CASE REPORT


https://doi.org/10.5005/jp-journals-10006-1739
Journal of South Asian Federation of Obstetrics and Gynaecology
Volume 11 | Issue 6 | Year 2019

Large Port-site Hematoma Following Laparoscopic Surgery and Its Management


Ajay Agrawal1, Marie Christine Valerie Mendoza2, Kuang-Gen Huang3

1Department of Obstetrics and Gynecology, BP Koirala Institute of Health Sciences, Dharan, Kosi (Anchal), Nepal
2Department of Obstetrics and Gynecology, Philippine General Hospital, Manila, Metro Manila, Philippines
3Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan, Republic of China

Corresponding Author: Kuang-Gen Huang, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan, Republic of China, Phone: +886 975365887, e-mail: kghuang@ms57.hinet.net

How to cite this article Agrawal A, Mendoza MCV, Huang K-G. Large Port-site Hematoma Following Laparoscopic Surgery and Its Management. J South Asian Feder Obst Gynae 2019;11(6):397–399.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Background: Acute hemorrhage and delayed hematoma formation from laparoscopic port sites are uncommon but can be potentially significant complications. They become evident in days 2–6 postoperatively, manifesting as visible bruises, excessive pain, or an asymptomatic drop in hematocrit. Bleeding into the abdominal wall leading to giant abdominal wall hematoma requiring blood transfusion, prolonged hospitalization, and emergency surgical procedures is rare.

Case description: A woman who had successful second look laparoscopic surgery following debulking surgery for ovarian malignancy developed a large subcutaneous hematoma. She presented after 25 days of discharge from the hospital and was managed by incision and drainage.

Results: Exploration of the wound was done with evacuation of blood clots amounting to 300 cc. There was no identifiable bleeding point. The patient had an unremarkable postoperative course after the incision and drainage and was discharged after 2 days.

Conclusion: Sound techniques of port placement along with a thorough understanding of the anterior abdominal wall anatomy are crucial to prevent laparoscopic port-site hematoma.

Keywords: Complication, Laparoscopy, Port-site hematoma.

INTRODUCTION

Progress in the use of laparoscopy has led to the development of more advanced procedures requiring placement of many trocars through the abdominal wall. In laparoscopic gynecologic surgery for malignancy, usually four lateral accessory ports beyond the umbilicus are utilized, which is reported to be safe and feasible.1 Trocar injury resulting in acute hemorrhage and delayed hematoma from the port sites are uncommon but are potentially serious complications that can be prevented. However, though rare, the secondary puncture sites are responsible for anterior abdominal wall vascular injuries particularly to the inferior epigastric artery (IEA). Most of the time, these injuries are unrecognized during laparoscopy due to the tamponade effect of the cannula and the pneumoperitoneum and the reduction in venous return attributable to the steep Trendelenburg position in which the patient is placed. They become evident in days 2–6 postoperatively by visible bruises, excessive pain, or an asymptomatic drop in hematocrit. Bleeding into the abdominal wall leading to a giant abdominal wall hematoma requiring blood transfusion, prolonged hospitalization, and emergency surgical procedures is rare.

A woman who had successful second look laparoscopic surgery following debulking surgery for ovarian malignancy developing a large subcutaneous hematoma and its management is being reported. Consent was taken from the patient for the purpose of case report. Ethical committee of Chang Gung Memorial Hospital, Linkou, Taiwan, ruled out the need for ethical clearance for this case report.

CASE DESCRIPTION

This is an 83-year-old female with underlying ovarian cancer with history of debulking staging surgery with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and para-aortic lymph node dissection done 1 year back through a midline abdominal incision. Histopathological examination revealed ovarian mucinous cystadenoma with focal borderline features. The adnexal and harvested lymph nodes were negative for malignancy.

Four months after the debulking surgery, she presented with progressive bilateral pretibial pitting edema and abdominal distension for 2 months. There was associated diffuse abdominal pain without aggravating or relieving factors. There were no other systemic symptoms. On examination, she was weak-looking, but her vital signs were within normal range. She had grade III pitting lower limb edema and rebounding pain. Abdomen was distended without superficial vein engorgement. Abdominal pain was diffuse and dull aching. Abdominal computed tomography (CT) scan was arranged, which was compatible with cancerous peritonitis, splenic metastasis, and extensive subcutaneous edema. Imaging of the liver or pancreas was negative for liver cirrhosis. Laboratory data showed mild elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia, prolonged prothrombin time, and normal renal function.

Fig. 1: Large port-site hematoma

Fig. 2: Sonography shows 10-cm hematoma in subcutaneous space

Fig. 3: Left lower trocar inserted adjacent to inferior epigastric vessels (yellow moon)

With the impression of ovarian cancer recurrence with peritoneal carcinomatosis, she was admitted for second look laparoscopy. On laparoscopic examination, there was no carcinomatosis or any nodule in the abdominal and pelvic cavity. Liver was normal in size, but features of cirrhosis were noted.

