Title: Inadvertent gastric injury with veress entry at the umbilicus: a video case report and review of the literature
Abstract: Laparoscopy is widely used in gynaecological surgery and has numerous benefits including reduced blood loss, lower infection and adhesion formation, shorter recovery and better cosmetic result. The procedure is usually performed under general anaesthesia and face-mask ventilation with positive pressure prior to intubation. The standard point of entry is at the umbilicus where a veress needle is inserted through the abdominal wall and confirmatory tests ensure correct placement before pneumoperitoneum is established via carbon dioxide insufflation. The rate of complications is reported to be low (0.18–0.41%) and a third occur during veress or trocar insertion. Complications include injury to blood vessels, solid organ or hollow viscous. Gastric injury is very rare and few isolated cases have been reported previously. A study reviewing 56 patients with 62 gastrointestinal injuries incurred during gynaecological laparoscopy, revealed one case with gastric injury caused by umbilical veress entry (1.6%). All reported cases describe gastric distension secondary to insufflation via face-mask ventilation, with the exception of one case of 'aerophagia' due to patient anxiety. Face-mask ventilation is a necessary step for general anaesthetic induction however carries a risk of up to 26.6% for gastric insufflation. Thus, the possibility of gastric distension and perforation must be considered when entering the abdominal cavity for laparoscopy. We present a case of a 33 year old woman who underwent an elective laparoscopic right ovarian cystectomy for a persistent complex ovarian cyst with an elevated CA 125 level of 58. Her past medical history was significant for bilateral dermoid cysts that were removed laparoscopically at age 23. Following general anaesthesia induction, veress entry and gas flow connection revealed low intra-abdominal pressures of 3–5 mmHg. The pressure rise abnormally fluctuated from low to as high as 19 mmHg by which time an apparent pneumoperitoneum had been created. On optical port insertion, a very distended stomach was seen with a puncture wound to the anterior wall. Further investigation by upper gastrointestinal surgeons revealed a haematoma on the posterior wall, signifying likely complete perforation of the stomach. They proceeded to laparoscopically repair the stomach by oversewing the puncture wounds and placed a drain in the lesser sac. A right ovarian cystectomy was then performed with no further complications. Post-operatively, the patient was fasted with a nasogastric tube and commenced on intravenous pantoprazole until a gastrogafrin swallow confirmed integrity of the stomach wall with no extravasion of contrast or drain output. The nasogastric tube and drain were removed and oral diet gradually introduced. Patient was discharged home on day 3. A video presentation of laparoscopic gastric perforation repair will be demonstrated. A review of the existing literature, preventative measures and management will be discussed.