In this scenario, an armed trocar enters the pseudospace—without the safety shield deployed—because no resistance was encountered during penetration of the incision, owing to the fact that two 10–12-mm trocars have previously traversed the same skin incision.
As the tip of the trocar comes into contact with the leading edge of the peritoneum, it encounters resistance, and the razor-sharp blade cuts through the anterior peritoneum, traverses the narrow peritoneal space, and cuts through the posterior peritoneum and the underlying great vessel.
Often, the trocar’s knife edge injures an artery by glancing off the curved surface of the vessels and embedding itself in the neighboring or underlying vein.
The best technique to manage a pseudo-pneumoperitoneal pocket is to abandon the subumbilical site, insert a Touhy needle in the left upper quadrant, and enter and overinflate the peritoneal cavity, thereby obliterating the properitoneal gas space.
When injury occurs: 7 recommended management steps
In the event of a vascular injury, early diagnosis and treatment are vital. Do not observe retroperitoneal hematomas. The following steps are recommended:
- Call for a vascular surgeon immediately and indicate that the situation is an emergency. Do not waste time trying to locate the injury before calling for help.
- Get emergency type and cross-match for at least 6 U of whole blood.
- Obtain baseline lab measurements, including hemoglobin, hematocrit, platelets, fibrinogen, and fibrin split products.
- Open the abdomen using a vertical incision for maximum access and visibility.
- Get accurate outputs and blood-loss estimates and have anesthesia keep careful records of fluids given.
- Advise anesthesia staff to obtain additional help. This will facilitate starting additional IV sites, rapidly infusing blood products, obtaining key samples for laboratory data, and maintaining accurate and detailed records of blood gases, blood loss, replacement fluids, and blood products.
- Use a circulator to manage urgent medications or laboratory tests.
The author reports no financial relationships relevant to this article.