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 Complications of induction of
  pneumoperitoneum by
      “veress needle”


             Dr . Sumeet Shah
             ,MBBS ( MAMC ), MS, DNB, MNAMS, FIAGES
                        (Fellowship ( MAS

              Laparoscopic & Bariatric Surgeon
                 Max Healthcare, New Delhi

               sumeetshah01@gmail.com
Complications of Closed (Veress)
            Access
 Extraperitoneal insuffalation of gas
 Injury to gastro intestinal tract
 Bladder injury
 Blood vessel injury
 Puncture of liver & spleen
 Gas embolism
1. Extra-peritoneal gas
         insufflation
 Failure to introduce the
  Veress' needle into the
  peritoneal cavity may produce
  extra-peritoneal emphysema.
 This occurs in about 2% of
  cases.
1. Extra-peritoneal gas
         insufflation
 The diagnosis is made by
  palpation of crepitus caused by
  bubbles of CÓ2 under the skin..
 If this is recognized early, the gas
  may be allowed to escape and the
  needle re-introduced through the
  same or another site.
Extra-peritoneal gas . 1
            insufflation
If the complication is not recognized
 during the introduction of gas, the typical
 appearance of extra-peritoneal gas may be
 recognized when an attempt is made to
 introduce the telescope.
It is always essential to view through the
 telescope during its insertion through its
 cannula.
Extra-peritoneal gas . 1
          insufflation
    The typical spider-web
    appearance caused by pre-
peritoneal insufflation will be seen
when the telescope reaches the end
     of the cannula and further
stripping of the peritoneum by the
   tip of the telescope avoided.
Extra-peritoneal gas . 1
           insufflation
The laparoscope should be
 withdrawn and attempts made to
 express the gas.
The needle may then be re-introduced
 through the same or another site.
Alternatively the trocar and cannula
 may be introduced by
Extra-peritoneal gas insufflation . 1

 The aspiration test and the
   high insufflation pressure
 will make it obvious that
  the needle is sited incorrectly
    in which case it should be
     withdrawn and re-sited.
2. Injury to gastro-intestinal
             tract
  Certain conditions may predispose
   to injury by the Veress' needle.
             These include :
1. Distension of the gastro-intestinal
   tract or
2. Adhesions of bowel to the
   abdominal wall.
2. Injury to gastro-intestinal
             tract

Penetration of the stomach
  may occur when an upper
 abdominal site of insertion
 is chosen or the stomach is
 distended during induction
        of anesthesia.
2. Injury to gastro-intestinal
             tract
Gastric distension may also occur if
 anesthesia is maintained with a mask
 and should be suspected if there is
 upper abdominal distension or
 increased tympanism.
In this case the stomach should be
 aspirated with a naso -gastric tube.
2. Injury to gastro-intestinal
               tract
The  diagnosis of gastric
 perforation by the Veress' needle
 may be made when the patient
 belches gas.
The laparoscope should be
 introduced and the stomach
 inspected carefully.
2. Injury to gastro-intestinal tract

Provided the stomach wall has not
 been torn, no surgical treatment is
 necessary but a broad spectrum
 antibiotic should be given.
If the stomach has been torn,
 surgical repair either by laparotomy
 or laparoscopy is mandatory.
2. Injury to gastro-intestinal
             tract
 Aspiration following initial
    insertion of the needle
      should permit early
  recognition of perforation
   of the bowel but it is not
          fool-proof.
2. Injury to gastro-intestinal
             tract
Bowel   penetration should be
  suspected if there is
1.Asymmetric abdominal
  distension,
2.Belching,
3.Passing of flatus or a fecal odour.
2. Injury to gastro-intestinal
             tract
The  induction of
 pneumoperitoneum should be
 stopped and the needle re-sited
 to introduce the
 pneumoperitoneum correctly.
The gastro-intestinal tract should
 be examined carefully for
 perforation.
2. Injury to gastro-intestinal tract

It is important that both
 sides of the bowel be examined
         as the exit wound may
 be larger than the entry
 wound.
Fecal soiling demands
 immediate laparotomy and
 repair of the bowel.
2. Injury to gastro-intestinal tract


       A  simple needle
    penetration requires no
   treatment but the patient
      should be kept under
     observation and given
  broad spectrum antibiotics.
Bladder injury . 3

Routine  catheterization of
   the bladder and proper
sitting of the needle should
       prevent bladder
         penetration.
Bladder injury . 3

