Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy

BACKGROUND: Serious complications may occur during laparoscopic surgery, as in any surgical procedure. Injuries of major retroperitoneal vascular structures are uncommon but important complications of laparoscopy. METHODS: We report on 9 major vascular injuries in 8 patients in the course of 8 laparoscopic procedures between 1994 and 2002. RESULTS: The primary operations were cholecystectomy in 7 patients and appendectomy in one patient. Six vascular injuries occurred during placement of the first umbilical trocar, two in the course of the insertion of a Veress needle, and one during the insertion of the second trocar. A laparotomy was performed immediately in all cases. Left common iliac arteries were injured in two patients, aorta in three patients, right common iliac vein in one patient, both right common iliac artery and vein in one patient, and inferior vena cava in one patient. Polytetrafluoroethylene (PTFE) graft interposition was employed in two common iliac arteries and a tubular PTFE graft in one aortic injury, and Dacron patchplasty in one common iliac artery injury. Two aortic, two common iliac vein, and an inferior vena cava injury were repaired primarily. There were also four visceral organ injuries, which were repaired primarily. The major retroperitoneal vascular complication rate was 0.07%. An average of 3.5 units of whole blood were transfused in each case and the average stay in hospital was 6.8 days. There was no mortality. CONCLUSIONS: The surgeon's experience and knowledge are the essential factors for prevention of major vascular injuries during laparoscopic procedures. In case of an injury, immediate laparotomy must be performed to achieve hemostasis and a surgeon who is familiar with vascular surgery should employ the definitive treatment.     

The direct trocar technique: an alternative approach to abdominal entry for laparoscopy.

OBJECTIVE: The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for accessing the abdominal cavity for operative laparoscopy. We review our approach to abdominal entry in 1385 laparoscopies performed between September 1993 and June 2000 by our group at Stanford University Hospital, a tertiary Medical Center. METHODS: We performed a retrospective chart review of 1385 patients who underwent operative laparoscopy during the study years. The mode of abdominal entry, patient demographics, and complications were reviewed. RESULTS: The transumbilical direct trocar entry method was used in 1223 patients. In 133 patients, the Veress needle insertion technique was used. Open laparoscopy was used in 22 patients. Three (0.21%) major complicadons occurred: 1 enterotomy, 1 omental herniation, and 1 bowel hemiation. One complication was related to primary access (0.072%) in a patient who had an open laparoscopy. She sustained an enterotomy during placement of the primary trocar. The bowel was repaired laparoscopically. No trocar-related injuries occurred among the 1223 patients in whom the direct trocar entry technique was used. One patient had an omental herniation and required a repeat laparoscopy on postoperative day 2. The second patient had a repeat laparoscopy on the 12th postoperative day to repair a bowel herniation. None of our patients required a laparotomy. No vascular injuries occurred. CONCLUSION: Based on our experience, the direct trocar technique is a safe approach to abdominal entry for laparoscopic surgery.     

Complications of pediatric laparoscopic surgery

Background: Surgical complications of laparoscopy most often occur during Veress needle or primary trocar placement. Veress needle punctures are insignificant and require no further treatment, whereas trocar-induced vascular injuries can be catastrophic. The frequency of vascular and viscus injuries is difficult to calculate because several complications are not reported in the literature. Methods: During a 10-year-period (1984–1995), at the Division of Pediatric Surgery at ``Federico II' University of Naples, 430 laparoscopic procedures were performed in 395 children with a mean age of 5 years. The incidence of complications related to laparoscopy was 1.8% with eight complications, one of which was rather severe. The complications included one abdominal wall hematoma, two perforations of abdominal viscus (stomach, ovary), one umbilical scar complication, one postoperative hydrocele, one subcutaneous emphysema, and one pneumothorax during a Nissen procedure. The only severe complication occurred in a young girl with neurologic problems and a kyphoscoliosis operated on via laparoscopy for a gastroesophageal reflux. She suffered injuries of both right common iliac vessels and several intestinal perforations due to blind introduction of the first umbilical trocar. Results: In this case rapid conversion, complex vascular reconstruction, and multiple intestinal sutures were performed. The Nissen fundoplication with pyloroplasty was performed traditionally and the patient left the hospital free of symptoms after 20 days. The other seven complications were resolved without any problem intra- or postoperatively. Conclusions: The authors believe that the open approach with a blunt trocar is most important in helping to avoid complications in pediatric laparoscopy. Received: 5 July 1996/Accepted: 19 November 1996     

