Post-Operative Hemorrhage From Surface of Prostate: an Unusual Complication After Pre-Peritoneal Laparoscopic Inguinal Hernia Repair

Sarah C Oltmann, MD, Mark J Watson, MD. University of Texas Southwestern Medical Center

INTRODUCTION
It has been described that laparoscopic inguinal hernia repair carries greater risk of bleeding complications when compared to open inguinal hernia repairs. This is most commonly found to originate from the epigastric vessels on the anterior abdominal wall. We describe a case of unusual post operative bleeding following laparoscopic inguinal hernia repair.
METHODS AND PROCEDURES
A case report of an unsual site of hemorrhage after a pre-peritoneal laparoscopic inguinal hernia repair.
RESULTS
A 74 year old male was referred for a small, painful, reducible right inguinal hernia. His past history was significant for benign prostatic hypertrophy and difficulty with urinary retention after previous operations. His surgical history included a left inguinal hernia repair with mesh and right shoulder surgery. He underwent laparoscopic pre-peritoneal inguinal hernia repair. Initial inflation of the balloon trochar was difficult, and hemorrhagic staining of the perperitoneal fat was noted at the pubic symphysis. No bleeding was noted through the case. Four hours post op, patient was complaining of lightheadedness and dizziness and was noted to be hypotensive. Lower abdominal exam showed some fullness with tenderness, and the patient reported rectal urgency. He was taken back to the OR and a lower midline incision was created. Over a liter of clotted blood was evacuated. The epigastric vessels and anterior abdominal wall were without bleeding. The polypropylene mesh was removed and dark blood was found to pool beneath the symphasis pubis. The urinary bladder was retracted posteriorly and bleeding appeared to emanate from the anterior surface of the prostate which was enlarged. This was controlled with electrocautery and topical hemostatic agents. The hernia was subsequently repaired by giant prosthetic reinforcement of the visceral sac. Six units of packed red blood cells were transfused intraoperatively, and an additional one post-op. The patient recovered uneventfully and has returned to full activities.
CONCLUSIONS
The approach of laparoscopic inguinal hernia repair evolved from TAPP, TransAbdominal PrePeritoneal repair to TEP, Totally ExtraPeritoneal hernia repair early in its development. An inflatable dissection balloon, used for the extraperitoneal exposure, has been found superior to simple blunt dissection. Several balloon models are available for this preperitoneal dissection. In this particular procedure, the dissection balloon was likely advanced below the symphasis allowing stretching of the venous plexus anterior to this enlarged prostate during initial attempts at inflation. Pneumatic insufflation of the preperitoneal space likely tamponaded the small vessels during the procedure which began to hemorrhage at the completion the case when the insufflation was released.
Care should be exercised in dissection balloon placement that does not allow advancement posteriorly past the symphasis pubis. This can be especially relevant in those patients with BPH, where the prostate may be in close proximity to the posterior surface of the pubis symphasis.