Vascular Complications

  • David Michael Hatcher
  • René Sotelo


Vascular complications are among the most common and potentially devastating complications to arise in the perioperative setting. These include vascular injuries during initial access and intraoperatively, postoperative bleeding, and thromboembolic events. Rapid, safe, and effective identification and management of these issues are crucial in minimizing harm to the patient. Vascular injuries occurring in the minimally invasive setting present a unique challenge, though the principles of repair remain the same: adequate exposure, proximal and distal vascular control, and repair. Equipment should be available in the operating room in the event of a vascular injury including an open tray, laparoscopic and robotic needle drivers, gauze sponges, vascular clamps, hemostatic agents, and a “rescue stitch.” Management of bleeding may ultimately require blood transfusion, open conversion, angioembolization, or reexploration. The occurrence of these complications can be minimized through careful patient selection, adequate preoperative planning, knowledge of the surgical anatomy, and precise surgical technique.


Vascular injury Vascular complications Bleeding Management Access injury Veress needle injury Trocar injury Thromboembolic complications Robotic surgery Minimally invasive surgery 


  1. 1.
    Tewari A, Sooriakumaran P, Bloch D, Seshadri-Kreaden U, Hebert A, Wiklund P. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol. 2012;62:1–15.CrossRefPubMedGoogle Scholar
  2. 2.
    Bhoryul S, Vierra MA, et al. Trocar injuries in laparoscopic surgeries. J Am Coll Surg. 2001;192:677–83.CrossRefGoogle Scholar
  3. 3.
    Champault G, Cazacu F, et al. Serious trocar incidents in laparoscopic surgery: a French study of 103,852 operations. Surg Laparosc Endosc. 1996;6(5):367–70.CrossRefPubMedGoogle Scholar
  4. 4.
    Hashizume H, Sugimachi K. Study group of endoscopic surgery needle and trocar injury during laparoscopic surgery in Japan. Surg Endosc. 1997;11:1198–201.CrossRefPubMedGoogle Scholar
  5. 5.
    Hasson HM. Open laparoscopy: a retrocar of 150 cases. J Reprod Med. 1974;12:234–8.PubMedGoogle Scholar
  6. 6.
    Hasson HM. A modified instrument and method for laparoscopy. Am J Obstet Gynecol. 1971;110:886–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Collins S, Lehman DS, McDougall EM, et al. AUA BLUS handbook of laparoscopic and robotic fundamentals. Linthicum: American Urological Association; 2015.Google Scholar
  8. 8.
    Bonjer JH, Hazebroek EJ, Kazemier GMC, Meijer WA, Lance JF. Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg. 1997;84:599–602.CrossRefPubMedGoogle Scholar
  9. 9.
    Hanney RM, Carmalt HL, et al. Use of Hasson cannula producing major vascular trauma at laparoscopy. Surg Endosc. 1999;13:1238–40.CrossRefPubMedGoogle Scholar
  10. 10.
    Wherry DC, Marohn MR, et al. An external audit of laparoscopic cholecystectomy in the steady state performed in a medical treatment facility of the Department of Defense. Ann Surg. 1996;224:145–54.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Pereira AJ, Gamarra QM, Leibar TA, Astobieta O y A, Ibarluzea González G. Incidencias y complicaciones en nuestras primeras 250 prostatectomias radicales roboticas. Actas Urol Esp. 2010;34:428–39.Google Scholar
  12. 12.
    Phillips PA, Amaral FA. Abdominal access complications in laparoscopic surgery. J Am Coll Surg. 2001;192:525–36.CrossRefGoogle Scholar
  13. 13.
    Florio G, Silvestro C, Polito DS. Peri-umbilical Veress needle pneumoperitoneum: technique and results in 2126 cases. Chir Ital. 2003;55(1):51–4.PubMedGoogle Scholar
  14. 14.
    Agresta F, De Simone P, Ciardo LF, Bedin N. Direct trocar insertion vs Veress needle in nonobese patients undergoing laparoscopic procedure: a randomized prospective single-center study. Surg Endosc. 2004;18(12):1778–81.CrossRefPubMedGoogle Scholar
  15. 15.
    Azevedo J, Azevedo O, Miyahira S, Miguel G, Becker O, Hypólito H, et al. Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review. Surg Endosc. 2009;23:1428–32.CrossRefPubMedGoogle Scholar
  16. 16.
    Larobina M, Nottle P. Complete evidence regarding major vascular injuries during laparoscopic access. Surg Laparosc Endosc Percutan Tech. 2005;15(3):119–23.CrossRefPubMedGoogle Scholar
  17. 17.
    Vilos GA, Ternamian A, Dempster J, et al. Laparoscopic entry: a review of techniques, technologies, and complications. J Obstet Gynaecol Can. 2007;29(5):433–65.CrossRefPubMedGoogle Scholar
  18. 18.
    Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007;106(1):164–77.CrossRefPubMedGoogle Scholar
  19. 19.
    Merlin T, Hiller J, Maddern G, Jamieson G, Brown A, Kolbe A. Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery. Br J Surg. 2003;90:668–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Thomas MA, Rha KH, et al. Optical access trocar injuries in urological laparoscopic surgery. J Urol. 2003;170(1):61–3.CrossRefPubMedGoogle Scholar