The safety and efficacy of direct trocar insertion with elevation of the rectus sheath instead of the skin for pneumoperitoneum

Abdominal access in endoscopic surgery carries a finite risk of visceral injury. Bleeding, subcutaneous emphysema, gastrointestinal tract perforation, minor and major vascular injury, and intraperitoneal adhesions are the potential complications associated with abdominal access and creation of pneumoperitoneum. There are 4 basic techniques used to create pneumoperitoneum: blind Veress needle, direct trocar insertion, optical trocar insertion, and open laparoscopy. Veress needle and direct trocar insertion are blind techniques, and their use can result in severe visceral and vascular injuries. To prevent visceral and vascular injuries caused by the technique used for the creation of pneumoperitoneum, laparoscopic surgeons and gynecologists look for safe and effective laparoscopic access techniques. Direct trocar insertion without previous pneumoperitoneum was reported to be a safe alternative to Veress needle insertion. We carried out this study to compare the ease of use, safety, and efficacy of direct trocar insertion with elevation of the rectus sheath and blind insertion of the Veress needle in laparoscopic surgery. In 578 laparoscopic procedures, the patients were assigned to one of the following groups: blind insertion of the Veress needle (group 1, n = 301) and direct trocar insertion with elevation of the rectus sheath using 2 towel clips (group 2, n = 277). Total complication rates were 15.7% (n = 33) and 3.3% (n = 4) in groups 1 and 2, respectively (P < 0.05). Direct trocar insertion with elevation of the rectus sheath using 2 towel clips is an easy, safe, and effective technique.     

Open port placement of the first laparoscopic port: a safe technique.

BACKGROUND: Blind insertion of the Veress needle and of the first trocar is a significant cause of complications in laparoscopic surgery. Despite this risk, the closed technique is still more popular than the open one. Our aim is to report the results of our experience with the routine use of the modified open technique in laparoscopic surgery and to describe the technical details of the creation of pnuemoperitoneum by the open technique that we used. METHODS: A prospective study was conducted in the department of surgery at Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi. A modified method of open laparoscopy was performed on 755 consecutive patients requiring laparoscopy or laparoscopic surgery over a 5-year period from August 1998 to February 2003 in 1 surgical unit. RESULTS: The mean time taken was 4 minutes (range, 2 to 10). No intraoperative complications occurred during trocar insertion. Forty-nine (6.49%) patients had minor umbilical sepsis, 22 (2.91%) had periumbilical hematoma, but none had umbilical hernia during 3 months of follow-up after surgery. CONCLUSION: Based on our own experience, we recommend open laparoscopy as a safe and easy approach for routine laparoscopic interventions.     

Laparoscopy and major retroperitoneal vascular injuries (MRVI)

Injury to major retroperitoneal vessels is a potential serious complication of laparoscopy occurring when the Veress needle or trocar is inserted. This report is a review of major retropertioneal vascular injuries (MRVI) occurring during laparoscopy, as these injuries have not been well documented in the literature. A retrospective, observational review of general surgical laparoscopy cases was conducted over a 3.5-year period in three community, university-affiliated hospitals. We identified 4 MRVI in 3591 laparoscopic procedures. These cases were critically analyzed and compared. The incidence of MRVI was 0.1%. All cases occurred with the closed (blind) insertion technique of Veress needle and primary trocar insertion technique with disposable safety shield trocars. All patients sustaining MRVI had acute hypotension introperatively and significant blood loss necessitating postoperative transfusions. Recognition and rapid conversion to laparotomy are keys to enhancing outcome. There is significant potential for morbidity and mortality with laparoscopic MRVI, although each patient in this series was discharged without obvious short-term problems. The advantages of an open approach for primary trocar insertion are numerous and should alleviate the risk of MRVI associated with general laparoscopic surgery.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, FL, USA, 11–14 March 1995; and the Third European Congress of the European Association for Endoscopic Surgery, Luxembourg, 13–17 June 1995     

