Testicular Artery Hemorrhage after Inguinal Hernia Repair

Testicular Artery Hemorrhage after Inguinal Hernia Repair

Volume 25 ’ Number 5 ’ May ’ 2014 REFERENCES 1. Eisenberg E, Carr B, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: ...

1MB Sizes 0 Downloads 34 Views

Volume 25



Number 5



May



2014

REFERENCES 1. Eisenberg E, Carr B, Chalmers TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg 1995; 80: 290–295.

Testicular Artery Hemorrhage after Inguinal Hernia Repair From: Ahmed Sheikh, BA David Klyde, MD Sohail Contractor, MD Rutgers Biomedical and Health Sciences University Rutgers, The State University of New Jersey University Hospital H 108 150 Bergen Street Newark, NJ 07101

805

2. Kambadakone A, Thabet A, Gervais DA, et al. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics 2011; 31:1599–1621. 3. Kane NM, Korobkin M, Francis IR, et al. Percutaneous biopsy of left adrenal masses: prevalence of pancreatitis after anterior approach. AJR Am J Roentgenol 1991; 157:777–780.

Complications of inguinal hernia surgery include injury to bladder, bowel, vas deferens, and vasculature of the inguinal canal (1). Vascular injury during inguinal hernia repair can occur by damage to any of the following vessels: rectus muscle vessel, inferior epigastric vessels, venous plexus at the pubic symphysis, aberrant obturator vein, testicular vessels, and iliac vessels (1). Figure 4 illustrates some of the vascular structures supplying the inguinal canal. Injury to the inferior epigastric and other pelvic vessels during surgical dissection or stapling of the mesh can result in bleeding (2). Avoidance of traction and preperitoneal

Editor: This report met criteria for institutional review board exemption at our institution. A 56-year-old man with no significant past medical or surgical history underwent elective left hernia surgery with a standard Lichtenstein open mesh repair. He became unstable 4 hours postoperatively with a systolic pressure of 70 mm Hg and a pulse of 130 and suprapubic and left lower quadrant discomfort. Abdominal examination revealed fullness in the left lower quadrant. A decrease in hemoglobin level from 15 g/dL to 8.1 g/dL was observed. Blood transfusions were initiated, and exploratory surgery was performed, which failed to reveal active bleeding. A preperitoneal hematoma with expressible blood clots from the internal ring was noted. Surgical packing was attempted with a transient response, and the patient was subsequently transferred to interventional radiology. A left pelvic and femoral angiogram failed to reveal hemorrhage. A subsequent aortogram showed extravasation from the distal left testicular artery 10–12 cm cephalad to the operative site (Fig 1). The left testicular artery was selectively catheterized with a 5-F SOS Omni catheter (AngioDynamics, Queensbury, New York), and brisk hemorrhage from the distal vessel was seen (Fig 2a, b). Subselective catheterization using a 3-F microcatheter (Renegade Hi-Flo; Boston Scientific, Natick, Massachusetts) and embolization using flow-directed absorbable gelatin sponge (Gelfoam; Ethicon, Somerville, New Jersey) slurry infusion until stasis were performed (Fig 3a, b). No further evidence of clinical bleeding was seen. However, the patient developed an ischemic left testicle and underwent left orchiectomy. He was discharged 8 days later and was healthy at follow-up evaluation at 2 months.

None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.12.003

Figure 1. Aortogram demonstrates extravasation from the testicular artery above the inguinal canal (arrow).

806



Letters to the Editor

Sheikh et al



JVIR

Figure 2. Nonselective (a) and selective (b) testicular angiograms demonstrate the area of extravasation from the distal testicular artery (arrow).

Figure 3. Nonselective (a) and selective (b) testicular angiograms demonstrate no further extravasation from the testicular artery (arrows).

dissection caused by pneumoperitoneum are important in preventing this injury. The spermatic vessels may sustain injury when dissecting the spermatic cord. The spermatic cord should not undergo excessive traction,

and hemostasis of bleeding cord vessels should be secured to avoid postoperative hematomas (2). To our knowledge, testicular artery hemorrhage after inguinal hernia repair has not been reported in the literature.

Volume 25



Number 5



May



2014

807

Figure 4. Line diagram outlining the vascular supply in relation to the inguinal canal.

Testicular artery hemorrhage generally is a rare occurrence. In one reported case of testicular artery hemorrhage after radical orchiectomy, retroperitoneal bleeding was seen and treated using selective Gelfoam embolization of the testicular artery (3). In two other reported cases of testicular artery hemorrhage, bleeding was secondary to loss of adequate control of the testicular artery during an orchiectomy in one case and was thought to result from either an endoscopic duodenal perforation or injury during a drainage catheter exchange in the second case (4). Treatment was selective coil embolization of the testicular artery with no report of testicular infarction. The authors stated the need to achieve proximal and distal embolization around the site of the identified vascular injury given the collateral supply to testicular artery from the cremasteric artery (branch of inferior epigastric artery) and artery to the ductus deferens (branch of superior vesical artery). The collateral supply also allows for ligation of the testicular artery during surgery without resulting testicular ischemia (4).

Our patient presented with testicular artery hemorrhage after inguinal hernia repair. The bleeding was not within the operative site but proximal to the deep inguinal ring, likely resulting from retraction of the testicular artery into the retroperitoneum proximal to the internal inguinal ring. Our initial surgical intervention was to attempt control of local inguinoscrotal bleeding; however, with the discovery of the preperitoneal bleed, endovascular therapy was sought. The pelvic vasculature was studied first to exclude bleeding from these vessels with subsequent identification of the testicular artery as the etiology. The bleeding was seen arising off the distal testicular artery. Attempts were made to gain access across the bleeding site to perform embolization in a distal-to-proximal manner; however, the microwire and catheter could not be advanced into an optimal position for this. Flow-directed Gelfoam embolization was performed. After embolization, testicular infarction was treated with orchiectomy. Coil embolization of the artery as described in prior reports may be a safer alternative to the use of Gelfoam (4).

