A rare case of life-threatening extra-peritoneal bleeding a.

INTRODUCTION: Although inguinal hernia repair is a routine procedure and frequently performed as one-day surgery, we should be particularly aware of the possible complications, which could be life-threatening if not recognized in due course. CASE REPORT: We report a case of life-threatening extra-peritoneal bleeding after open inguinal hernia repair requiring damage control surgery. DISCUSSION: Several vessels can be responsible for massive extraperitoneal bleeding - external iliac vessels, lower epigastric artery, crema steric vessels and corona mortis. Although damage control surgery was developed to treat the severe trauma, it can also be a life-saving maneuver in cases as the presented one. Hemodynamic instability with distended abdomen is a primary indication for laparotomy, but in some cases the contrast CT provides valuable information about the location and the size of hematoma and can guide the operative approach - midline laparotomy or revision of the wound as in our case. To the best of our knowledge, this is the first reported case of life-threatening retroperitoneal bleeding after open inguinal hernia repair. The present case is a good example for the application of damage control in pathology considered as one-day surgery. CONCLUSIONS: Although casuistic, the life-threatening bleeding after open hernia repair should be suspected. The prompt surgical response with damage control can be life-saving maneuver even in the routine hernia surgery. Detailed knowledge of the anatomy and carefull dissection are required to avoid this kind of complications.

[LAPAROSCOPIC PLASTY OF INGUINAL HERNIAS].

Laparoscopic hernioplasty, of them in 19 - for recurrence of hernia after auto- (in 10) and alloplasty in accordance to Liechtenstein procedure (in 9), and in 11, suffering bilateral hernias - were performed in 2011-2016 yrs in 149 patients. All the patients are alive. Complications have occurred in 21 patients. The main technical complexities have occurred in injury of upper epigastric vessels. Оperative interventions, using laparoscopic procedures are effective, pathogenetically substantiated, guaranteeing comfortable course of postoperative period and possibility of early rehabilitation of the patients.

Safe introduction of ancillary trocars in gynecological surgery: the "yellow island" anatomical landmark.

AIM: This technical note aims to suggest a safe introduction of ancillary trocars in gynaecological surgery, in order to prevent inferior epigastric artery damage. MATERIAL OF STUDY: We performed a narrative overview, synthesizing the findings of literature retrieved from searches of computerized databases. RESULTS: Among the different techniques, the identification of the "yellow island" as anatomical landmark seems to be a useful aid to avoid complication. This particular landmark is identified taking the lateral third of a line between the anterior superior iliac spine and the umbilicus as reference points, by a subperitoneal accumulation of adipose tissue located in that area. DISCUSSION: "Yellow island" could be considered a safe place for trocars introduction because epigastric artery never runs there, even in patients with particular anatomical variants. This technique is particularly useful in obese patients, in which "yellow island" appears to be more evident respect to lean ones. Furthermore, the use of "open" trocars insertion may reduce the possibility of epigastric artery lesions respect to "Verres needle technique". CONCLUSION: The identification of the "yellow island" anatomical landmark could be considered an useful aid for the safe introduction of ancillary trocars in gynaecological surgery. KEY WORDS: Gynaecology, Laparoscopic surgery, Trocars placement.

Inferior epigastric artery: Surface anatomy, prevention and management of injury.

The anatomical position of the inferior epigastric artery (IEA) subjects it to risk of injury during abdominal procedures that are close to the artery, such as laparoscopic trocar insertion, insertion of intra-abdominal drains, Tenckhoff(®) catheter (peritoneal dialysis catheter) and paracentesis. This article aims to raise the awareness of the anatomical variations of the course of the IEA in relation to abdominal landmarks in order to define a safer zone for laparoscopic ancillary trocar placement. Methods of managing the IEA injury as well as techniques to minimise the risk of injury to the IEA are reviewed and discussed.

Well differentiated neuroendocrine tumor of the appendix and low-grade appendiceal mucinous neoplasm presenting as a collision tumor

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[Vascular complications after pelvic rami fracture]. / Complicación vascular tras fractura de ramas pélvicas.

