Design: Video article of a major vascular lesion during laparoscopy first entry with Veress needle, reporting initial laparoscopic and subsequent laparotomic management.

Setting: Patient in supine decubitus with legs in a semi lithotomy position, under spinal and general anesthesia.

Patients or Participants: Female, 41 years old, BMI 42.1 kg/m², with history of three laparotomies, complaining of abnormal uterine bleeding, dysmenorrhea and dyspareunia and diagnosed with uterine fibroids and bilateral uterosacral ligament endometriosis by magnetic resonance imaging.

Interventions: The proposed treatment was total hysterectomy, bilateral salpingectomy and resection of endometriosis foci. There were multiple attempts to place the Veress needle, which led to a right common iliac artery injury resulting in a life-threatening hemorrhage that demanded an immediate management, requiring laparoscopic suture.

Measurements and Main Results: After the diagnosis of the lesion, the first step was to isolate the injured vessel and control the major bleeding with metallic clips, which allowed a wider dissection. Observing that the lesion affected a major vessel of arterial origin, the ligation of the vessel through a laparoscopic knot became necessary, given the infeasibility of performing laparotomy in time to control the bleeding, because of the high BMI and the history of multiple laparotomies, which hampers laparotomic access. After controlling the bleeding, the vascular surgery team could perform a laparotomy, identifying the lesion of the right common iliac artery. It was necessary to exert a segment of the artery with primary anastomosis. The patient progressed well with no lower limb sequels and received two units of packed red blood cells.

Conclusion: Initial laparoscopic management for major vascular injury should be considered in patients with difficult laparotomic access due to the need for immediate hemorrhage control. Proper anatomic knowledge and laparoscopic skills are essential for an optimal disclosure.