Vascular Injury

Because of the close spatial relationship between the hiatal area and the major vascular structures in the upper abdomen, vascular injuries to major vessels (aorta, vena cava, left hepatic artery, short gastric vessels) may occur during anti-reflux surgery (Table 6.1). Use of an open approach allows the surgeon to put his index finger right on the damaged vessel for immediate control of the bleeding and, subsequently, for easy vascular repair with either a ligature of the vessel (left hepatic artery, short gastric vessels) or a suture of the vascular wall (aorta, vena cava). In contrast, with the laparo-scopic approach, immediate control is much more difficult to achieve. For this reason, inex-

Table 6.1. Intraoperative complications and predisposing factors.

Vascular injury Direct injury to the aorta, inferior vena cava, left hepatic artery, short gastric vessels, spleen, right ventricle

Crushing of the liver with the hepatic retractor

Esophageal and gastric tear Inaccurate periesophageal dissection Excessive cautery Inadvertent puncture Undue traction Blind maneuver (laparoscopy) Intraluminal bougie

Vagal injury Posterior esophageal dissection Removal of the fat pad Direct injury to either vagal trunk Dense adhesions (reoperative surgery, panesophagitis) Complete division of the lesser omentum

Pneumomediastinum (laparoscopy) Extended transhiatal mobilization of the esophagus High intraabdominal insufflation pressure

Pneumothorax (laparoscopy) Inadvertent injury to the pleura Panesophagitis Esophageal shortening Large hiatal hernia perienced laparoscopists should have the conventional instrumentation opened on a table located in the operating theater, ready to be used at any time. Achieving hemostasis laparoscopi-cally can be a challenging task for the most experienced surgeon even if advanced technologies are readily available (bipolar cautery, ultrasound, argon beam). The use of smooth forceps grasping the damaged vessel is recommended, but injury to either the aorta or inferior vena cava requires immediate conversion to laparotomy. The use of a high-flow insufflator helps to maintain a high intraabdominal pressure while suctioning intraperitoneal blood. Placement of hemostatic clips on the left hepatic or splenic arteries must not totally occlude the vessels because of the potential risk of hepatic or splenic ischemia and necrosis.

In open surgery, injury to the spleen is the most frequent cause of intraoperative bleeding, and is usually related to excessive traction on the greater omentum or stomach. This can necessitate urgent splenectomy if hemostasis cannot be achieved. The incidence of this event has been reduced by the use of minimally invasive surgical techniques. In large series of open anti-reflux procedures the reported splenectomy rate ranged from 1 to 3%,2,19,20 whereas both the overall incidence of splenic injury and splenectomy rate calculated from >6000 laparoscopic anti-reflux procedures was 0.24 and 0.06%, respectively.16 Although these data come from specialized centers with high caseload volumes,21 splenectomy has not been reported in many laparoscopic series exceeding 100 patients.1 More gentle maneuvers together with the magnification of the image in laparoscopic surgery probably account for the reduced risk of perioperative hemorrhage compared with conventional surgery.22

Another cause of intraoperative bleeding during laparoscopic fundoplication is inadvertent laceration of the liver because of excessive pressure exerted by the hepatic retractor on the liver. The small hepatic fracture that is bleeding is usually secured with a compression plug. In case of failure of this technique, a variety of other hemostatic options are available, including argon or bipolar coagulation, biological glue, or collagen-based hemostatic mesh. Overly strong use of the liver retractor may cause myocardial contusion, and cardiac tamponade has been reported caused by laceration of the


right ventricle.23 Management of these problems is beyond the scope of this chapter.

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