CASE 15152 Published on 13.12.2017

Life-threatening haemorrhage after laparoscopic hysterectomy

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, MD.

"Luigi Sacco" University Hospital,Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
Patient

54 years, female

Categories
Area of Interest Genital / Reproductive system female ; Imaging Technique CT
Clinical History
Middle-aged, postmenopausal female patient undergoing elective laparoscopic hysterectomy to manage uterine leiomyomas causing pelvic fullness and bloody spotting. Intraoperative findings of moderately enlarged, mobile uterus; normal adnexa and Douglas pouch. Surgery completed with colporrhaphy.
A day after surgery, worsening pelvic pain, stable vital signs, laboratory evidence of blood loss (haemoglobin drop from 11 to 8.6 g/dl).
Imaging Findings
Emergency multidetector computed tomography (CT) including unenhanced (Fig. 1) and CT-angiography (Fig. 2) acquisitions showed haemoperitoneum in the upper abdomen, and a vast hyperattenuating haematoma occupying most of the pelvis, causing compression on the urinary bladder. Within the haematoma, serpiginous contrast medium extravasation indicating active arterial bleeding was clearly detected.
Open surgery (performed 48 hours after laparoscopy) confirmed presence of nearly 1 litre of blood in the abdominal cavity, and identified arterial haemorrhage from the left-sided angle of the vaginal vault and small vessels of the ipsilateral ovarian pedicle which were treated by coagulation and suture.
Histopathology of hysterectomy specimen confirmed benign leiomyomas, the largest measuring 8 cm in size.
Discussion
Despite development of alternative non-surgical therapeutic options for benign disorders, hysterectomy remains one of the most prevalent interventions performed in women and the second most common gynaecologic operation after Caesarean section. Indications encompass several different disorders of the female reproductive system, including bleeding or symptomatic fibroids, adenomyosis, malignant tumours, endometriosis, postpartum haemorrhage, pelvic inflammatory disease and prolapse in descending order of frequency [1].
According to surgeon’s experience, parity, uterine size, mobility and underlying disease hysterectomy may be performed using either a transabdominal (open or laparoscopic), transvaginal or combined route, and may be completed with salpingo-oophorectomy and lymphadenectomy if required. Hysterectomy is associated with non-negligible morbidity, resulting in overall 3.7% 30-day rate of major complications with any technique, 0.17% mortality and 1.65% reoperation rate. Main risk factors include advanced age, comorbidities and cancer surgery. Compared to abdominal hysterectomy, both vaginal and laparoscopic hysterectomy (LH) are associated with shorter hospital stays, faster recovery, lower risks and morbidity. However, LH is time-consuming, requires great surgical skills, and carries a not-negligible risk of bleeding, urinary and bowel injury [2-4].
As in this case, multidetector CT effectively triages early iatrogenic complications after LH. Among these, haemorrhage may result from either uncontrolled bleeding at the site of vaginal cuff closure, or laceration of mesenteric or abdominal wall vessels (particularly the inferior epigastric artery) during Trocar or Veress needle insertion. Whereas self-limiting vaginal vault haematomas are not unusual and generally asymptomatic, severe bleeding may extend from the surgical site to the pelvis and abdominal cavity, and manifests with cause hypotension, blood loss and fever. Fresh blood is characteristically hyperdense due to its high protein content, and tends to increase in attenuation from clotting within a few hours [5-9].
Similarly to traumatic organ injuries, detection of serpiginous or amorphous active contrast medium extravasation in the either arterial or venous acquisition indicates ongoing bleeding and requires immediate, active treatment. If available, transcatheter embolisation of the uterine or internal iliac arteries is increasingly used for minimally invasive treatment of iatrogenic bleeding, and may obviate repeated surgery [10].
Differential Diagnosis List
Pelvic haematoma with active bleeding - early complication after laparoscopic hysterectomy
Vaginal vault haematoma
Abdominal wall haematoma from laparoscopic access
Peritonitis from iatrogenic bowel injury
Final Diagnosis
Pelvic haematoma with active bleeding - early complication after laparoscopic hysterectomy
Case information
URL: https://eurorad.org/case/15152
DOI: 10.1594/EURORAD/CASE.15152
ISSN: 1563-4086
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