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      Study of the course of inferior epigastric artery with reference to laparoscopic portal

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          Abstract

          INTRODUCTION:

          Laparoscopy has been in vogue for more than 2 decades. Making portals in the anterior abdominal wall for introducing laparoscopic instruments is done with trocar and cannula which is a blind procedure. Stab incision and trocar insertion, though safe, at times can lead to injury of blood vessels of anterior abdominal wall more so the inferior epigastric artery (IEA). Trauma to abdominal wall vessels is 0.2%-2% of laparoscopic procedures and said to be 3 per 1000 cases. Injury to IEA is one of the commonest complications seen. Purpose of the present study was to observe the course of IEA in 50 formalin preserved cadavers, by dissection.

          MATERIALS AND METHODS:

          In 50 formalin fixed cadavers, IEA was exposed by opening the rectus sheath. Rectus was divided and IEA was exposed. Five reference points A, B, C, D, and E were defined. A was at pubic symphysis, while E at umbilicus. B, C, and D were marked at the distance of 3.5, 7, and 10.5 cm, respectively from pubic symphysis. Distances of the IEA from these midline points were measured with the help of sliding vernier calipers.

          RESULTS:

          Significant observation was variations in the length of IEA. It was seen to end at a lower level than normal (three cases on right and four on left side) by piercing rectus. In 14, cadavers artery did not reach up to umbilicus on both sides. Nearest point of entry of IEA in to rectus sheath at the level of pubic symphysis was 1.2 cm on left and 3.2 cm on right side. Farthest point from point A was 6.8 cm on right and 6.9 cm on left side. Width of strip of abdominal wall which was likely to have IEA beneath was up to 4 cm till level C and beyond which it widened up to 5cm on left side and 6 cm on right at umbilicus.

          DISCUSSION:

          Present study did reveal notable variations in length and termination of IEA. No uniformity in entry of IEA in to the rectus sheath was observed. Findings did concur with earlier observations but the strip of skin of arterial zone was not equidistant from midline but had moved more medially on left side. Medial limit of this safety zone found to be lesser than 2 cm on left side. However, the lateral limit of the zone was within 7.5 cm. Additional variation was strip of abdominal wall likely to have IEA beneath was up to 4 cm till level C and had diverging limits beyond C. IEA was more notorious in its course. These variations prompt for a preoperative mapping of IEA and thus a useful step in preoperative protocol.

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          Most cited references 8

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          Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels.

          To determine the efficacy of CT scan in mapping the superior and inferior epigastric vessels, relative to landmarks apparent at laparoscopy. Trauma to abdominal wall blood vessels occurs in 0.2% to 2% of laparoscopic procedures. Both superficial and deep abdominal wall vessels are at risk. The superficial vessels may be located by transillumination; however, the deep epigastric vessels cannot be effectively located by transillumination and, thus, other techniques should be used to minimize the risk of injury to these vessels. Abdominal and pelvic CT images of 100 patients were studied. The location of the superior and inferior epigastric vessels from the midline were determined at five levels, correlated with each other and with the patient age, body mass index, and history of midline laparotomy using Pearson's correlation coefficient and multivariate analysis. CT scan was successful in mapping the epigastric vessels in 95% of patients. At the xiphoid process level, the superior epigastric vessels (SEA) were 4.41 +/- 0.13 cm from the midline on the right and 4.53 +/- 0.14 cm on the left. Midway between xiphoid and umbilicus, the SEA were 5.50 +/- 0.16 cm on the right of the midline and 5.36 +/- 0.16 cm on the left. At the umbilicus, the epigastric vessels were 5.88 +/- 0.14 cm on the right and 5.55 +/- 0.13 on the left of the midline. Midway between the umbilicus and symphysis pubis, the inferior epigastric (IEA) were 5.32 +/- 0.12 cm on right and 5.25 +/- 0.11 cm on the left. At the symphysis pubis, the IEA were 7.47 +/- 0.10 cm on the right and 7.49 +/- 0.09 cm away from the midline on the left side. Epigastric vessels are usually located in the area between 4 and 8 cm from the midline. Staying away from this area will determine the safe zone of entry of the anterior abdominal wall.
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            Complications of laparoscopic pelvic surgery: recognition, management and prevention.

            Laparoscopic surgery has many advantages but it is not without complications. The complexity of the surgery significantly influences the complication rate. Laparoscopic surgeons ought to be aware of the possible complications and how they could be prevented, recognized without delay, and managed safely and efficiently. Important complications include injuries to the vessels, bowel and urinary tract. Incisional hernia ought to be reduced by careful closure of the fascia whenever a trocar > or =10 mm is used at the extraumbilical site. Gas embolism is a rare but potentially life threatening complication. Shoulder pain is a minor complication but is exceedingly common; it is less likely to occur if as much gas as possible is removed at the end of the operation while the patient is still in head down Trendelenburg position. Rare complications include pneumothorax, subcutaneous and pre-peritoneal emphysema, cardiac arrhythmia, nerve injury and venous thrombosis. Laparoscopic surgeons should also understand the principles of electrosurgery and how to avoid complications arising from the use of electrical energy including capacitative coupling, direct coupling and insulation failure.
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              Gray's Anatomy

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                Author and article information

                Journal
                J Minim Access Surg
                J Minim Access Surg
                JMAS
                Journal of Minimal Access Surgery
                Medknow Publications & Media Pvt Ltd (India )
                0972-9941
                1998-3921
                Oct-Dec 2013
                : 9
                : 4
                : 154-158
                Affiliations
                Department of Anatomy, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune-411018, Maharashtra, India
                Author notes
                Address for Correspondence: Dr. Manvikar Purushottam Rao, Department of Anatomy, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune-411018, Maharashtra, India. E-mail: ulhasmanvi@ 123456yahoo.com
                Article
                JMAS-9-154
                10.4103/0972-9941.118826
                3830133
                Copyright: © Journal of Minimal Access Surgery

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Original Article

                Surgery

                inferior epigastric artery, laparoscopy injury, portal, rectus sheath

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