Massive Intraoperative Bleeding after Laparoscopic Assisted Abdominoperineal Resection: A Case Report and Systematic Review of the LiteratureM. Beuran, B. Stoica, I. Tănase, I. Negoi, S. Păun
Clinical case, no. 2, 2015
Introduction: The laparoscopic-assisted abdominoperinealresection (LAPR) has been proved to be associated with ashorter postoperative recovery, with equivalent oncologicalresults and similar survival when compared with conventionalopen surgery, for patients with low rectal cancer.Method: Case report of a massive intraoperative bleedingduring LAPR and systematic review of the English languageliterature, using PubMed Medline, ISI Thopmson, OVID and EMBASE databases.Results: 58 years old patient admitted in emergency settingfor rectal bleeding. Rectal examination revealed a protruding,frail tumor, located 2 cm from the anal verge. Total colonoscopyrevealed an infiltrative, protruding tumor, situated at 2cm from the anal verge, with a 5 cm cranial extension,without any additional colonic lesions. ComputedTomography showed a 4,5 cm circumferential rectal wallthickening, without any enlarged mesorectal or abdominallymph nodes. The patient was transported to operating roomfor a LAPR. During final hemostasis, at the level of perinealsurgical wound, an acute massive bleeding occurred from thepresacral vessels with severe blood loss. This bleeding couldnot be managed laparoscopicaly and conversion to laparotomywas decided, with pelvic packing. At 48 hours after the initialsurgical approach, the tamponing packs were removed, withoutsigns of active bleeding. There were applied haemostaticagents and the perineal wound was sutured, without furtherbleeding during in-hospital stay.Conclusions: A rapid and effective control of the presacralbleeding is mandatory to prevent a fatal outcome. Pelvicpacking remains a life-saving procedure and the treatment ofchoice in severe cases.