Peritoneal fluid was sent for cytology which was negative for malignancy. She did well in the postoperative period. With the diagnosis of normal size liver cirrhosis, she was managed and discharged home. Twenty-five days after discharge, she presented to the emergency room with complaints of lower abdominal pain. Her vital signs were stable, but on abdominal examination, there was a large 10 × 10-cm swelling over the left lower abdominal region surrounding the left lower lateral trocar insertion site (Fig. 1). Abdominal sonography was done which showed left trocar site hematoma measuring 9 × 10 cm (Fig. 2). Under the impression of subcutaneous hematoma, exploration of hematoma and drainage was performed under spinal anesthesia. A 1.5-cm incision was done over the previous left lower abdominal trocar wound, and blood clots amounting to 300 cc were drained. The hematoma cavity was checked using a 5-mm telescope, and no apparent bleeding point was seen. A subcutaneous drain was placed, and the wound was closed with 2-0 polygalactin suture. The postoperative period was uneventful with removal of the abdominal drain the next day. She was discharged after 2 days in stable condition and followed up after 1 month in the outpatient clinic with no recurrence of hematoma or other bleeding problems.

DISCUSSION

Port-site bleeding due to inferior epigastric vessel injury has been reported in 0.2–2% of patients.24 Bleeding from the trocar area due to vessel damage can be detected as soon as the trocars are inserted. There can be bleeding around the port site or blood can be seen dripping along the shaft of the cannula. Measures to control hemorrhage such as use of direct electrocoagulation, tamponade with inflated balloon of the Foley catheter through the trocar site, or full-thickness abdominal wall sutures can be employed. Occasionally, vessel tear may not be immediately diagnosed because of pressure from the cannula itself which can only be revealed after cannula removal at completion of surgery.

Bleeding is usually associated with insertion of the most lateral port. This port is typically inserted under direct vision with overhead lights turned off. Pressing the light source firmly against the lateral abdominal wall from the inside to illuminate the area of intended port insertion on the outside can aid in proper visualization of the major subcutaneous vessels and injury can be avoided. However, this may not possible in obese patients. This simple yet essential technique dramatically reduces the chance of port-site bleeding. Avoiding oblique entry and understanding the course of the IEA in relation to easily identifiable bony surface landmarks help in minimizing injury to IEA. A retrospective review of the video recording of the index patient revealed that the lower lateral accessory port was placed just adjacent to the inferior epigastric vessels which was injured during manipulation though there was no immediate bleeding during insertion at that time (Fig. 3).

The IEA originates from the external iliac artery immediately above the inguinal ligament. It courses superiorly and medially toward the umbilicus. It lies just medial to the round ligament as the ligament passes through the deep inguinal ring into the inguinal canal and lateral to the obliterated umbilical vessels. It pierces the fascia transversalis to enter the rectus sheath anterior to the arcuate line. It ascends behind the rectus muscle, supplying the lower central part of the anterior abdominal wall, and anastomoses with the superior IEA.5 The superficial epigastric vessels originate from the femoral artery just below the inguinal ligament. They pass through the saphenous opening in the fascia lata and ascend onto the abdomen in the superficial fascia covering the external oblique muscle. The vessels ascend almost to the level of the umbilicus.5

Direct visualization transperitoneally is the ideal approach to avoid inferior epigastric vessel injury during laparoscopic accessory trocar placement. The trocar should be inserted lateral to the vessels at a 90° angle to the abdominal wall. Where it is not possible to visualize the vessels, for example, in obese patients, methods of transillumination and identification of surface landmarks are often relied on. Transillumination can identify the superficial epigastric vessels, and these vessels follow a course similar to the deeper inferior epigastric vessels and can serve as surrogate to guide safe placement of the lateral ports. The surgeon should also directly visualize the removal of accessory trocars and not just during initial trocar entry, as this may reveal inadvertent bleeding points at the end of surgery under lower intra-abdominal pressure.

Computed tomography angiographic studies have been conducted to localize the course of IEA in relation to fixed landmarks such as the mid-inguinal point, anterior superior iliac spine (ASIS), and umbilicus.6 The secure distance for safe trocar placement has been suggested to be more than 6 cm at the level slightly superior to the ASIS and more than 9 cm from the midline at the level of umbilicus.68 Injury to IEA can lead to mild to severe hemorrhage and can also result in grave sequelae like necrosis of rectus abdominis muscle and ischemia of the lower limbs as IEA is an important collateral supply to the leg.9

Delayed complication of IEA injury leading to hematoma like the index case can be managed by incision and drainage of hematoma and exploration of the wound. Ligation of identified bleeders should be done, but most of the time, there is no detectable bleeder. A subcutaneous drain can be placed in the dead space after evacuation if one is in doubt about recurrence of bleeding. Drainage of hematoma rather than conservative management by compression will avoid bruising and discoloration of skin of abdomen and thigh as well as risk of infection.

CONCLUSION

Sound techniques of port placement along with a thorough understanding of the anterior abdominal wall anatomy are crucial. Knowledge of the course of abdominal wall vessels and the possibility of variations in the origin of these vessels can determine the safe areas for trocar placement at specific anatomic sites to minimize the risk of abdominal vessel injuries. In cases of inferior epigastric vessel injury leading to large hematoma formation, exploration of the wound and incision and drainage may be performed.

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