The case is presented of a 78 year-old patient who suffered a right ileo- and ischiopubic rami fracture after a casual fall. A few hours later, she presented with sudden abdominal pain and hypotension. Imaging test showed extraperitoneal hemorrhage with active bleeding and hemodynamic compromise. The progressive worsening, with anemia and hemodynamic instability, required her being sent to the reference hospital for selective embolization of the bleeding point. After embolization, the patient́s situation stabilized, and she was then able to sit down one week later. The fracture consolidated 3 months later. Although low-energy pelvic fractures by lateral compression do not usually present with complications, sometimes they require a strict control due to the potential risk of vascular injuries.

An unusual cause of acute abdominal pain in dengue fever.

Dengue fever is an acute febrile viral disease caused by the bite of Aedes aegypti mosquito. It is a major health problem especially in tropical and subtropical areas including South East Asia and Pakistan. In the past few years, dengue fever has been endemic in Northern Punjab. Physicians managing dengue fever come across varied and uncommon complications of dengue fever. We report a case of dengue fever that developed severe right upper quadrant abdominal pain and induration after extreme retching and vomiting for 2 days. A rectus sheath hematoma was confirmed on noncontrast computed tomography (CT). Rectus sheath hematoma as a complication of dengue fever has rarely been reported before and never from this part of the world. Rectus sheath hematoma is an uncommon and often clinically misdiagnosed cause of abdominal pain. It is the result of bleeding into the rectus sheath from damage to the superior or inferior epigastric artery or their branches or from a direct tear of the rectus muscle. It can mimic almost any abdominal condition (See Fig.) (See Table).

Flap survival after previous vascular pedicle division and preexisting scar formation at the pedicle site: an experimental study.

BACKGROUND: We conducted an experimental study to investigate if it would be possible to re-elevate a flap at a standard flap site if its vascular pedicle was mutilated previously and there was a preexisting scar formation at the pedicle site. MATERIALS AND METHODS: Thirty-five male Sprague-Dawley rats were divided into 3 groups. In the control group (n = 5), animals received a procedure in which unilateral axial pattern abdominal flap was elevated, and then sutured to its original place. The remaining 2 groups underwent 2-stage procedures. In the first stage, scar tissue was created with either a skin incision (group 2, n = 15) or excision (group 3, n = 15) at the prospective pedicle site of the abdominal flap. In the second stage, abdominal flap was raised in 5 rats as a scar-pedicled flap at day 7, day 21, and day 42. Flaps were sutured in their places. Seven days later, flap survival was evaluated. RESULTS: Control flaps had complete survival (day 7, 95.5%; day 21, 94.8%; and day 42, 94.5%). Group 2 and group 3 flaps raised on day 7 (group 2, 65.4%; group 3, 63.9%) and on day 21 (group 2, 65.7%; group 3, 66.7%) showed decreased survival compared to control group flaps (P < 0.05). On day 42, group 1 flaps had better survival when compared to group 2 flaps (82.6% vs 70.0%, P < 0.05). Group 1 flaps showed progressive vascular network formation as evidenced by contrast medium first in the proximal two thirds of the flaps on day 7, and later via visualization of the axial pattern vascular tree on day 42. In group 3, approximately half of the flap was filled with barium contrast and no single pedicle was identified on day 42. CONCLUSIONS: Preexisting scar tissue and pedicle division in the pedicle site of a standard flap diminished dimensions of surviving flap when compared to control flaps. Incision-scar-pedicled flaps achieved better survival compared to excision-group flaps, particularly in the late postoperative period. The study findings showed that it may be possible to raise a flap from previously mutilated site secondary to scar formation and pedicle injury.

Retroperitoneal hematoma after manual reduction of indirect inguinal hernia.