  21. 21.
    Brown JA, Canal D, Sundaram CP. Optical-access visual obturator trocar entry into desufflated abdomen during laparoscopy: assessment after 96 cases. J Endourol. 2005;19(7):853–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Catarci M, Carlini M, et al. Major and minor injuries during the creation of pneumoperitoneum. A multicenter study of 12,919 cases. Surg Endosc. 2001;15(6):566–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Gill I, Kavoussi L, Clayman R, Ehrlich R, Evans R, Fuchs G, et al. Complications of laparoscopic nephrectomy in 185 patients: a multi-institutional review. J Urol. 1995;154:479–83.CrossRefPubMedGoogle Scholar
  24. 24.
    Stolzenburg J, Truss M. Technique of laparoscopic (endoscopic) radical prostatectomy. BJU Int. 2003;91:749–57.CrossRefPubMedGoogle Scholar
  25. 25.
    Siqueira T, Kuo R, Gardner T, Paterson R, Stevens L, Lingeman J, et al. Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis experience. J Urol. 2002;168:1361–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Abreu A, Chopra S, Berger A, Leslie S, Desai M, Gill I, et al. Management of large median and lateral intravesical lobes during robot-assisted radical prostatectomy. J Endourol. 2013;27:1389–92.CrossRefPubMedGoogle Scholar
  27. 27.
    Nepple KG, Sandhu GS, Rogers CG, et al. Description of a multicenter safety checklist for intraoperative hemorrhage control while clamped during robotic partial nephrectomy. Patient Saf Surg. 2012;6:8.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Kerbl K, Chandhoke PS, Clayman RV, et al. Ligation of the renal pedicle during laparoscopic nephrectomy: a comparison of staples, clips and sutures. J Laparoendosc Surg. 1993;3:9.CrossRefPubMedGoogle Scholar
  29. 29.
    Baldwin DD, Desai PJ, et al. Control of the renal artery and vein with the nonabsorbable polymer ligating clip in hand-assisted laparoscopic donor nephrectomy. Transplantation. 2005;80(3):310–3.CrossRefPubMedGoogle Scholar
  30. 30.
    Kapoor R, Singh KJ, et al. Hem-o-lok clips for vascular control during laparoscopic partial nephrectomy: a single center experience. J Endourol. 2006;20(3):202–4.CrossRefPubMedGoogle Scholar
  31. 31.
    Biggs G, Hafron J, Feliciano J, et al. Treatment of splenic injury during laparoscopic nephrectomy with BioGlue, a surgical adhesive. Urology. 2005;66:882.CrossRefPubMedGoogle Scholar
  32. 32.
    Legrand A, Bignon A, Borel M, et al. Perioperative manage-ment of asplenic patients. Ann Fr Anesth Reanim. 2005;24:807.CrossRefPubMedGoogle Scholar
  33. 33.
    Shekarriz B, Upadhyay J, Wood D. Intraoperative, perioperative, and long-term complications of radical prostatectomy. Urol Clin North Am. 2001;28:639–53.CrossRefPubMedGoogle Scholar
  34. 34.
    Dall’Oglio M, Srougi M, Pereira D, Nesrallah A, Andreoni C, Kauffmann J, et al. Rupture of vesicourethral anastomosis following radical retropubic prostatectomy. Int Braz J Urol. 2003;29:221–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Stolzenburg J, Do M, Rabenalt R, Dietel A, Pfeiffer H, Reinhardt F, et al. Endoscopic extraperitoneal radical prostatectomy. In: Stolzenburg J, Türk I, Liatsikos E, editors. Laparoscopic and robot-assisted surgery in urology. Berlin: Springer; 2007. p. 121–33.Google Scholar
  36. 36.
    Benway BM, Bhayni SB, Rogers CG, et al. Robot-assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of peri-operative outcomes. J Urol. 2009;182:866.CrossRefPubMedGoogle Scholar
  37. 37.
    Gupta AD, Semins MJ, Marx JK, et al. Renal artery pseudoaneurysm after partial nephrectomy. J Urol. 2010;183:2390.CrossRefPubMedGoogle Scholar
  38. 38.
    Maynard G. Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement. 2 nd ed. Rockville: Agency for Healthcare Research and Quality; 2015. ARHQ Publication No. 16-0001-EF.Google Scholar
  39. 39.
    Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on thrombosis (in consultation with the council on cardiovascular radiology), American Heart Association. Circulation. 1996;93(12):2212–45.CrossRefPubMedGoogle Scholar
  40. 40.
    Culkin DJ, Exaire EJ, Green D, Soloway MS, Gross AJ, Desai MR, White JR, Lightner DJ. Anticoagulation and antiplatelet therapy in urologic practice: ICUD and AUA review paper. J Urol. 2014;192(4):1026–34.CrossRefPubMedGoogle Scholar
  41. 41.
    Hariharan U, Shah SB. Venous thromboembolism and robotic surgery: need for prophylaxis and review of literature. J Hematol Thrombo Dis. 2015;3:227.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.USC Institute of Urology, Keck Medicine of USCLos AngelesUSA
  2. 2.USC Institute of Urology, University of Southern CaliforniaLos AngelesUSA

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