Eur J Anat, 16 (1): 43-48 (2012)

An analysis of the anatomical trajectory of theinferior epigastric arteries in the era ofvideolaparoscopic surgery: Is there in fact a â??safetyzoneâ?� for the prevention of iatrogenic lesions?

Douglas Andrade, Débora Abranches, Natália Souza, Raphael Pereira, André Saud, Rafael Prinz, João Pereira-Correia

Department of Anatomy, Faculty of Medicine, Estácio de Sá University, Rio de Janeiro, Brasil

ABSTRACT Despite the fact that the videolaparoscopic method is considered safe, lesions of the nerves and vessels of the anterior abdominal wall can occur during the insertion of the sharp trocars to access the peritoneal cavity due to the rich vasculonervous distribution of that region. With vascular lesions, the inferior epigastric arteries (IEA) are the most affected. Transfusions, rectus abdominis muscle necrosis, hematomas or the formation of abscesses and reoperation have been described as complications. We dissected IEAs from the anterior abdominal walls of 48 adult human cadavers. Four points of reference were determined on the median line, from the pubic symphysis to the umbilicus. Next, the distance of the right and left IEA from all these reference points was evaluated. Computerized morphometric and statistical analyses were performed. Our results suggest that if the insertion of this primary port occurs in the median line, closer to the pubic symphysis, the risk of epigastric lesion will be lower. With respect to the insertion of lateral auxiliary trocars (secondary and tertiary ports) for pelvic videolaparoscopic access, we recommend that these be inserted at least 5 cm away from the median line for the region that runs from the umbilicus to the pubic symphysis. However, because of anatomical variations, we cannot be certain about absolutely safe incision points, although the risk of injury can be reduced through knowledge of the location of the arterial vessels of the abdominal wall. We strongly recommend that, until studies with a higher level of evidence about the detailed distribution of the inferior epigastric arteries in the anterior abdominal wall are conducted, especially in patients under peritoneal insufflation, that imaging methods, such as the sonographic localization of abdominal wall vessels before laparoscopy, should be used, especially in patients with an increased risk of bleeding, the obese, and those with abdominal scarring.

Keywords: Epigastric artery, Laparoscopy, Iatrogenic disease, Dissection, Intraoperative complication