This report presents the case of a 59-year-old man with sudden severe pain in the right lower abdomen after manually reducing the right indirect inguinal hernia who had bilateral indirect inguinal hernia for 5 years. A subsequent contrast computed tomography scan with contrast of the abdomen and pelvis revealed a significant extensive retroperitoneal hematoma at the abdomen and pelvis of the right side. There was contrast leaked out, which was suspected from inferior epigastric artery. He underwent successful laparotomy. The bleeding ruptured inferior epigastric artery at the interior side of the deep inguinal ring was found, the deep inguinal ring was avulsed, ligature of the inferior epigastric artery and removal of the retroperitoneal hematoma were done, and the patient was discharged from hospital on the seventh postoperative day. This is the first report in the literature on retroperitoneal hematoma caused by manual reduction of indirect inguinal hernia.

Corona mortis: anatomical data and clinical considerations.

BACKGROUND: Minimally invasive procedures, such as the TVT-Secur™, have been linked to injury to the corona mortis. Injury during the insertion of the TVT-Secur™ happens due to the vessel's position close to the place of the margin (25-30 mm from the symphysis pubis). AIMS: Systematic description of the aberrant vessel anatomy so as to help gynaecologists determine the risk of peri- and postoperative complications during the TVT-Secur™ and related procedures. METHODS: In a cadaver study, the lesser pelvis of ten female cadavers with venous or arterial coronae mortis was dissected. The origin, diameter and course of the aberrant vessels, as well as the distance from the symphysis pubis, were documented. RESULTS: Arterial coronae mortis were found in eight hemipelvises. All vessels originated from the ipsilateral inferior epigastric artery and all crossed over the superior pubic rami. Average distance from the symphysis pubis was 52.4 mm. Average vessel diameter was 3 mm. Venous coronae mortis were identified in ten hemipelvises. Eight drained into the external iliac and four into the inferior epigastric artery. Nine vessels crossed over the superior pubic rami. Average distance from the symphysis pubis was 46.7 mm. Average vessel diameter was 3.13 mm. CONCLUSION: Although individual variation makes direct contact with the vessel possible, in most cases there is a window of eight millimetres at least between the margin of the TVT-Secur™ and most aberrant veins. Possible aberrant arteries seem to lie even further.

Making paracentesis safer: a proposal for the use of bedside abdominal and vascular ultrasonography to prevent a fatal complication.

Paracentesis has been considered a relatively safe procedure; however, hemorrhagic complications do occur and can be fatal, especially in the context of coagulopathy. We describe the case of a 47-year-old man with coagulopathy secondary to end-stage liver disease, whose hospital course was complicated by paracentesis-related hemoperitoneum leading to abdominal compartment syndrome. Emergent laparotomy revealed left inferior epigastric artery laceration caused by paracentesis. Despite operative control of bleeding, postoperatively, the patient developed severe metabolic acidosis, disseminated intravascular coagulation, and ultimately died from complications of hemorrhagic shock. Understanding key anatomic structures is essential for patient safety in the setting of paracentesis. While recognizing the lack of clinical studies demonstrating the effectiveness of ultrasonography use in paracentesis, we discuss the benefit of bedside abdominal ultrasonography to locate ascites and avoid intraabdominal structures, as well as vascular ultrasonography, during needle insertion to avoid abdominal wall vessels.

Transcatheter arterial embolisation for haemorrhage from the inferior epigastric artery after acupuncture: a case report.

We report a rare case of haemorrhage from the inferior epigastric artery, which was injured after acupuncture. The haemorrhage was successfully controlled by transcatheter arterial embolisation. To the best of our knowledge, this is the first report describing the use of transcatheter arterial embolisation for inferior epigastric artery haemorrhage following acupuncture.

Percutaneous management of inferior epigastric artery injury after cardiac catheterization.

Inferior epigastric artery injury after cardiac catheterization and percutaneous coronary intervention is sporadically reported in the literature, yet it is a serious complication that can lead to life-threatening retroperitoneal hemorrhage and poor clinical outcomes after percutaneous coronary intervention. We present two cases of inferior epigastric artery injury from inadvertent puncture during cardiac catheterization and a discussion in the management and prevention of this potentially fatal complication.