Clinical Risks And Mitigation Strategies For The Veress Needle

https://en.wikipedia.org/wiki/Veress_needle

Despite its sophisticated design, the Veress needle-being a blind-access instrument-carries inherent clinical risks. Understanding these potential complications and their mitigation strategies is crucial for every surgeon. Primary concerns include vascular injury, bowel perforation, subcutaneous emphysema, and gas embolism.

1. Vascular Injury

Among the most severe complications, laceration of major vessels (e.g., inferior epigastric artery, aorta, iliac vessels) can precipitate exsanguination. Risk factors include improper entry site selection (e.g., too medial), excessive insertion depth/angle, distorted anatomy from prior surgery, and difficulty appreciating loss of resistance in obese patients.

• Mitigation:​ Palmer's Point (left upper quadrant, 3 cm below the costal margin in the mid-clavicular line) is often safer than the umbilicus as it typically avoids the epigastric vessels. Always elevate the abdominal wall during insertion to maximize the safety distance. For high-risk patients (morbid obesity, prior abdominal surgery), consider the open (Hasson) technique or ultrasound-guided access.

2. Bowel Perforation

Unrecognized bowel injury (especially small bowel) can lead to peritonitis, abscess formation, or sepsis. Predisposing factors include adhesions from previous surgery, bowel distension bringing loops closer to the abdominal wall, and a horizontal insertion angle.

• Mitigation:​ Meticulously review surgical history preoperatively. In adhesive cases, a "two-step" insertion technique may help. Rigorously perform aspiration and hanging drop tests before insufflation; any suggestion of bowel content mandates immediate cessation and conversion to open or endoscopic management.

3. Subcutaneous Emphysema

The most frequent complication, this involves CO₂ dissection into tissue planes, causing crepitus in the neck, chest, or scrotum. While usually benign, extensive emphysema can impair ventilation and obscure the surgical field.

• Mitigation:​ Confirm complete intraperitoneal placement of the side port before initiating insufflation. Commence with low-flow insufflation (1–2 L/min) while closely monitoring IAP. If emphysema develops, pause insufflation and adjust needle position. Mild cases typically resolve spontaneously; severe cases may require needle decompression.

4. Gas Embolism

Exceedingly rare but catastrophic, this occurs if CO₂ directly enters the circulation (e.g., portal or IVC systems), potentially causing cardiovascular collapse.

• Mitigation:​ Never insufflate under high pressure. Pre-insufflation checks must unequivocally rule out intravascular placement (negative aspiration, normal initial pressure). If embolism is suspected (sudden hypotension, cyanosis, mill-wheel murmur), immediately cease insufflation, place the patient in the left lateral decubitus position (Durant maneuver), initiate CPR, and attempt aspiration via a central venous catheter.

Case Analysis

A tertiary hospital reported a case of inferior epigastric artery injury during Veress insertion. The patient, a middle-aged male (BMI 28), was accessed via the infraumbilical route without adequate abdominal wall elevation and with an overly vertical angle. Post-insertion, he developed hypotension and abdominal distension. Emergency CT confirmed active arterial hemorrhage, necessitating urgent laparotomy for hemostasis. The lessons are clear: meticulous abdominal wall elevation is paramount in obese patients, and entry site selection must be individualized-the umbilicus is not universally safe.

These cases underscore that Veress needle safety hinges on surgical experience, disciplined technique, and profound respect for potential hazards. Ongoing education, simulation training, and adherence to safety protocols remain the cornerstones of risk reduction.