External Iliac Vein Injury and Repair During Robotic-assisted Pelvic Lymphadenectomy

Study objective: To demonstrate a surgical video wherein an incidental external iliac vein injury was encountered and repaired robotically during a pelvic lymphadenectomy procedure.

Design: Step-by-step explanation of the technique using a surgical video.

Setting: A 70-year-old white woman was referred to our division for fallopian tube carcinoma. She presented with bilateral adnexal masses and increasing abdominal girth. Preoperative imaging did not reveal any retroperitoneal lymphadenopathy or carcinomatosis. She was taken to the operating room for robotic-assisted debulking.

Interventions: Surgical staging was performed, including robotic hysterectomy, bilateral adnexectomy, pelvic and para-aortic lymphadenectomy, omentectomy, and pelvic washings. A 10-mm thermal laceration to the left external iliac vein occurred while using the monopolar scissors during left pelvic lymphadenectomy. After immediate clamping of the injury site with ProGrasp forceps, the laceration on the external iliac vein was primarily repaired by use of a running intracorporeal 4-0 polypropylene suture, using the robotic system. The insufflation pressure was increased to 20 mm Hg for the duration of primary repair to limit the hemorrhage. The increase in insufflation pressure was communicated to the anesthesiologist for close monitoring of the cardiopulmonary status.

Conclusion: Repair of external iliac vein injury, using the robotic system, was successfully and safely performed in this patient. Robotic repair of major vascular injuries should only be attempted by experienced laparoscopic surgeons with extensive vascular surgery experience, because these injuries are associated with significantly high mortality rate.