Hemoperitoneum as severe and unusual complication in the stapler recto-anopexy for hemorrhoidal prolapse. Case report

Abstract

We report unusual but severe complication after Longo recto-anopexy for hemorrhoidal prolapse, i.e. large intramural hematoma of the rectum and subsequent hemoperitoneum. We make some assessment about the technique.

Full text

G Chir Vol. 32 - n. 5 - pp. 272-274
May 2011
272
methods, tecniques, drugs
Introduction
Nowadays, rectopexy using staplers according to Lon-
go’s technique (1) for treatment of the mucosal hemor-
roidal rectal prolapse is widely diffused in all countries,
above all due to incontestable postoperative patient sa-
tisfaction and quick comeback into social life.
Overcoming of the learning curve has also made su-
rer the technique, limiting to low percentages (1-2%) anal
bleeding that initially was more feared the complication.
Nevertheless, rare and unusual complications have spo-
radically been reported, because of their objective gravity.
Many Authors have judged disproportionate these com-
plications versus the type of surgical procedure and some
of them put this technique in discussion (2, 3).
We report a case of a very unusual hemorrhagic com-
plication with our personal remarks.
Case report
Z.A.M., male, 32 years old, came to our observation (Outpa-
tient Coloproctology) in July 2007. He was affected by hypertension;
he also referred many episodes of allergic reaction during previous
surgical procedures (including glottid edema). Diagnosis was he-
morroid prolapse, III grade. We suggested patient Longo’s rectopexy,
explaining him risks and benefits.
The patients underwent routine preoperative tests for elective sur-
gery: blood examination, EKG and chest X-ray. Different anae-
sthesiological consultations have been performed. Patient signed infor-
med consent and underwent surgery in September.
Anaesthesist, as usually, decided to perform spinal anesthesia. Sur-
geon had a large experience of Longo’s technique (about 350 personally
operated patients, complications according to literature).
When surgeon was firing the stapler, patient underwent an im-
portant allergic reaction, with glottid edema; his abdominal and pel-
vic muscles started to contract, so completing the operation was more
difficult than usually. Patient was intubated and went to Intensive
Care Unit (ICU).
Exubation occurred few hours later; conditions were good even
if anaesthesist reported mild abdominal pain during palpation at ni-
ght. The day after, at surgical check, severe abdominal pain and ten-
derness were verified. A CT scan was immediatly performed, de-
monstrating abdominal bleeding together with remarkable thickness
of rectal and sigmoidal wall with air inside .
The patient was immediately treated by laparoscopic exploration
that showed bleeding in the pelvic cavity between the small bowel
loops and adjacent to the liver and the spleen, with many blood cloats
SUMMARY: Hemoperitoneum as severe and unusual complication
in the stapler recto-anopexy for hemorrhoidal prolapse. Case re-
port.
A. RACALBUTO, I. ALIOTTA, M. SANTANGELO, R. LANTERI, P.V. FOTI,
V. MINUTOLO, A. LICATA
We report unusual but severe complication after Longo recto-ano-
pexy for hemorrhoidal prolapse, i.e. large intramural hematoma of the
rectum and subsequent hemoperitoneum. We make some assessment
about the technique.
RIASSUNTO: Un caso di emoperitoneo come complicanza grave ed
inusuale nella chirurgia con stapler del prolasso rettale mucoso emor-
roidario.
A. RACALBUTO, I. ALIOTTA, M. SANTANGELO, R. LANTERI, P.V. FOTI,
V. MINUTOLO, A. LICATA
Gli Autori, da una rara ma grave complicanza della rettoanopes-
sia secondo la tecnica di Longo - un esteso ematoma intramurale del ret-
to con conseguente emoperitoneo - espongono alcune considerazioni sul-
la tecnica.
KEY WORDS: Hemorroidal prolapse - Stapler recto-anopexy - Hemoperitoneum.
Prolasso emorroidario - Rettoanopessia con stapler - Emoperitoneo.
Hemoperitoneum as severe and unusual complication
in the stapler recto-anopexy for hemorrhoidal prolapse. Case report
A. RACALBUTO, I. ALIOTTA, M. SANTANGELO, R. LANTERI,
P.V. FOTI1, V. MINUTOLO, A. LICATA
University of Catania, Italy
Department of Surgical Sciences, Organs Transplant and New Technologies
