Introduction

Compared to the pre-minimally invasive era, the range of laparoscopic surgeries available across various surgical specialties has expanded exponentially. Although uncommon, complications of laparoscopic surgeries are unique and differ from those seen in conventional open surgeries. Injuries to both intraperitoneal and retroperitoneal structures are encountered during entry access, which is typically performed blindly using a Veress needle or direct trocar insertion (1). It is during this critical phase that the majority of serious laparoscopic complications occur (2).
Major vascular injuries are among the most feared complications of laparoscopy and are often underreported (3, 4). The incidence of such injuries is estimated to range from 0.2% to 0.5% (1, 3, 5, 6). The vessels most commonly injured include the common iliac arteries and veins, the inferior vena cava, and less frequently the abdominal aorta (5). These injuries often occur during entry access, typically within the first few seconds of surgery. Several risk factors have been associated with increased risk of major vascular injury, including low body mass index (BMI), improper trocar placement, use of excessive force, and lack of surgical experience (7).
Reports documenting aortic injury during entry access by blunt trocar in laparoscopy are limited. Here, we describe a case where the aortic injury occurred during closed entry access, performed by a final year (third-year) Urology resident, while being supervised by a laparoscopic surgeon with over 12 years of experience. This case underscores the unpredictable nature and potential severity of such complications. The multidisciplinary team’s prompt recognition and coordinated management were crucial in averting a fatal outcome.

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Case Presentation

A 41-year-old male patient, with no comorbidities and a BMI of 22.1 kg/m², was scheduled for an elective laparoscopic left nephrectomy due to a non-functioning left kidney, resulting from a 21-mm obstructing pelvi-ureteric junction stone. He had no past surgical history. The patient was positioned in the right lateral decubitus position under general anesthesia. Per our institution protocol, pneumoperitoneum was created by the Veress needle in the left iliac fossa. Upon insertion, the standard two clicks of the needle were heard, and safety tests—aspiration and hanging drop of saline—were performed as usual. The intraperitoneal pressure on entry was 4 mmHg, and the abdomen was insufflated to 12 mmHg. A 12-mm skin incision was made two finger breadths above and lateral to the umbilicus, and a conical blunt-tip 12-mm trocar was inserted with a controlled screwing motion.
Upon removal of the obturator, a gush of fresh red blood was observed. The obturator was immediately reinserted to maintain the tamponade. Anticipating a possible major vessel injury, the patient was promptly repositioned supine, and the anesthesia team was alerted. At this point, the patient started having significant deterioration in blood pressure (70/40 mmHg) with tachycardia (104 beats per minute). The anesthesiology team swiftly established central intravenous access and secured a wide-bore peripheral cannula, initiating volume resuscitation with crystalloids and inotropic support (titrated dose of injection noradrenaline 8 mg in 50 mL normal saline). An arterial line was also placed for continuous blood pressure monitoring and blood gas analysis. A massive transfusion protocol was activated. 
During midline laparotomy, a substantial volume of bright red blood was evacuated from the peritoneal cavity. Removal of the trocar revealed a gush of blood from the retroperitoneum, confirming an aortic injury. A cell saver was employed to conserve approximately 800 mL of the patient’s blood, 300 mL of which was later auto-transfused. Manual tamponade was applied, and a vascular surgery consult was immediately requested. The trocar had punctured the mesentery, injuring the anterior wall of the infrarenal abdominal aorta, while sparing the bowel, resulting in the formation of an expanding retroperitoneal hematoma. Through careful dissection, the aorta was exposed, and a 17-mm puncture with jagged edges was identified. The posterior wall of the aorta and its intima were normal. Just before placing an aortic clamp, 5000 IU of heparin was injected intravenously. Proximal aortic control was achieved with an aortic cross-clamp placed briefly, and the puncture was repaired using interrupted 5-0 polypropylene pledgeted sutures. No leakage was noted after releasing the aortic clamps. A thorough bowel inspection was subsequently performed to rule out any other injuries. Following meticulous hemostasis, the effects of heparin were reversed with 25 mg of intravenous protamine sulfate.
The plan for nephrectomy was deferred considering additional difficulty in identifying the renal hilum and hemodynamic instability. The abdomen was closed in layers, and an intraperitoneal drain was left in place. Intra-operatively, metabolic acidosis (pH of 7.22, bicarbonate 21 mmol/L, and a lactate of 4.2 mmol/L) was corrected with 50 mL of intravenous sodium bicarbonate. The patient had no arrhythmias throughout the procedure, and inotropic support was gradually tapered in response to improvement in blood pressure. In the end, the estimated blood loss was approximately 2800 mL, with 900 mL (3 units) of packed red cells, 300 mL of autologous blood from the cell saver, 520 mL (3 units) of fresh frozen plasma, and 240 mL (4 units) of platelets transfused during the surgery. The intra-operative urine output was 300 mL.
The patient was transferred to the intensive care unit with an endotracheal tube in situ and minimal vasoactive agents. On the evening of the post-operative day (POD) 0, the blood gas analysis showed resolving metabolic acidosis. He was extubated the following day and transferred to the general ward on POD 3. The relevant post-operative blood investigations were as follows: hemoglobin 14.8 g/dL (reference range: 13.2–16.6 g/dL), potassium 4.60 mmol/L (reference range: 3.5–5.1 mmol/L), calcium 7.6 mg/dL (reference range: 8.6–10.2 mg/dL), urea- 34 mg/dL (reference range: 17–49 mg/dL), creatinine 1.08 mg/dL (reference range: 0.6–1.35 mg/dL), INR 1.17 (reference range: 0.85–1.15), D-dimer 5248 ng/mL (reference range: 0–500 ng/mL), and fibrinogen 164 mg/dL (reference range: 238–498 mg/dL). Intravenous meropenem was administered due to the large incision and significant blood loss. The post-operative course was hurdled by ileus, which was managed conservatively. The abdominal drain was removed on POD 5, and the patient was discharged on POD 8 with a clean abdominal wound. At a 2-month follow-up, the patient is doing well, and plans for a left open nephrectomy are being considered.

