Design: Case Presentation

Setting: Operating room at a tertiary academic medical center

Patients or Participants: A 45 year old gravida 2 para 2 with symptomatic fibroid is counseled for a robotic hysterectomy. Her postoperative course was complicated by hemorrhagic shock secondary to veress/trocar entry at the umbilicus, causing an injury to a variant medial branch of the inferior epigastric artery.

Interventions: Embolization by interventional radiology and laparoscopic evacuation of hematoma

Measurements and Main Results: Resolution of bleeding from medial branch of the inferior epigastric artery

Conclusion: Trocar insertion rarely causes injury to major blood vessels such as inferior vena cava, aorta, and iliac vessels. The most common injury to blood vessel is inferior epigastric artery, which was reported to be 0.2 - 2% of laparoscopic injuries. Identification of anatomic landmarks typically help surgeon placed trocars in same areas to performed laparoscopic or robotic surgery. Understanding the course of inferior epigastric artery will help minimize these injuries. This unique case demonstrates that despite understanding the main course of the artery, there is a 10% incidence of a medial branch of the inferior epigastric artery crossing the midline and can lead to trauma of this vessel at the umbilicus. It is important to be aware of variant anatomy as well as management options when an injury to an artery is identified.