Hemorrhage Control Following Laceration of Inferior Upper Epigastric Vessels

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Hemorrhage Control Following
Laceration of Inferior Upper
Epigastric Vessels

With the use of multiple trocar insertion through the abdominal wall, especially the left and right lower quadrants of the abdomen, there is a significant chance of the trocar injuring the inferior epigastric vessels located on the lateral aspects of the rectus abdominis muscle. Laceration of these vessels creates a significant abdominal wall hematoma. If the tears in the subfascia and peritoneum are significant, uncontrolled bleeding from the inferior epigastric vessels may enter the peritoneal cavity, and the patient could progress into hypovolemic shock without the appearance of an abdominal wall hematoma.

Before resorting to a laparotomy to control the bleeding, the surgeon is advised to first attempt hemorrhage control with a simple procedure using equipment available in any hospital, i.e., a Foley catheter and Kelly clamp.

Physiologic Changes. The changes are those of blood loss.

Points of Caution. Care must be utilized to select a Foley catheter that will easily fit the trocar sheath. After the hemorrhage has been controlled, the patient must be admitted to the hospital for close observation to ensure that the inferior epigastric vessels are adequately entrapped between the balloon of the Foley catheter and the Kelly clamp placed adjacent to the skin.

Technique

The frontal view shows the relationship between the rectus muscle, the inferior epigastric vessels, and the insertion of a laparoscopic trocar in the lower quadrant of the abdomen. The cross-sectional view shows the relationship between the skin, rectus fascia, rectus muscle, inferior epigastric vessels, and the trocar hat has perforated these vessels.

The trocar is withdrawn from the trocar sleeve. A Foley catheter is inserted down the trocar sleeve, and the balloon is inflated.

The trocar sleeve is advanced up the shaft of the Foley catheter, and traction is placed ventrally on the Foley catheter against the abdominal wall from within the abdominal cavity outward. The balloon is tightly lodged against the bleeding vessels to control hemorrhage.

To maintain the traction and thus the pressure on the bleeding vessels, a Kelly clamp is applied to the catheter adjacent to the abdominal wall skin. The catheter balloon remains in place for 24-36 hours, after which the Kelly clamp is released, the balloon on the Foley is deflated, and the catheter is withdrawn from the wound. Additional observation is required to ensure that the bleeding is controlled. In most cases, this technique will control the bleeding without laparotomy.