The document discusses complications that can occur during induction of pneumoperitoneum using the Veress needle for closed laparoscopic access. It describes injuries that can occur to the gastrointestinal tract, bladder, blood vessels, liver and spleen. It also mentions extra-peritoneal insufflation of gas, gas embolism, and strategies to prevent and manage these complications if they occur. Safety measures are outlined to minimize risks when using either closed Veress needle or open Hasson trocar techniques for establishing laparoscopic access.

1. Complications of induction of
pneumoperitoneum by
“veress needle”
Dr . Sumeet Shah
,MBBS ( MAMC ), MS, DNB, MNAMS, FIAGES
(Fellowship ( MAS
Laparoscopic & Bariatric Surgeon
Max Healthcare, New Delhi
sumeetshah01@gmail.com

2. Complications of Closed (Veress)
Access
 Extraperitoneal insuffalation of gas
 Injury to gastro intestinal tract
 Bladder injury
 Blood vessel injury
 Puncture of liver & spleen
 Gas embolism

3. 1. Extra-peritoneal gas
insufflation
Failure to introduce the
Veress' needle into the
peritoneal cavity may produce
extra-peritoneal emphysema.
This occurs in about 2% of
cases.

4. 1. Extra-peritoneal gas
insufflation
The diagnosis is made by
palpation of crepitus caused by
bubbles of CÓ2 under the skin..
If this is recognized early, the gas
may be allowed to escape and the
needle re-introduced through the
same or another site.

5. Extra-peritoneal gas . 1
insufflation
If the complication is not recognized
during the introduction of gas, the typical
appearance of extra-peritoneal gas may be
recognized when an attempt is made to
introduce the telescope.
It is always essential to view through the
telescope during its insertion through its
cannula.

6. Extra-peritoneal gas . 1
insufflation
The typical spider-web
appearance caused by pre-
peritoneal insufflation will be seen
when the telescope reaches the end
of the cannula and further
stripping of the peritoneum by the
tip of the telescope avoided.

7. Extra-peritoneal gas . 1
insufflation
The laparoscope should be
withdrawn and attempts made to
express the gas.
The needle may then be re-introduced
through the same or another site.
Alternatively the trocar and cannula
may be introduced by

8. Extra-peritoneal gas insufflation . 1
The aspiration test and the
high insufflation pressure
will make it obvious that
the needle is sited incorrectly
in which case it should be
withdrawn and re-sited.

9. 2. Injury to gastro-intestinal
tract
 Certain conditions may predispose
to injury by the Veress' needle.
 These include :
1. Distension of the gastro-intestinal
tract or
2. Adhesions of bowel to the
abdominal wall.

10. 2. Injury to gastro-intestinal
tract
Penetration of the stomach
may occur when an upper
abdominal site of insertion
is chosen or the stomach is
distended during induction
of anesthesia.

11. 2. Injury to gastro-intestinal
tract
Gastric distension may also occur if
anesthesia is maintained with a mask
and should be suspected if there is
upper abdominal distension or
increased tympanism.
In this case the stomach should be
aspirated with a naso -gastric tube.

12. 2. Injury to gastro-intestinal
tract
The diagnosis of gastric
perforation by the Veress' needle
may be made when the patient
belches gas.
The laparoscope should be
introduced and the stomach
inspected carefully.

13. 2. Injury to gastro-intestinal tract
Provided the stomach wall has not
been torn, no surgical treatment is
necessary but a broad spectrum
antibiotic should be given.
If the stomach has been torn,
surgical repair either by laparotomy
or laparoscopy is mandatory.

14. 2. Injury to gastro-intestinal
tract
 Aspiration following initial
insertion of the needle
should permit early
recognition of perforation
of the bowel but it is not
fool-proof.

15. 2. Injury to gastro-intestinal
tract
Bowel penetration should be
suspected if there is
1.Asymmetric abdominal
distension,
2.Belching,
3.Passing of flatus or a fecal odour.

16. 2. Injury to gastro-intestinal
tract
The induction of
pneumoperitoneum should be
stopped and the needle re-sited
to introduce the
pneumoperitoneum correctly.
The gastro-intestinal tract should
be examined carefully for
perforation.

17. 2. Injury to gastro-intestinal tract
It is important that both
sides of the bowel be examined
as the exit wound may
be larger than the entry
wound.
Fecal soiling demands
immediate laparotomy and
repair of the bowel.

18. 2. Injury to gastro-intestinal tract
A simple needle
penetration requires no
treatment but the patient
should be kept under
observation and given
broad spectrum antibiotics.

19. Bladder injury . 3
Routine catheterization of
the bladder and proper
sitting of the needle should
prevent bladder
penetration.

