Major blood vessel injury is a true emergency during endoscopic procedures. Too often, fear of litigation quashes the opportunity to assess the cause and learn from the experience of others. Frequently, only through a medicolegal review can such events be evaluated. A review of 47 such cases highlighted several key lessons. Proper technique for inserting the Veress needle, laparoscopic cannula, and open cannulas can prevent most accidents. If standard precautions during insertion are breached, safety shields on disposable cannula sleeves may not prevent or reduce the risk of major vessel injury. Distorted anatomy or steep Trendelenburg position may increase the risk. Retroperitoneal hematomas require exploratory laparotomy for proper assessment. Dissections around the great vessels of the pelvis require the same methods and precautions during laparoscopy as during laparotomy.