Iliac vascular injuries during elective laparoscopic surgery

Although it is extremely uncommon, iliac vascular injury is a serious complication of laparoscopic surgery. We performed a retrospective review of five patients who sustained injury to the iliac vessels during elective laparoscopic surgery. We reviewed the mechanism and location of injury for each case and examined ways in which such complications can be prevented. There were four women and one man; their mean age was 32 years. Three patients were undergoing laparoscopy at our institution, and two patients were transferred from outlying facilities soon after the injuries occurred. There were a total of seven iliac vascular injuries among our five patients. Three cases involved injury caused by the insufflation needle; the other two were injured by trocar introduction. Postoperative sequelae included decreased lower-extremity pulses in two patients and lower-extremity edema in three patients. The incidence of iliac vascular injury can be significantly reduced by proper insertion technique, the use of an open (Hasson) approach rather than the percutaneous insufflation needle, and a thorough knowledge of the vascular anatomy in the pelvic region.     

Trocar and Veress needle injuries during laparoscopy

Background: Inadvertent lesions of the intraabdominal organs and vessels caused by trocars and Veress needles are rare but serious complications of laparoscopic surgery. Establishing the pneumoperitoneum is believed to be the most dangerous step. Methods: The Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 14,243 patients undergoing various standard laparoscopic procedures between 1995 and 1997. This database was investigated with special regard to intraabdominal complications caused by trocars and Veress needles. Results: There were 22 trocar and four needle injuries (incidence, 0.18%). Nineteen lesions involved visceral organs; the remaining seven were vessel injuries. The small bowel was the single most affected organ (six cases), followed by the large bowel and the liver (three cases each). All vascular lesions, except for one laceration of the right iliac artery, occurred as venous bleeding of either the greater omentum or the mesentery. Fourteen trocars were inserted under direct vision. Nineteen trocar injuries were recognized intraoperatively; diagnoses of two small bowel and one bladder injuries were made postoperatively. Needle injuries were all diagnosed intraoperatively. Only five injuries could be repaired laparoscopically; the remaining lesions were repaired openly. Four patients underwent an open reoperation, and another patient needed five reoperations. There was one death (4.0%). Conclusions: Trocar and needle injuries are rare complications of laparoscopy. However, if not recognized intraoperatively and repaired immediately, they induce increased morbidity and mortality. Both open and closed establishment of the pneumoperitoneum are related to a potential danger of perforating lesions, but inserting the first trocar under direct vision allows early recognition and immediate repair.     

Major Vascular Injury in Laparoscopic Urology

Background and Objectives:

Major vascular injury is the most devastating complication of laparoscopy, occurring most commonly during the laparoscopic entry phase. Our goal is to report our experience with major vascular injury during laparoscopic entry with closed- and open-access techniques in urologic procedures.

Methods:

All 5347 patients who underwent laparoscopic urologic procedures from 1996 to 2011 at our hospital were included in the study. Laparoscopic entry was carried out by either the closed Veress needle technique or the modified open Hasson technique. Patients'' charts were reviewed retrospectively to investigate for access-related major vascular injuries.

Results:

The closed technique was used in the first 474 operations and the open technique in the remaining 4873 cases. Three cases of major vascular injury were identified among our patients. They were 3 men scheduled for nephrectomy without any history of surgery. All injuries occurred in the closed-access group during the setup phase with insertion of the first trocar. The injury location was the abdominal aorta in 2 patients and the external iliac vein in 1 patient. Management was performed after conversion to open surgery, control of bleeding, and repair of the injured vessel.

Conclusions:

Given the high morbidity and mortality rates associated with major vascular injury, its clinically higher incidence in laparoscopic urologic procedures with the closed-access technique leads us to suggest using the open technique for the entry phase of laparoscopy. Using the open-access technique may decrease laparophobia and encourage a higher number of urologists to enter the laparoscopy field.     

Direct visual or blind insertion of the primary trocar

BACKGROUND: We set out to assess the difference in complication rates between primary umbilical insertion by a blind trocar and insertion with an optical surgical obturator. METHODS: In a retrospective survey, we investigated the rate of severe complications by primary umbilical trocar entry. Of 1546 patients undergoing gynecological laparoscopies at a tertiary-care university hospital, 1000 cases were operated by blind umbilical insertion with a conventional primary trocar whereas 546 used an optical primary trocar. RESULTS: The rate of major complications during insertion of the primary trocar in the blind insertion group was five of 1000 (0.5%), whereas there were no major complications in the optical-guided insertion group (0.0%). CONCLUSIONS: In comparison with the blind insertion of a sharp trocar, optical guidance provides a safe and functional primary insertion method that allows to detect adhesions to be detected at an early stage, thus preventing injuries to the bowel and abdominal vessels.     

