The clinical consequences range in severity from local hematoma formation, obliteration of the operative field, or prolongation of the operation to life-threatening hemorrhage requiring blood replacement and reoperation. In general, bleeding is one of the most frequent complications of laparoscopic surgery and is potentially fatal when a great vessel is involved. Port site hemorrhage is also potentially one of the most preventable complications. Its occurrence can be minimized by recognition of abdominal wall anatomy and patient-specific risk factors and by attention to appropriate technical details during port placement. Adverse consequences of abdominal wall bleeding can be muted by timely recognition and control.

B. Relevant Anatomy

1. Anatomy of abdominal wall blood vessels. The vasculature of the anterior and anterolateral abdominal wall consists of superﬁcial subcutaneous vessels, deep subfascial vessels, and vessels to the muscles (Figures 21.1, 21.2).

a. Superﬁcial vessels

i. Above the umbilicus, the skin and subcutaneous tissue are supplied by arterial branches from various sources includ- ing the superior epigastric artery, musculophrenic artery, and lower intercostal arteries. These anastomosing branches per- forate the abdominal wall muscles to reach the subcutaneous tissue. The corresponding superﬁcial veins drain to the superior vena cava via the internal mammary, long thoracic and intercostal veins, and their branches.

ii. Below the umbilicus, the superficial abdominal wall is supplied by three branches of the femoral artery: superficial epigastric artery (anterior), the superficial circumflex iliac

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21. Trocar- and Port-Related Bleeding 255

artery (lateral), and the superﬁcial external pudendal artery (medial groin). The corresponding veins drain to the femoral vein at the saphenous opening and thus to the inferior vena cava.

iii. The superficial veins from the supra- and infraumbilical regions communicate with each other through the thora- coepigastric vein, which ascends from the groin toward the axilla. This vein may be particularly prominent when there is obstruction of the inferior vena cava. The superficial sys- temic veins of the abdominal wall also communicate indi- rectly with the portal venous system via the paraumbilical veins and the umbilical vein in the falciform ligament. In cases of portal hypertension, the superficial veins near the umbilicus may become varicose in appearance (“caput medusae”).

b. Deep vessels

i. The rectus abdominis muscle receives its blood supply from the superior and inferior epigastric arteries. The superior epigastric artery originates from the internal mammary artery and courses through the costoxiphoid opening at the diaphragm to the posterior surface of the rectus muscle. The inferior epigastric artery branches from the external iliac artery just above the inguinal ligament. It ascends obliquely and medially toward the umbilicus, pierces the transversalis

Figure 21.1. Segmental innervations (left) and arterial supply (right) to the abdominal wall.

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fascia, and enters the rectus sheath anterior to the arcuate line (the linea semicircularis or semilunar fold of Douglas).

The superior and inferior epigastric vessels anastomose with each other at about the umbilical level.

ii. The lower lateral abdominal wall is supplied by the deep circumflex iliac artery, which arises from the external iliac artery lateral to the inferior epigastric artery. It is situated laterally in the iliac fossa between the transversus abdominis and internal oblique muscles. Near the anterosuperior iliac spine, the deep circumflex artery gives off a large ascending branch that can be injured by trocars placed in the low flank.

The deep circumﬂex artery anastomoses with the lumbar and inferior epigastric arteries.

iii. The lateral abdominal wall and ﬂank are supplied by the last six posterior intercostal arteries (from the descending Figure 21.2. Axial view of anterior abdominal wall at (A) 1 cm below umbilicus and (B) 3 cm above symphysis pubis. Soft tissue layers indicated by gray;

bone indicated by patterned areas. Vessel locations shown as mean ± SD. Vessel locations without SDs are extrapolated locations.

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thoracic aorta) and by the four lumbar arteries (from the abdominal aorta). These vessels course between the transversus abdominis and internal oblique muscles. Their branches enter the lateral aspect of the rectus sheath and anastomose with the superior and inferior epigastrics.

C. Surgical Implications of the Vascular Anatomy

The varied and plentiful blood supply of the truncal wall obviously puts many vessels at risk during placement of laparoscopic trocars in the abdomen or flank. The superficial epigastric and circumflex iliac vessels and the deeper inferior and superior epigastrics are probably the most frequently injured. Tran- sillumination of the abdominal wall may identify the superficial vessels in nonobese patients. However, transillumination does not visualize the deeper vessels in the muscular compartments. In the inguinal region, the inferior epigastric vessels can be seen laparoscopically just superficial to the parietal peri- toneum and lateral to the medial umbilical ligament (which contains the remnant of the umbilical artery). They are not generally visible at the level of the umbilicus, and they otherwise have no reliable laparoscopic landmarks. The location of the superficial epigastric vessels only roughly correlates with the location of the inferior epigastric vessels. Both occupy a more lateral position in the supra- pubic region and become more medial as they rise toward the umbilicus. In over- weight individuals, the inferior epigastric artery tends to be slightly more lateral.

