Inferior epigastric vessels injury; What to do ?

1. INFERIOR
EPIGASTRIC
VESSELS INJURY
AHMED MOUSTAFA AL-
AMELY

2. AGENDA
 VESSELS OF ANTERIOR ABDOMINAL WALL
 SUPERFICIAL EPIGASTRIC VESSELS
 CIRCUMFLEX ILIAC VESSELS
 DEEP EPIGASTRIC VESSELS
 SURFACE ANATOMY
 INCIDENCE AND CAUSES OF INJURY
 PREVENTION OF INJURY
 MANAGEMENT OF INJURY
 MISSED INJURY

3. VESSELS OF ANTERIOR ABDOMINAL WALL
 Epigastric vessels ( Superficial and deep )
 Circumflex iliac vessels ( Superficial and deep )

4. SUPERFICIAL EPIGASTRIC VESSELS
 Origin : Femoral artery
 Course : Through superficial fascia toward the umbilicus
 Identified by intra-abdominal transillumination to avoid their injury

5. CIRCUMFLEX ILIAC VESSELS
 Superficial circumflex iliac originate from external iliac artery.
 Deep circumflex iliac originate from femoral artery.

6. DEEP EPIGASTRIC VESSELS
 Superior deep epigastric vessels
 Inferior deep epigastric vessels

7. SUPERIOR DEEP EPIGASTRIC VESSELS
 Origin: Internal mammary artery
 Course: Descends through the thorax into the rectus
muscle accompanied by 2 veins.
 Termination : Anastomose with inferior epigastric vessels
at the level of umbilicus.

8. INFERIOR DEEP EPIGASTRIC VESSELS
 Origin: External iliac artery just above the inguinal ligament.
 Course: It ascends obliquely and medially along the medial margin of the
deep inguinal ring, pierces the transversalis fascia, and passes in front of
the arcuate line, runs between the rectus abdominis and posterior rectus
sheath.
 Termination : By piercing the rectus abdominis at the umbilical level, it
divides into numerous branches and anastomoses with the superior
epigastric artery.

9. SURFACE ANATOMY
 The course of the Inferior epigastric artery (IEA) is highly variable.
 Distance of IEA from the midline:
 At pubic symphysis : The shortest distance of IEA from the midline at this level was 1.2 cm on the left and 3.5
cm on the right; the farthest distance was 6.9 cm on the left and 6.8 cm on the right.
 At the level of anterior superior iliac spines (ASIS) : The median distance of IEA from midline at this level was
4.9 cm on the left and 4.7 cm on the right
 At the level of umbilicus: The mean distance of IEA from midline was 3.1 cm on the left and 3.4 cm on the
right.

10. INCIDENCE OF INJURY
 0.3% to 2.5% during operative laparoscopy
 Recognition of vessel injury :
 Observing blood dripping down the cannula
 Abdominal wall discoloration or development of a haematoma around or near the incision.
 In some instances, the blood may track to a more distant site, manifesting as a pararectal or vulval mass

11. CAUSES OF INJURY
The anatomical position of the IEA subjects it to risk of injury during abdominal procedures that are close to the
artery.
 laparoscopic trocar insertion
 Insertion of intraabdominal drains.
 Peritoneal dialysis catheter
 Paracentesis

12. PREVENTION OF INJURY
 Internal identification
 External identification

13. INTERNAL IDENTIFICATION
 Direct visualisation transperitoneally is the ideal approach to
avoid inferior epigastric vessel injury during laparoscopic
accessory trocar placement, which should be inserted lateral to
the vessels at a 90° angle to the abdominal wall.
 Always identify the IEA as they course along the parietal
peritoneum in the lateral umbilical fold.
 The IEA are located lateral to the medial umbilical fold but medial
to the deep inguinal ring
 Identify the deep inguinal ring by locating where the round
ligament enters the inguinal canal

14. INTERNAL IDENTIFICATION

15. INTERNAL IDENTIFICATION
 Having difficulty finding the deep inferior epigastric vessels?
Look between the round ligament insertion and median
umbilical ligament!
 Place your trocar lateral to round ligament insertion.

16. EXTERNAL IDENTIFICATION
 If the Inferior epigastric vessels are obscured by excess tissue and can
not be easily identified.
 Place the trocar approximately 8 cm lateral to the midline and 5 cm
above symphysis pubis .
 These right and left abdominal area approximate McBurney’s point and
Hurd’s point, respectively.
 To avoid injury to IEA, trocars can be safely inserted 8 cm away from the
midline (or) in the lateral third of the distance between the midline and a
sagittal plane running through ASIS.

17. EXTERNAL IDENTIFICATION
 The medial and lateral safer zones can be drawn to reduce the risk
of IEA injury:
 1) medially, within 1 cm either side of the midline
 2) laterally, more than 8 cm from the midline or more than two-
thirds along the horizontal line between the midline and a sagittal
plane through the ASIS.
 It should be recognised that the IEAs located in the area between
4 cm and 8 cm from the midline and 80% of IEAs had at least one
branch more than 1 mm in diameter emerging from the lateral
border of the rectus sheath.

18. MANAGEMENT OF IEA INJURY
 First of all, Don’t panic

19. MANAGEMENT OF IEA INJURY
 Do not remove the trocar
 Leave the trocar in place to help tamponade the vessel and aid in
localizing the site of injury.
 Move the trocar 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 trocar within the abdomen
tamponades the bleeding.

20. MANAGEMENT OF IEA INJURY
 Then, grasp the vessel by non traumatic grasper through
the contralateral port below the site of injury ( towards the
origin ) to avoid retraction of the vessel and to prevent
further expansion of the hematoma

21. MANAGEMENT OF IEA INJURY
 Then , you have three choices , either :
 Insertion of foley’s catheter
 Coagulation
 suturing

22. MANAGEMENT OF IEA INJURY
 A Foley catheter inserted through the port site, and the
balloon inflated in the peritoneal cavity by 30 ml water.
 The balloon can then be pulled up against the bleeding
point with a resultant tamponade effect.
 The catheter can be secured externally using a clamp.
 Leave the catheter in place for 24-48 hours

23. MANAGEMENT OF IEA INJURY
 Coagulation of the vessel by bipolar proximal and distal to
the site of injury if the vessel has not retracted to the
abdominal wall.

24. MANAGEMENT OF IEA INJURY
 Suturing the vessel proximal and distal to the site
of injury.
 Take the stitch by port closure needle using the
same technique like closing the port site.
 Leave the suture in place for 48-72 hours.
 By prolene on silicon tube or piece of gauze to
avoid necrosis of the skin. ( Like tension sutures as
in the image )

25. MANAGEMENT OF IEA INJURY
 Do not forget to ensure hemostasis on decreasing the intra-
abdominal pressure.
 If all these measures failed or the hematoma is enlarging, do not
hesitate to do immediate laparotomy.

26. MISSED INJURY
 It is advisable to directly visualise the removal of accessory trocars, as this may reveal inadvertent bleeding
points
 Bleeding may not immediately be apparent to the surgical team due to a number of factors, including
increased abdominal pressure (pneumoperitoneum) or decreased venous pressure associated with the
Trendelenburg position.
 If the lacerated vessel presents postoperatively as a haematoma, initial management should be with local
compression. The temptation to open or aspirate the haematoma should be resisted, as such a manoeuvre
may inhibit the tamponade effect and could increase the risk of abscess formation.
 If the haematoma continues to enlarge, however, or if there is evidence of haemodynamic compromise, wound
exploration is indicated.

27. THANK YOU
DOLOR SIT AMET