Persistent pseudoaneurysm after non-operative management of a Grade 4 liver injury.

A hepatic pseudoaneurysm (HPA) after blunt or penetrating liver injury is an unusual but potentially lethal complication that can develop from an injured hepatic artery branch [1-5]. Endovascular intervention with coil embolization to treat HPA is a safe and effective method and has become the standard first-line treatment, with a success rate achieving 70-100 % [13,14,15]. Infrequently the pseudoaneurysm is fed by collateral vessels and endovascular intervention may be unsuccessful. Other minimally invasive treatment options that can be considered include image guided percutaneous thrombin injection, endovascular placement of covered stents and injection of liquid agents such as fibrin glue [10,11]. We present a case of a young female who developed a post-traumatic persistent hepatic pseudoaneurysm requiring a total of nine interventions, including six endovascular interventions with angiography, three endoscopic procedures for bleeding, one percutaneous injection, and two re-admissions to the hospital. Although she avoided initial operative management, her three-month hospital course can be considered a failure of conservative management of blunt hepatic trauma due to the accrued health care costs and resources. The literature on the management of persistent pseudoaneurysm is limited. The decision to treat a persistent HPA that are found incidentally and stable in size needs further investigation.

Major Bleed Post Minimally Invasive Surgical Repair of Inguinal Hernia.

At our center, over 200 patients undergo minimally invasive repairs of inguinal hernias every year using a laparoscope and a robotic-assisted technique. In three patients who underwent a minimally invasive procedure for uncomplicated indirect inguinal hernia, the postoperative course was complicated with bleeding and required an exploratory laparotomy. Post-procedure, the patients developed tachycardia and hypotension with a drop in hemoglobin, for which the patients required surgical re-exploration in an emergent fashion. The factors leading to bleeding were analyzed and are reported herein to increase awareness and prevent the occurrence of these complications during inguinal hernia surgery.