The lateral border of the rectus abdominis muscle is the least likely area to contain major vessels. Based on the sparse normative data available, it has been recommended that lateral trocars be placed at least 5 cm above the symphysis pubis and approximately 8 cm from the midline (rectus margins) to avoid vessel injury (Figure 21.3).

D. Risk Factors for Trocar- and Port-Related Bleeding

Prevention of trocar and port site bleeding is founded on recognition of risk factors and implementation of measures to reduce risk. A thorough history and physical may reveal conditions or ﬁndings that may increase the chances of a port wound bleeding event. Examples of patient-related risk factors follow:

1. Patients with coagulation disorders or thrombocytopenia.

2. Patients with liver disease or portal hypertension.

3. Conditions that alter the conﬁguration of the abdominal wall such as distension, masses, or organomegaly, surgical incisions, or obesity may be associated with variations in the location of abdominal wall vessels.

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E. Trocar Design and Selection of Port Location

1. Trocar design. The type of trocar and port that is utilized impacts on the risk of abdominal wall bleeding.

a. Larger-diameter trocars cause more injury than smaller trocars, particularly at nonmidline insertion sites. Trocars with a cutting tip are more likely to cause bleeding than are conically tipped, blunt, or radially expanding trocars. Similarly, trocar-less ports that are screwed into and through the abdominal wall via a skin incision are less likely to injure an abdominal wall vessel because these ports push tissue aside and do not actually cut tissue. These are threaded metal reusable ports with an oblique blunt extension from the tip that advances the port through the abdominal wall by applying downward pressure while screwing it into the wall.

b. Conventional pyramidally tipped nondisposable trocars and cruciate-tipped disposable trocars lacerate tissue as they advance whereas blunt and trocar-less designs split and separate tissue less traumatically.

Figure 21.3. Location of deep and superﬁcial vessels of anterior abdominal wall, frontal view. Black vessels with gray shadows indicate mean ± SD for data from computed tomographic scans; vessels without SDs are extrapolated. Dashed lines, relative location of rectus abdominis muscle lateral margin and symphysis pubis; solid circles, standard sites for midline laparoscopic trocar placement; let- tered circles, recommended locations for lateral trocar placement: A, ideal location for lateral trocars 5 cm above symphysis, 8 cm from midline; B, alternate location for lateral trocars 3 cm above symphysis, 4 cm from midline; C, location for trocars near level of umbilicus, 8 cm from midline.

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2. Trocar site. Trocar sites should be selected so as to best avoid major abdominal wall vessels (see preceding section on Anatomy of abdominal wall blood vessels).

a. Midline sites have a lower risk of bleeding than do more lateral locations.

b. Transillumination may facilitate identiﬁcation of superﬁcial vessels in thinner patients.

c. Nonmidline trocars should be placed lateral to the rectus abdominis muscle, where possible.

d. In the upper abdomen, the falciform ligament should be avoided.

e. Secondary ports should be inserted under direct vision.

f. When the initial port is at a nonmidline position, placement by a direct “cut-down” technique (Hasson) may minimize vessel injury.

g. In patients at high risk for port wound bleeding and when the sit- uation demands placement of a 10-mm port (or larger) in a high- risk location, it is safest to place the port via the direct cut-down method.

F. Management of Port Site Bleeding

1. Identiﬁcation

a. Intraoperative bleeding. Port site bleeding is usually manifested intraoperatively by a fairly continuous dripping of blood from around the cannula or as a collection of blood and clot on the surface of the omentum or viscera under the port site. It may also present as external bleeding on the skin surface or as a develop- ing abdominal wall hematoma. It is critical for the surgeon to carefully inspect each port site for bleeding after placement of the port and upon completion of the operation. While this may seem elementary, prospective data demonstrate that the majority (nearly 80%) of abdominal wall bleeding complications are not detected intraoperatively. Because the port itself may tamponade bleeding, each port wound should be observed laparoscopically and externally after the sheath has been removed. Holding a ﬁnger lightly over the skin as a seal will prevent escape of pneu- moperitoneum without tamponading any bleeding vessels.

Because the site of the last port removed cannot be viewed laparoscopically, this should be a midline port or one that was initially placed by cut-down under direct visualization.

b. Postoperative bleeding. A local abdominal wall or port site hematoma is the most often noted sign of abdominal wall bleeding following a laparoscopic operation. Direct bleeding from the port incision may also be noted. Rarely, an abdominal wall or ﬂank ecchymosis may develop if bleeding has been persistent and the blood has tracked along tissue planes. The potentially most dangerous presentation of postoperative port wound bleeding is intraperitoneal hemorrhage. In this circumstance, the patient may WHE21 6/16/2005 2:25 PM Page 259

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develop abdominal distension and the typical features of hemor- rhagic shock (tachycardia, oliguria, cold extremities, hypoten- sion). Obviously, the potential for high-volume blood loss is greater when bleeding into the peritoneal cavity as opposed to bleeding into the abdominal wall itself.