Risks of the Minimal Access Approach for Laparoscopic Surgery: Multivariate Analysis of Morbidity Related to Umbilical Trocar Insertion

n = 8, 2.0%), followed by umbilical hernias ( n = 6, 1.5%) and umbilical wound infection ( n = 5; 1.2%). The rate of penetrating injuries was 0.2% ( n = 1). Of 20 complications, 15 (75%) were related to the umbilical insertion site. Female sex and closed laparoscopy were associated with umbilical morbidity by univariate analysis. In a multivariate analysis, closed laparoscopy was the only factor associated with these complications (odds ratio = 6.0; p = 0.04). Age, gender, obesity, diabetes mellitus, previous abdominal surgery, and the specific procedure had no influence. In conclusion, gaining access to the peritoneal cavity for laparoscopic surgery may cause severe complications, most of which are related to the umbilical trocar. Although closed laparoscopy can be safely used, open laparoscopy is associated with a lower morbidity rate; therefore its utilization is recommended.     

Vascular complications during laparoscopy. An analysis of a personal case]

Vascular complications of laparoscopy most often occur during Veress needle or primary trocar placement. Veress needle punctures are insignificant and require no further treatment, whereas trocar induced vascular injuries can be catastrophic. The frequency of vascular or viscus injuries is difficult to calculate since several complications are not published. A vascular complication occurred in a young girl with neurologic problems and a kyphoscoliosis operated on in laparoscopy for a gastroesophageal reflux is discussed. After the establishment of pneumoperitoneum, an important hemoperitoneum was rapidly evident at insertion of the laparoscope. An open laparotomy was performed showing right common iliac vessel injuries and several intestinal perforations. After a complex vascular reconstruction and a multiple intestinal suture, the Nissen fundoplication with pyloroplasty was performed traditionally and the patient leave the hospital free of symptoms after 20 days. In laparoscopy, as in all areas of surgery, experience knowledge and meticulous attention to details are the most important factors in order to avoid complications. The authors believe that the open approach with Hasson cannula is the most important factor in avoiding complications.     

Non-trocar related major retroperitoneal bleeding during laparoscopic appendectomy

Most of the reported vascular injuries in laparoscopic appendectomies occur during trocar or Veress needle insertions. As laparoscopy continues to evolve, it is essential that surgeons report unusual complications in an effort to raise awareness and guide management of any iatrogenic injury incurred during minimally-invasive procedures. We report the case of a patient who sustained a major non-trocar related retroperitoneal vascular injury during a routine LA.     

Safety of Veress needle for laparoscopic entry in children: Myth or reality?

IntroductionRecent reports suggested that blind laparoscopic entry techniques, including Veress needle (VN), might increase the risks of potentially fatal complications.Materials and methodsAll consecutive patients who underwent laparoscopy in two Pediatric Hospitals with the use of a Veress needle during a 14-year period have been included. In all cases the first trocar was a radially expanding one (STEP). Complications related to the insertion technique are reported as well as those related to the whole laparoscopic technique.ResultsA total of 3463 patients younger than 18 years of age underwent laparoscopy between January 2006 and December 2019. Of these, 205 (5.9%) were younger than 6 months of age at surgery. Two-hundred-eighty-four patients (8.2%) previously underwent abdominal surgery. During first trocar insertion no major or minor vascular injuries occurred. Two patients (0.06%) experienced bowel lesions. Nine (0.26%) experienced failed entry. Fourteen patients (0.4%) experienced postoperative issues related to trocars positioning, namely, 9 omental eviscerations through port site insertion and 5 cases of hemoperitoneum owing to epigastric vessels lesion during operative trocar positioning. No other issues strictly related to laparoscopic entry technique have been recorded during the study period. No specific risk factors predisposing to complications have been identified but the presence of a positive history of previous abdominal procedures proved to be significantly related to a higher occurrence of bowel injury during Veress needle insertion (p = 0.0067).Discussion and conclusionsAlthough with a number of biases and limitations, our study suggests that creation of pneumoperitoneum with VN combined to first trocar entry with STEP technology in children can represent a safe alternative. An exception is represented by patients who underwent previous abdominal surgeries who should be approached with caution, possibly with an open approach. Anyway, given the relatively poor quality of high-quality studies on this regard, we strongly support the implementation of well-designed RCT in children in order to answer this delicate topic.Type of studyRetrospective.Level of evidenceIV     