Ifpneumaturia is noted the
  needle should be partially
 withdrawn and the creation
    of pneumoperitoneum
         continued.
Bladder injury . 3

The  bladder peritoneum should
 be carefully inspected to ensure
 that no significant injury has
 been caused.
The treatment of a simple
 puncture is conservative with
 postoperative bladder drainage.
Blood vessel injury . 4

 The Veress' needle may
   penetrate:
1. omental or
2. mesenteric vessels or
3. any of the major abdominal
   or pelvic arteries or veins.
Blood vessel injury . 4

Minor   vascular injuries involving
the omental or mesenteric vessels
 are difficult to prevent as
  it is impossible to ensure that
 the omentum is not close to the
    abdominal wall during blind
    insertion of the insufflating
              needle.
Blood vessel injury . 4

  Injury may be suspected if:
1. blood returns up the open needle
      or if :
2. free blood is seen in the
   peritoneal cavity after insertion of
   the laparoscope.
Blood vessel injury . 4

Ifblood returns up the needle and
 the patient's condition is stable,
 the site of injury may be
 investigated laparoscopically.
The needle should be left in place
 and a 5 mm laparoscope introduced
 through a suprapubic cannula.
4. Blood vessel injury
Minimal  bleeding may usually be
 controlled by bipolar coagulation or a
 laparoscopic suture.
Laparotomy is not usually necessary
 except in the case of injury to the
 superior mesenteric artery.
Such injury requires repair by a
 vascular surgeon
            (Bassil et al, 1993)
4. Blood vessel injury
   Injury to the major vessels may be
                  prevented by:
1.   Lifting the abdominal wall,
2.   Angling the needle towards the pelvis
     once the initial thrust through the
     fascia has been made           and by
3.   Inserting only as much of the needle
     as necessary.
4. Blood vessel injury

Thin patients and children are
    at particular risk of this injury.
Withdrawal of blood on aspiration
 following insertion of the needle
 should allow early detection of
 blood vessel injury.
4. Blood vessel injury
If  injury to a vessel such as
 the aorta, inferior vena cava
or common iliac vessel
      is suspected,
     the needle should be left
 place to mark the site of the
     injury and laparotomy
 performed through a mid-line
4. Blood vessel injury

There   is usually a large
 haematoma which obscures the
 site of the injury.
The aorta should be compressed
 with a clamp or hand until a
 vascular surgeon arrives to
 perform definitive surgery.
4. Blood vessel injury

Dramatic  collapse may result from
 penetration of a major vessel but the
 bleeding may not be immediately
 evident if it is retro-peritoneal.
The loose areolar tissue anterior to
 the aorta can allow accumulation of a
 considerable amount of blood before
 frank intra-abdominal bleeding is
 seen.
4. Blood vessel injury
A  thorough search must be
 made to determine the extent
 of vessel damage.
This includes retraction of
 bowel to expose the aorta
 above the pelvic brim which is
 the most common site of
 perforation.
4. Blood vessel injury

 Failure   to do search may
 result in continued bleeding
   and formation of a large
haematoma leading to a
           second episode of
    shock some hours later
Puncture of liver or spleen . 6



 The liver or spleen may be
    punctured by the Veress
Gas embolism . 5
Intravascular  insufflation of
 gas may lead to gas embolism
 or even death.
This can only happen if the
 penetration by the Veress'
 needle goes unrecognized and
 insufflation commences.
Gas embolism . 5

It should be prevented by routine
 use of the aspiration test.
The patient should be turned on
 to the left lateral position and,
If immediate recovery does not
 take place, cardiac puncture
 performed to release the gas.
Open vs. Closed Access

 Numerous studies have shown no
 clear benefit for one over the other
 The incidence of bowel and vascular
 injury for both are between 0.0 and
 0.1%
 Risk factors for both included
 previous surgery, thin habitus,
 distention, and obesity
                      JOGC 2007;193May:433-447
Safety and Closed Access (Veress
             (Needle
    Initial pressure > 10 mm Hg
    Access at Palmer’s Point with prior lower abdominal incisions (or
    use open technique)
       When using Palmer’s Point, always decompress stomach with OG
        tube
       Do not use Palmer’s Point in presence of upper abdominal
        incisions
   Use Palmer’s Point for very thin and very obese patients
   For thin patients and umbilical access, angle needle 45 degrees
    caudal and for obese patients, introduce needle perpendicular to
    the skin
   Do not waggle needle
   Abort umbilical site after 3 failed attempts
   Use pressure instead of volume endpoint (20 mm Hg)
   Check for access injuries upon entry and closure