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Discussion

In our case, the vascular injury resulted from the tip of the trocar perforating the anterior wall of the aorta. Pneumoperitoneum was established using a Veress needle, followed by the insertion of a conical, blunt-tip 12-mm trocar using a controlled screwing motion. In retrospect, the abdominal wall caved in significantly during trocar placement (Figure 1). We suspect that a snug incision in the rectus sheath led to the inadvertent application of excessive screwing force (Figure 2). Additionally, due to the patient’s lean build, the distance between the trocar tip and the aorta was reduced further as the abdominal wall collapsed inward, likely contributing to the injury. The fact that a blunt-tip trocar caused a full-thickness aortic perforation was highly unexpected. Clinically, and based on preoperative computed tomography, there was no evidence of a stiff or calcified aortic wall. A literature review identified a similar case described by Pring in 2007 (4), who postulated that a lack of abdominal fat and the application of excessive force led to shearing of the peritoneum overlying the aorta, resulting in vascular injury.

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Figure 1.

Caving in of abdominal wall (blue box), major retroperitoneal vessels (yellow box).

 

Figure 2.

Excessive screwing force with a blunt trocar on the aortic wall.

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Closed access technique, low BMI, excessive force, improper trocar placement, and surgeon inexperience are recognized risk factors for major vascular injury during laparoscopic procedures (3, 6, 7). Our hospital is a tertiary referral center and teaching institution with a moderate laparoscopic caseload. Residents receive training in laparoscopic urological procedures such as laparoscopic nephrectomy, pyeloplasty, pyelolithotomy, and donor nephrectomy under the supervision of senior faculty.
In the present case, despite supervision and the trainee having independently performed nine prior laparoscopic procedures, a vascular injury occurred. We suspect that a combination of factors—including inadequate pneumoperitoneum, a tight rectus sheath incision, low BMI, and excessive screwing force applied by the relatively inexperienced surgeon—resulted in torque on the aortic wall, ultimately leading to perforation. The jagged edges and relatively large size (17 mm) of the perforation support this hypothesis (Figure 3).

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Figure 3.