Optical access trocar injuries in urological laparoscopic surgery

PURPOSE: Inadvertent injuries during trocar and Veress needle placement are a rare but potentially serious complication of laparoscopic surgery. An access alternative is an optical trocar under direct vision. Limited data are available regarding the safety of this technique. We reviewed complications related to optical access trocars during standard transperitoneal urological laparoscopic procedures performed at a single institution. MATERIALS AND METHODS: From 1995 to 2001 the optical access trocar was used as the initial trocar in 1,283 urological laparoscopic procedures. The procedures included simple and radical nephrectomy in 309 cases, donor nephrectomy in 386, partial nephrectomy in 79, pyeloplasty in 173 and various other procedures in 336. Intra-abdominal complications caused by optical access trocar were assessed. RESULTS: The optical trocar was inserted at the umbilicus in 88 patients (7.4%), in the right upper quadrant in 445 (34.7%) and in the left upper quadrant in 750 (58.5%). There were 4 injuries (0.31%) associated with the optical access trocar. Complications occurred on the left side in 3 cases and on the right side in 1, including 1 injury to bowel, 1 mesenteric injury resulting in a retroperitoneal hematoma and 2 injuries to epigastric vessels. Three cases were recognized and repaired immediately but in a case of epigastric vessel injury the expanding abdominal wall hematoma required postoperative repair. CONCLUSIONS: Optical access trocars provide a safe and rapid technique for initial trocar placement. Results of this large series support the finding that few trocar related complications are associated with the optical access trocar.     

Major vascular injuries during laparoscopic cholecystectomy

Background: Since the introduction of laparoscopic cholecystectomy, major vascular injury has been a rare but very serious complication of the procedure. Methods: All 2,589 laparoscopic cholecystectomies performed at our institution between May 1, 1990, and December 31, 1996, were retrospectively reviewed to identify major vascular injury and the mechanisms involved. All these procedures were performed either by surgical attendings or senior surgical residents. Results: During the 1,372 operations performed here between May 1, 1990, and May 1, 1994, there were three major vascular injuries. One was to a portal vein, due to dissection during lysis of adhesions; the other two, to the aorta and vena cava, were due to trocar insertions. There was one mortality secondary to liver failure following repair of the portal vein injury. Between May 1, 1994, and December 1, 1996, there were no major vascular injuries; our overall incidence was 0.11%. A review of the literature on this subject is included. Conclusions: Laparoscopic cholecystectomy is a very safe procedure; major vascular injury is a rare complication, but mandates early recognition and consideration of prompt exploratory laparotomy. These injuries can be avoided by strict adherence to laparoscopic guidelines: obtaining pneumoperitoneum by the open technique, inserting side trocars under direct vision, elevating the abdominal wall prior to trocar insertion, and training surgeons in a laparoscopic laboratory.     

Major and minor injuries during the creation of pneumoperitoneum. A multicenter study on 12,919 cases

Background: Lap Group Roma was established in 1999 to promote and control the development of laparoscopic surgery in the area of Rome and its province. Complications during the creation of pneumoperitoneum were given a high priority of investigation, and a retrospective enquiry was immediately carried out. Methods: A questionnaire about all laparoscopic surgical practice performed from January 1994 to December 1998 was sent to the supervisors of 28 centers of general surgery in the area of Rome and its province participating to the Lap Group Roma, requesting demographics, type of procedure for the creation of pneumoperitoneum, type and timing of operation, and major vascular, visceral, and minor vascular injuries related to the creation of pneumoperitoneum. Results: The questionnaire was returned by 57% of the centers, for a total of 12,919 laparoscopic procedures. The type of procedure used to create the pneumoperitoneum involved a standard closed approach (Veress needle + first trocar) in 82% of the cases, an open (Hasson) approach in 9% of the cases, and the use of an optical trocar in 9% of the cases. There were seven major vascular injuries (0.05%), eight visceral lesions (0.06%), and nine minor vascular lesions (0.07%), for an overall morbility of 0.18%. There was no death related to these complications. The rate of complications differed significantly (p < 0.0001) depending on the type of approach used. It was 0.27% with the optical trocar (3 of 1,009 cases), 0.18% with the closed approach (20 of 10,664 cases), and 0.09% with the open approach (1 of 1,135 cases). Conclusions: There is no foolproof technique for the creation of pneumoperitoneum, and this inquiry confirms the need of a constant search for prevention and early treatment of complications encountered during this obligatory phase of any laparoscopic approach. A well-conducted and prolonged prospective audit of clinical practice could help in identifying the risk factors that can make an alternative approach (open or video controlled) preferable to the widely used closed approach. apd: 3 April 2001     