808



Letters to the Editor

REFERENCES 1. Chowbey PK, Pithawala M, Khullar R, Sharma A, Soni V, Baijal M. Complications in groin hernia surgery and the way out. J Minim Access Surg 2006; 2:174–177. 2. Miguel PR, Reusch M, daRosa ALM, Carlos JRB. Laparoscopic hernia repair—complications. JSLS 1998; 2:35–40.

Re: “Radiofrequency Ablation of Hepatic Cysts: Evaluation of Therapeutic Efficacy” From: Maxime Ronot, MD, PhD Julie Benzimra, MD Valérie Vilgrain, MD, PhD Department of Radiology (M.R., J.B., V.V.) University Hospitals Paris Nord Val de Seine Beaujon 100 Boulevard du Général Leclerc 92118 Clichy, France Université Paris Diderot–Paris 7 (M.R., V.V.) Sorbonne Paris Cité; and Institut National de la Santé et de la Recherche Médicale U773 (M.R., V.V.) Centre de Recherche Biomédicale Bichat-Beaujon CRB3 Paris, France

Editor: We read with interest the study by Kim et al (1) reporting on radiofrequency (RF) ablation of hepatic cysts. This elegant study showed that significant volume reduction could be achieved with percutaneous ablation in most cases. Results were significantly associated with the initial volume of the cyst, with large ones presenting with significantly lower volume reduction. Therefore, the authors concluded that RF ablation may be effective for the treatment of benign hepatic cysts and could be considered as an alternative to conventional sclerotherapy or surgery. As stated by the authors (1), these results are in line with previous reports by Rhim et al (2) and Du et al (3). However, this study raises several concerns. First, although the relationship between the presence of the cyst and the symptoms experienced by patients is not always unequivocal, the volume of the cyst is probably the most important factor. Indeed, as hepatic cysts grow, they can compress bile ducts, liver vessels, or surrounding organs such as stomach, inferior vena cava, or, rarely, the mediastinum. Therefore, whatever the treatment (surgery, sclerotherapy, or ablation as reported by the authors [1]), it is important to evaluate the volume reduction of the cysts. Nevertheless, the first goal of the treatment is to relieve patient symptoms and not to decrease the volume of the lesions, per se. Therefore, a proper evaluation of the efficacy of percutaneous RF ablation as an alternative therapeutic option should None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.01.005

Ronot et al



JVIR

3. Ingram MD, Symes AJ, Naerger HG, Hatrick AG. Testicular artery embolization for the treatment of life-threatening hemorrhage postorchidectomy. Cardiovasc Intervent Radiol 2009; 32:381–384. 4. Niederhauser BD, Andrews JC, Friese JL, Bjarnason H, Woodrum DA. Testicular artery embolization for the treatment of iatrogenic hemorrhage: report of two cases. J Vasc Interv Radiol 2011; 22:1347–1348.

include detailed reports of the evolution of the different symptoms: complete relief, symptom decrease, or absence of change. Other treatments, such as sclerotherapy, have been associated with marked decrease of the cyst volume, and, more importantly, to clinical efficacy (4). Technical success is indeed very important, but we believe the endpoint of any interventional radiologic procedure should be patient-centered. Our second concern is about what the authors refer to as “septated cysts” (1). Hepatic cysts are typically anechoic lesions, without any sedimentation, septa, or thickened cyst wall. The presence of septations, as illustrated by figure 4 in their study (1), is classically considered as a sign of previous hemorrhage, or more rarely of the presence of a cystic biliary neoplasm. The authors did not give any detail regarding their diagnostic algorithm for complex hepatic cystic lesions. Usually, definite diagnosis is achieved by a combination of various imaging techniques (computed tomography, magnetic resonance imaging, and contrast-enhanced ultrasonography) according to defined imaging criteria. Percutaneous fluid sampling might also be performed for cytologic and biochemical analysis. There might fortunately be no case of biliary cystic neoplasm included in the study group of Kim et al (1); however, based on only the results they present, we would be very much concerned of a such possibility. The reported volume reduction rate was 34.4% in septated cysts after aspiration, in contrast to 83.0% in nonseptated ones (1). The authors speculated that septations might lead to inhomogeneous heat conduction, resulting in insufficient heat to kill cystic epithelium. We cannot exclude that some of these lesions were not hepatic cysts but cystic tumors, the latter requiring surgical resection.

REFERENCES 1. Kim PN, Lee Y, Won HJ, Shin YM. Radiofrequency ablation of hepatic cysts: evaluation of therapeutic efficacy. J Vasc Interv Radiol 2014; 25:92–96. 2. Rhim H, Kim YS, Heo JN, et al. Radiofrequency thermal ablation of hepatic cyst. J Vasc Interv Radiol 2004; 15:95–96. 3. Du XL, Ma QJ, Wu T, Lu JG, Bao GQ, Chu YK. Treatment of hepatic cysts by B-ultrasound-guided radiofrequency ablation. Hepatobiliary Pancreat Dis Int 2007; 6:330–332. 4. Tikkakoski T, Makela JT, Leinonen S, et al. Treatment of symptomatic congenital hepatic cysts with single-session percutaneous drainage and ethanol sclerosis: technique and outcome. J Vasc Interv Radiol 1996; 7: 235–239.