                                            JOGC 2007;193May:433-447
(Safety and Open Access (Hasson

 Avoid access through previous
 surgical scar
  Use more lateral access in such
   cases
Enter peritoneal cavity under
 direct vision
Check for access injuries on entry
 and closure
Laparoscopy complications   veress

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Laparoscopy complications veress

  • 1.  Complications of induction of pneumoperitoneum by “veress needle” Dr . Sumeet Shah ,MBBS ( MAMC ), MS, DNB, MNAMS, FIAGES (Fellowship ( MAS Laparoscopic & Bariatric Surgeon Max Healthcare, New Delhi sumeetshah01@gmail.com
  • 2. Complications of Closed (Veress) Access  Extraperitoneal insuffalation of gas  Injury to gastro intestinal tract  Bladder injury  Blood vessel injury  Puncture of liver & spleen  Gas embolism
  • 3. 1. Extra-peritoneal gas insufflation Failure to introduce the Veress' needle into the peritoneal cavity may produce extra-peritoneal emphysema. This occurs in about 2% of cases.
  • 4. 1. Extra-peritoneal gas insufflation The diagnosis is made by palpation of crepitus caused by bubbles of CÓ2 under the skin.. If this is recognized early, the gas may be allowed to escape and the needle re-introduced through the same or another site.
  • 5. Extra-peritoneal gas . 1 insufflation If the complication is not recognized during the introduction of gas, the typical appearance of extra-peritoneal gas may be recognized when an attempt is made to introduce the telescope. It is always essential to view through the telescope during its insertion through its cannula.
  • 6. Extra-peritoneal gas . 1 insufflation The typical spider-web appearance caused by pre- peritoneal insufflation will be seen when the telescope reaches the end of the cannula and further stripping of the peritoneum by the tip of the telescope avoided.
  • 7. Extra-peritoneal gas . 1 insufflation The laparoscope should be withdrawn and attempts made to express the gas. The needle may then be re-introduced through the same or another site. Alternatively the trocar and cannula may be introduced by
  • 8. Extra-peritoneal gas insufflation . 1 The aspiration test and the high insufflation pressure will make it obvious that the needle is sited incorrectly in which case it should be withdrawn and re-sited.
  • 9. 2. Injury to gastro-intestinal tract  Certain conditions may predispose to injury by the Veress' needle.  These include : 1. Distension of the gastro-intestinal tract or 2. Adhesions of bowel to the abdominal wall.
  • 10. 2. Injury to gastro-intestinal tract Penetration of the stomach may occur when an upper abdominal site of insertion is chosen or the stomach is distended during induction of anesthesia.
  • 11. 2. Injury to gastro-intestinal tract Gastric distension may also occur if anesthesia is maintained with a mask and should be suspected if there is upper abdominal distension or increased tympanism. In this case the stomach should be aspirated with a naso -gastric tube.
  • 12. 2. Injury to gastro-intestinal tract The diagnosis of gastric perforation by the Veress' needle may be made when the patient belches gas. The laparoscope should be introduced and the stomach inspected carefully.
  • 13. 2. Injury to gastro-intestinal tract Provided the stomach wall has not been torn, no surgical treatment is necessary but a broad spectrum antibiotic should be given. If the stomach has been torn, surgical repair either by laparotomy or laparoscopy is mandatory.
  • 14. 2. Injury to gastro-intestinal tract  Aspiration following initial insertion of the needle should permit early recognition of perforation of the bowel but it is not fool-proof.
  • 15. 2. Injury to gastro-intestinal tract Bowel penetration should be suspected if there is 1.Asymmetric abdominal distension, 2.Belching, 3.Passing of flatus or a fecal odour.
  • 16. 2. Injury to gastro-intestinal tract The induction of pneumoperitoneum should be stopped and the needle re-sited to introduce the pneumoperitoneum correctly. The gastro-intestinal tract should be examined carefully for perforation.
  • 17. 2. Injury to gastro-intestinal tract It is important that both sides of the bowel be examined as the exit wound may be larger than the entry wound. Fecal soiling demands immediate laparotomy and repair of the bowel.
  • 18. 2. Injury to gastro-intestinal tract A simple needle penetration requires no treatment but the patient should be kept under observation and given broad spectrum antibiotics.
  • 19. Bladder injury . 3 Routine catheterization of the bladder and proper sitting of the needle should prevent bladder penetration.
  • 20. Bladder injury . 3 Ifpneumaturia is noted the needle should be partially withdrawn and the creation of pneumoperitoneum continued.