Aortic injury during diagnostic pediatric laparoscopy

Major vascular injury during laparoscopic procedures is a rare but catastrophic complication. We report a pediatric case of aortic laceration during the setup phase of diagnostic laparoscopy in a 5-year-old girl with recurrent abdominal pain. The Veress needle inserted below the umbilicus confirmed the proper placement by use of a saline-filled syringe. The abdomen was insufflated without difficulty. The first trocar was inserted at the same point as Veress needle. The video laparoscope was introduced, and a small amount of blood was seen in the abdomen. We converted the procedure to laparotomy immediately. There was a large retroperitoneal hematoma. The vascular laceration was identified at the origin of the iliac arteries. It was sutured with prolene 5/0. The girl was discharged without further complication on the 10th postoperative day. The incidence of major vascular injuries is 0.03% to 0.07%. The vessels most frequently involved are the aorta, the iliac arteries, the mesenteric vessels, and the vena cava. More than 400 cases have been reported in the literature, but only four of these involve pediatric patients. In the vast majority of cases, the complication took place during the setup phase of laparoscopy (75%), and were related to the introduction of either the Veress needle (30%) or the first umbilical trocar (43%), although the rate is opposite this in some studies.     

Direct trocar insertion technique: an alternative for creation of pneumoperitoneum.

OBJECTIVES: The direct trocar insertion technique (DTI) for the creation of pneumoperitoneum has been described as an alternative to open and Veress needle (VN) techniques. This study assesses the safety and feasibility of direct trocar insertion without a pre-existing pneumoperitoneum in patients undergoing elective laparoscopic procedures. METHODS: From November 2001 to February 2006, we retrospectively studied 196 (146 women and 50 men) consecutive patients. A single consultant laparoscopic surgeon performed all operations. The mean patient age was 57 years (range, 22 to 81). The procedures included 186 laparoscopic cholecystectomies, 3 laparoscopic appendectomies, 1 laparoscopic Nissen, 5 laparoscopic groin hernia repairs, and 1 conversion to open surgery. RESULTS: Creation of pneumoperitoneum with DTI was feasible in 99.5% of patients. No major complications were associated with the technique. Immediate minor postoperative complications included 1 (0.5%) wound infection and 3 (1.5%) hematomas. At mean follow-up of 23 months, 4 (2%) umbilical wound stitch granulomas and 1 (0.5%) incisional hernia from the umbilical port site were observed. CONCLUSION: This study shows that that when performed by an experienced laparoscopic surgeon the direct trocar insertion technique is a safe and effective alternative for creation of pneumoperitoneum.     

One-trocar laparoscopy

Background: The aim of this paper is to show the efficacy of laparoscopy using only one umbilical trocar to treat abdominal complications of hydrocephalic children with ventriculoperitoneal shunts (VPS). Materials and Methods: In a 15-year period, 14 laparoscopies were performed on as many children with VPS complications: in the last 4 patients only one trocar was used to solve the complications, and this subgroup will be the object of the present study. Concerning the indication for surgery, the patients presented one catheter lost in the abdominal cavity; one cerebrospinal fluid pseudocysts; one bowel obstruction; and one malfunctioning peritoneal limbs of the catheter. We used the one-trocar laparoscopic approach in all the 4 patients, and the 10-mm trocar was always introduced through the umbilical orifice in open laparoscopy. Results: The laparoscopic technique was curative in all four cases and permitted the solution of the complication. Conclusions: One-trocar laparoscopic surgery can be considered as the ideal procedure in case of abdominal complications of VPS in children with hydrocephalus.