20. Bladder injury . 3
Ifpneumaturia is noted the
needle should be partially
withdrawn and the creation
of pneumoperitoneum
continued.

21. Bladder injury . 3
The bladder peritoneum should
be carefully inspected to ensure
that no significant injury has
been caused.
The treatment of a simple
puncture is conservative with
postoperative bladder drainage.

22. Blood vessel injury . 4
 The Veress' needle may
penetrate:
1. omental or
2. mesenteric vessels or
3. any of the major abdominal
or pelvic arteries or veins.

23. Blood vessel injury . 4
Minor vascular injuries involving
the omental or mesenteric vessels
are difficult to prevent as
it is impossible to ensure that
the omentum is not close to the
abdominal wall during blind
insertion of the insufflating
needle.

24. Blood vessel injury . 4
 Injury may be suspected if:
1. blood returns up the open needle
or if :
2. free blood is seen in the
peritoneal cavity after insertion of
the laparoscope.

25. Blood vessel injury . 4
Ifblood returns up the needle and
the patient's condition is stable,
the site of injury may be
investigated laparoscopically.
The needle should be left in place
and a 5 mm laparoscope introduced
through a suprapubic cannula.

26. 4. Blood vessel injury
Minimal bleeding may usually be
controlled by bipolar coagulation or a
laparoscopic suture.
Laparotomy is not usually necessary
except in the case of injury to the
superior mesenteric artery.
Such injury requires repair by a
vascular surgeon
(Bassil et al, 1993)

27. 4. Blood vessel injury
 Injury to the major vessels may be
prevented by:
1. Lifting the abdominal wall,
2. Angling the needle towards the pelvis
once the initial thrust through the
fascia has been made and by
3. Inserting only as much of the needle
as necessary.

28. 4. Blood vessel injury
Thin patients and children are
at particular risk of this injury.
Withdrawal of blood on aspiration
following insertion of the needle
should allow early detection of
blood vessel injury.

29. 4. Blood vessel injury
If injury to a vessel such as
the aorta, inferior vena cava
or common iliac vessel
is suspected,
the needle should be left
place to mark the site of the
injury and laparotomy
performed through a mid-line

30. 4. Blood vessel injury
There is usually a large
haematoma which obscures the
site of the injury.
The aorta should be compressed
with a clamp or hand until a
vascular surgeon arrives to
perform definitive surgery.

31. 4. Blood vessel injury
Dramatic collapse may result from
penetration of a major vessel but the
bleeding may not be immediately
evident if it is retro-peritoneal.
The loose areolar tissue anterior to
the aorta can allow accumulation of a
considerable amount of blood before
frank intra-abdominal bleeding is
seen.

32. 4. Blood vessel injury
A thorough search must be
made to determine the extent
of vessel damage.
This includes retraction of
bowel to expose the aorta
above the pelvic brim which is
the most common site of
perforation.

33. 4. Blood vessel injury
Failure to do search may
result in continued bleeding
and formation of a large
haematoma leading to a
second episode of
shock some hours later

34. Puncture of liver or spleen . 6
The liver or spleen may be
punctured by the Veress

35. Gas embolism . 5
Intravascular insufflation of
gas may lead to gas embolism
or even death.
This can only happen if the
penetration by the Veress'
needle goes unrecognized and
insufflation commences.

36. Gas embolism . 5
It should be prevented by routine
use of the aspiration test.
The patient should be turned on
to the left lateral position and,
If immediate recovery does not
take place, cardiac puncture
performed to release the gas.

37. Open vs. Closed Access
 Numerous studies have shown no
clear benefit for one over the other
 The incidence of bowel and vascular
injury for both are between 0.0 and
0.1%
 Risk factors for both included
previous surgery, thin habitus,
distention, and obesity
JOGC 2007;193May:433-447

38. Safety and Closed Access (Veress
(Needle
 Initial pressure > 10 mm Hg
 Access at Palmer’s Point with prior lower abdominal incisions (or
use open technique)
 When using Palmer’s Point, always decompress stomach with OG
tube
 Do not use Palmer’s Point in presence of upper abdominal
incisions
 Use Palmer’s Point for very thin and very obese patients
 For thin patients and umbilical access, angle needle 45 degrees
caudal and for obese patients, introduce needle perpendicular to
the skin
 Do not waggle needle
 Abort umbilical site after 3 failed attempts
 Use pressure instead of volume endpoint (20 mm Hg)
 Check for access injuries upon entry and closure
JOGC 2007;193May:433-447

39. (Safety and Open Access (Hasson
 Avoid access through previous
surgical scar
Use more lateral access in such
cases
Enter peritoneal cavity under
direct vision
Check for access injuries on entry
and closure