  • 21. Bladder injury . 3 The bladder peritoneum should be carefully inspected to ensure that no significant injury has been caused. The treatment of a simple puncture is conservative with postoperative bladder drainage.
  • 22. Blood vessel injury . 4  The Veress' needle may penetrate: 1. omental or 2. mesenteric vessels or 3. any of the major abdominal or pelvic arteries or veins.
  • 23. Blood vessel injury . 4 Minor vascular injuries involving the omental or mesenteric vessels are difficult to prevent as it is impossible to ensure that the omentum is not close to the abdominal wall during blind insertion of the insufflating needle.
  • 24. Blood vessel injury . 4  Injury may be suspected if: 1. blood returns up the open needle or if : 2. free blood is seen in the peritoneal cavity after insertion of the laparoscope.
  • 25. Blood vessel injury . 4 Ifblood returns up the needle and the patient's condition is stable, the site of injury may be investigated laparoscopically. The needle should be left in place and a 5 mm laparoscope introduced through a suprapubic cannula.
  • 26. 4. Blood vessel injury Minimal bleeding may usually be controlled by bipolar coagulation or a laparoscopic suture. Laparotomy is not usually necessary except in the case of injury to the superior mesenteric artery. Such injury requires repair by a vascular surgeon (Bassil et al, 1993)
  • 27. 4. Blood vessel injury  Injury to the major vessels may be prevented by: 1. Lifting the abdominal wall, 2. Angling the needle towards the pelvis once the initial thrust through the fascia has been made and by 3. Inserting only as much of the needle as necessary.
  • 28. 4. Blood vessel injury Thin patients and children are at particular risk of this injury. Withdrawal of blood on aspiration following insertion of the needle should allow early detection of blood vessel injury.
  • 29. 4. Blood vessel injury If injury to a vessel such as the aorta, inferior vena cava or common iliac vessel is suspected, the needle should be left place to mark the site of the injury and laparotomy performed through a mid-line
  • 30. 4. Blood vessel injury There is usually a large haematoma which obscures the site of the injury. The aorta should be compressed with a clamp or hand until a vascular surgeon arrives to perform definitive surgery.
  • 31. 4. Blood vessel injury Dramatic collapse may result from penetration of a major vessel but the bleeding may not be immediately evident if it is retro-peritoneal. The loose areolar tissue anterior to the aorta can allow accumulation of a considerable amount of blood before frank intra-abdominal bleeding is seen.
  • 32. 4. Blood vessel injury A thorough search must be made to determine the extent of vessel damage. This includes retraction of bowel to expose the aorta above the pelvic brim which is the most common site of perforation.
  • 33. 4. Blood vessel injury Failure to do search may result in continued bleeding and formation of a large haematoma leading to a second episode of shock some hours later
  • 34. Puncture of liver or spleen . 6 The liver or spleen may be punctured by the Veress
  • 35. Gas embolism . 5 Intravascular insufflation of gas may lead to gas embolism or even death. This can only happen if the penetration by the Veress' needle goes unrecognized and insufflation commences.
  • 36. Gas embolism . 5 It should be prevented by routine use of the aspiration test. The patient should be turned on to the left lateral position and, If immediate recovery does not take place, cardiac puncture performed to release the gas.
  • 37. Open vs. Closed Access  Numerous studies have shown no clear benefit for one over the other  The incidence of bowel and vascular injury for both are between 0.0 and 0.1%  Risk factors for both included previous surgery, thin habitus, distention, and obesity JOGC 2007;193May:433-447
  • 38. Safety and Closed Access (Veress (Needle  Initial pressure > 10 mm Hg  Access at Palmer’s Point with prior lower abdominal incisions (or use open technique)  When using Palmer’s Point, always decompress stomach with OG tube  Do not use Palmer’s Point in presence of upper abdominal incisions  Use Palmer’s Point for very thin and very obese patients  For thin patients and umbilical access, angle needle 45 degrees caudal and for obese patients, introduce needle perpendicular to the skin  Do not waggle needle  Abort umbilical site after 3 failed attempts  Use pressure instead of volume endpoint (20 mm Hg)  Check for access injuries upon entry and closure JOGC 2007;193May:433-447
  • 39. (Safety and Open Access (Hasson  Avoid access through previous surgical scar Use more lateral access in such cases Enter peritoneal cavity under direct vision Check for access injuries on entry and closure