1 Institute of Radiology
© Copyright 2011, CIC Edizioni Internazionali, Roma
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Hemoperitoneum as severe and unusual complication in the stapler recto-anopexy for hemorrhoidal prolapse. Case report
into the pelvis. After many plentifull and washing, a 1 cm diameter
hole was identified in the intraperitoneal rectal wall . We decided to
perform a laparotomy. During surgery we removed residual blood
cloats in the pelvis and sutured the laceration of the intraperitoneal
rectum that involved only the serosa and the muscle of the rectum
whereas the mucosa was intact. We also performed a rectoscopy: a
very great hematoma was present in the wall of rectum hearly pro-
ducing the collapse of its lumen. So we decided to drain making a
small cut in the mucosa.
The patient went to ICU and was readmitted to our Surgical Unit
two days later. He was discharged without any other complication
seven days after surgery.
Discussion
Recto-anopexy according to Longo technique re-
presents nowadays a diffused surgical approach: its ad-
vantages and possible complications are ever described
and discussed with the patient before surgery.
Most frequent complications are free bleeding from
rectal lumen and simple small hematomas of the rectal
wall. These complications are generally simply to resol-
ve. Bleeding occurs in 3-4% of patients, according to li-
terature. We published a series in which rectal bleeding
was present in 3% of patients (4). Furthermore we found
some cases with pain due to rectal hematoma wall, that
we resolved with a trans-anal drainage.
In literature just few cases like ours have been reported
(5). Of 47 reports recently collected by SIUCP (Italian
Unitary Society of Coloproctology), consisting of rare
but severe complications, 15 bulky rectal hematomas was
reported, 10 stable and 5 active, but only one with hea-
ring of the peritoneum and abdominal bleeding as in the
our case. To explain the bleeding into the peritoneum
in our patient we think that probably the respiratory cri-
sis occurred during surgery (allergic reaction with glot-
tid edema), with sudden intubation, the increase of ar-
terial pressure, patient’s agitation, with stretching of ab-
dominal and pelvic muscles, caused an important trac-
tion at the suture level; the consequent hematoma pu-
shed way, through the rectal wall, opening into the ab-
dominal cavity.
This dynamic is supported by peritonism signs and
CT scan finding (Figs. 1-3). It’s important to note that
in our patient, unlike the similar case previously men-
tioned, that needed a colostomy, rectal mucosa was not
broken; so, no bacterial contaminations occurred and the
patient recovered in few days. No surgical techniques is
exempt from complications and the same occours for
Longo’s technique. Nevertheless many Authors have been
criticizing these techniques for the serious complications
described in literature (2, 3, 5).
We conclude with some remarks:
- hemorrhoid pathology is often underestimated and
considerated like simple surgery, not considering
and accepting probable complications;
- severe complications have been described for all
kinds of hemorrhoid surgical techniques (6);
- rectal prolapse is nowadays considered the cause
of hemorrhoid glide and, if we accept this con-
cept, surgery has to be directed to prolapse re-
Fig. 1 - CT scan shows the staple line along the wall of the rectum.
Fig. 2 - Plain CT scan shows hyperdense hematoma within the right wall of the
rectum. Note small. gas bubble within the left wall of the rectum (arrow) . He-
moperitoneum is also present.
Fig. 3 - Postcontrast CT scan shows hemoperitoneum adjacent to the liver and
spleen.
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A. Racalbuto et al.
section (recto-anopexy, STARR);
- rectopexy using stapler is to consider like a
(complete) rectal resection; so it should be cata-
logued in complex surgery;
- so severe complications of this surgery, quietly rare,
should be accepted; this is a recent technique, in
evolution, and above all, susceptible of improve-
ment.
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4. Racalbuto A, Aliotta I, Corsaro G, Lanteri R, Di Cataldo A, Li-
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