Ruptured aorta with jagged edges.

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Vascular and bowel injuries are the leading causes of morbidity and mortality associated with laparoscopic surgeries, with up to half of these injuries occurring at the time of entry access (2). Due to the blind nature of the procedure, most vascular injuries occur during the introduction of the Veress needle and the first trocar (1, 7). The incidence of major vascular injuries is reported to be between 0.2% and 0.5% (1, 5, 6). These injuries can be catastrophic, with mortality rates ranging from 6% to 13% (8).
The closed access technique involves creating pneumoperitoneum with Veress needle, followed by direct access using a primary trocar—a blunt-tip being the preferred choice (8). To enhance visualization and provide safer, faster entry, optical-access trocars were developed (8–10). However, superiority of one technique over the other has not been proved (9, 11, 12). While there has been one reported case of an aortic injury caused by open access using the Hasson trocar (4), this technique is generally considered to have an excellent safety profile (10).
Our laparoscopic surgery protocol always mandates that a trolley of sterile instruments for open surgery be kept on standby. Upon noticing the gush of bright red blood, our team maintained a low threshold of doubt and immediately alerted the anesthesia and vascular surgery teams. We believe that the prompt decision to perform a laparotomy, secure central venous access, and activate the massive transfusion protocol contributed significantly to the favorable outcome. As a tertiary care center, we had all the necessary facilities available, including a skilled surgical and anesthesia team, an ample supply of blood and blood products, and a cell saver. Case reports detailing instances where patients had to be transferred to higher centers for life-saving procedures highlight the harrowing distress that must be endured and the uncertainty of being able to keep the patient safe (6). As this case highlights, such injuries, though rare, can have catastrophic outcomes, making early detection and rapid intervention crucial.
In an academic setting such as ours, implementing a set of non-negotiable protocols for laparoscopy is essential to maintaining a strong safety profile. Following this incident, our department head has introduced several strategies to enhance patient safety. These include (a) using a blunt-tip optical trocar for entry, (b) using the outer sheath of the optical trocar to create an impression on the skin, thereby guiding the appropriate length of skin incision and avoiding an incision that is either too tight or too loose for the trocar, (c) ensuring supervision by both a senior consultant surgeon and an anesthetist, (d) preparing two separate trolleys—one with laparoscopic instruments and the other with open surgery tools, (e) mandating attendance at laparoscopic workshops and skill-labs prior to graduation, and (f) grouping, cross-matching, and reserving a unit of packed red blood cells in advance. While newer training modalities such as virtual reality simulators are available, they currently remain outside the scope of our program (7). Although complications may be inherently unpredictable, many can be avoided through rigorous vigilance and adherence to these safety measures.

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Conclusion

A favorable outcome in this case was achieved due to early recognition, prompt intervention, and the availability of a well-equipped surgical setup. Unlike open surgery, laparoscopy carries the risk of serious complications at the very start—during entry access. This case underscores the need to report such rare events, even in experienced hands, to strengthen the evidence base.

 

Learning objective
Surgical trainees must be equipped not only with technical skills but also with the ability to recognize complications early, manage crises effectively, and work cohesively within a team. Surgeons should anticipate risks in patients with low BMI or prior surgeries and routinely use blunt-tip trocars for safer access.

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Author contributions
RS led in data curation, methodology and in writing, reviewing & editing of the original draft. DKM led in conceptualization. DKM and VS led in supervision. VS led in validation.

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References​​

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9. Tinelli A, Malvasi A, Istre O, et al. Abdominal access in gynaecological laparoscopy: a comparison between direct optical and blind closed access by Verres needle. Eur J Obstet Gynecol Reprod Biol. 2010; 148(2): 191-4.

10. Mohammadi M, Shakiba B, Shirani M. Comparison of two methods of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed and complication in urologic surgery. BioMedicine. 2018; 8(4): 22.

11. Sharp HT, Dodson MK, Draper ML, et al. Complications associated with optical-access laparoscopic trocars. Obstet Gynecol. 2002; 99(4): 553-5.

12. Ahmad G, Baker J, Finnerty J, et al. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2019; 1(1).