Laparoscopic Hemostasis and Management of Following Pseudoaneurysm for Inferior Epigastric Artery Injury

Abstract

<h3>Study Objective</h3> An inferior epigastric artery (IEA) injury may occur during laparoscopic surgery, however the pseudoaneurysm of the IEA is a rare condition. We will report a case of hypovolemic shock due to injury of IEA during surgical drain placement, which was managed successfully with percutaneous coil embolization after a relapse scenario. <h3>Design</h3> A case report. <h3>Setting</h3> Gynecology and Obstetrics department of a general hospital. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> A 40-year-old, G0 woman underwent laparoscopic- assisted myomectomy after 4 courses of GnRH agonist for multiple uterine fibroids. The weight of the removed fibroids was 600g and a low-pressure continuous suction drain was placed in the lower left abdomen. The initial postoperative course was uneventful, however the patient presented with hypovolemic shock immediately after the removal of the drain tube which had inadvertently penetrated left IEA on post-operative day 1. Emergency laparoscopy was performed and hemostasis was obtained by compression suture at the distal and proximal areas of the IEA injury site using a straight needle from the abdominal wall. A computed tomography scan on post-operative day 2 revealed a 6mm-pseudoaneurysm arising from the left IEA. This disappeared spontaneously during conservative observation, and the patient was discharged on post-operative day 16. However, two weeks postoperative, an emergency percutaneous coil embolization was needed because of relapse of the pseudoaneurysm. Following this repair surgery no further postoperative relapse or complications were observed. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> The IEA is located 4 to 8cm from the midline on average. Direct visualization is preferred, however anatomical landmark of the anterior sacral iliac spine or midline is an alternative technique if visualization is not possible. Pseudoaneurysm may have a risk of subsequent rupture and cause life-threatening bleeding, therefore accurate evaluation and adequate treatments are required for vessel injuries. Coil embolization can be a relatively safe and optimal management for pseudoaneurysm as a minimally invasive procedure.