2. Control of intraoperative bleeding. Most instances of port site bleed- ing that are recognized intraoperatively require speciﬁc treatment to stop or control the bleeding. A number of techniques may be applica- ble depending upon the site and extent of the bleeding as well as the size of the patient.

a. Compression techniques for intraoperative bleeding. When bleeding is not severe, several minutes of simple direct pressure or compression may provide adequate hemostasis.

i. Sharply angling or torquing the port applies direct pressure to one aspect of the abdominal wall adjacent to the wound.

While viewing the bleeding port site via the laparoscope, the port is alternately torqued in different directions to deter- mine where the pressure should be applied to stop the bleeding (Figure 21.4). Once the bleeding site is localized, torque pressure should be maintained for several minutes. External pressure can be added by pressing down on the abdominal wall with one or several ﬁngers directly over the site. In this way, the bleeding site is compressed from opposing directions.

ii. The abdominal wall can also be compressed manually by inserting the second ﬁnger into the empty port wound and then applying upward pressure against the opposing thumb, which is pushing downward on the abdominal wall.

iii. Additional pressure can also be brought to bear on the site by sharply torquing an adjacent port (either alone or with an instrument inserted).

iv. Alternatively, the wound can be packed with gauze. Another option is to insert a Foley catheter (preferably with a 30-mL balloon) into the abdomen through the wound, inﬂate it, and then apply direct pressure to the port area by pulling upward on the Foley for several minutes.

b. Coagulation methods. Electrocoagulation can be applied either transcutaneously or transperitoneally with laparoscopic instruments. Ultrasonic instruments, bipolar devices, and other coagulation methods can be similarly used for this purpose. This approach may be effective when the bleeding point is near the skin or peritoneal surface but is not likely to be successful when the source is located more deeply.

c. Suture control of bleeding vessels. Suture ligature is the surest method of hemostasis. Sutures should be used whenever the bleeding is brisk or when injury to a larger artery is suspected or when other methods fail.

i. Bleeding from larger abdominal wall arteries is probably best managed by extending the incision at the port site to expose the vessel and control it by direct suture ligature.

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Figure 21.4. (A) Bleeding from a trocar site. (B) Cantilevering the sheath into each quadrant to ﬁnd a position that causes the bleeding to stop. When the proper quadrant is found, pressure from the portion of the sheath within the abdomen tamponades the bleeding vessel, thus stopping the bleeding. A stitch can then be passed under laparoscopic guidance.

ii. An alternate method that does not require extending the port incision involves the placement of full-thickness abdominal wall horizontal mattress sutures on either side of the bleeding port along the axis of the bleeding vessel. Number one nylon sutures on long curved needles (for placement of retention sutures) are best suited for this purpose. The needle WHE21 6/16/2005 2:25 PM Page 261

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is straightened out before inserting it through the abdominal wall into the abdomen. The needle is then grasped via a laparoscopic needle holder or other grasper and pulled fully into the abdomen. The needle is turned around under direct visualization and then pushed back out through the abdominal wall. These sutures are best tied over a bolster (usually one or several folded-up gauzes) for effective tamponade.

iii. A suture passer can be used to place a suture through the port skin incision (with the port in place) such that the bleeding vessel is encircled. A second suture, placed on the oppo- site side of the bleeding point, is often needed. These sutures are tied down separately after the port has been removed.

The port can then be carefully replaced.

iv. Other local techniques. Packing the trocar tract with hemo- static agents such as gelfoam soaked in thrombin is often effective, particularly when combined with mechanical compression. Injection of epinephrine solution around the port site has also been suggested but is not recommended because it may only provide temporary hemostasis.

3. Postoperative port wound bleeding. Local hematomas that develop postoperatively are usually self-limited and can usually be managed conservatively. The rare ﬂank or abdominal wall ecchymoses that result from port wound bleeding are also usually self-limited; however, on occasion, transfusion may be required. Approximately 10% of patients with postoperative abdominal wall bleeding require operative intervention. Most of these patients have had a signiﬁcant drop in hematocrit and usually have received transfusions. Unless there is an obviously bleeding port site, laparotomy will often be necessary to rule out an intraperitoneal source of hemorrhage in these patients.

G. Selected References

Bhoyrul S, Mori T, Way LW. Radially expanding dilatation: a superior method of laparoscopic trocar access. Surg Endosc 1996;10:775–778.

Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholectectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 1993;165:9–14.

Hurd WW, Bude RO, DeLancey JOL, Newman JS. The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy. Am J Obstet Gynecol 1994;171:642–646.

Hurd WW, Wang L, Schemmel MT. A comparison of the relative risks of vessel injury with conical versus pyramidal laparoscopic trocars in a rabbit model. Am J Obstet Gynecol 1995;173:1731–1733.

Schäfer M, Lauper M, Krähenbühl L. A nation’s experience of bleeding complications during laparoscopy. Am J Surg 2000;80:73–77.