Intra-abdominal Fluid Extravasation: Is Endoscopic Deep Gluteal Space Exploration a Risk Factor?

Abstract

Background: The extravasation of fluid into the intra-abdominal space is recognized as a possible complication of hip arthroscopic surgery/endoscopy. The exposure of anatomic areas to elevated pump pressures and high volumes of irrigation fluid increases the risk of fluid leakage into anatomic spaces around the hip joint, especially to the abdomen and pelvis. Purpose: To estimate the incidence and risk factors related to intra-abdominal fluid extravasation (IAFE) after hip endoscopy or arthroscopic surgery. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective study was carried out between June 2017 and June 2018. A total of 106 hip procedures (endoscopy or arthroscopic surgery) performed for extra- or intra-articular abnormalities were included. Before and after surgery, in the operating room, ultrasound was performed by a trained anesthesiologist to detect IAFE. The hepatorenal (Morison pouch), splenorenal, retroaortic, suprapubic (longitudinal and transverse), and pleural spaces were examined. Patients were monitored for 3 hours after surgery to assess for abdominal pain. The data collected included maximum pump pressure, duration and volume of irrigation fluid (Ringer lactate), total surgical time, and traction time. Results: The incidence of IAFE was 31.1% (33/106; 95% CI, 23.1%-40.5%). The frequency of IAFE was 52.9% (9/17) in cases with isolated extra-articular abnormalities and 15.9% (7/44) in cases with isolated femoroacetabular impingement; in cases with both extra- and intra-articular abnormalities, the frequency was 37.8% (17/45). An intervention in the subgluteal space was identified as a risk factor for IAFE (odds ratio, 3.62 [95% CI, 1.47-8.85]). There was no statistically significant difference between groups (with vs without IAFE) regarding total surgical time, maximum pump pressure, or fluid volume. Postoperative abdominal pain was found in 36.4% (n = 12) of cases with IAFE compared with 2.7% (n = 2) of cases without extravasation ( P < .001). No patient with IAFE developed abdominal compartment syndrome. Conclusion: IAFE was a frequent finding after hip arthroscopic surgery/endoscopy in patients with extra-articular abnormalities. Exploration of the subgluteal space may increase the risk of IAFE. Pain and abdominal distension during the immediate postoperative period were early warning signs for IAFE. These results reinforce the need for careful intraoperative and postoperative monitoring by the surgeon and anesthesiologist to identify and avoid complications related to IAFE.

Calculating Intraoperative Fluid Deficit to Prevent Abdominal Compartment Syndrome in Hip Arthroscopy

“…This becomes even more vital when recent studies have shown surgeon perception about intraabdominal fluid extravasation to be as low as 0.16%, compared to an incidence as high as 31.1% when intraabdominal ultrasound scanning is used during surgery. 5,8 Several methods have been proposed to detect the presence of intraabdominal fluid extravasation. Close inspection of the preoperative magnetic resonance image for anatomical variants, particularly between the iliopsoas bursa and hip joint capsule, should alert the surgeon and anesthesiologist for high-risk patients.…”

“…4 Although the exact cause of IAFE is case dependent, factors that have been found to contribute to increased risk are increased pump pressure, concomitant iliopsoas tenotomy, surgeon experience, and prolonged surgical time. 4,[6][7][8][9] IAFE during arthroscopic hip surgery directly increases intra-abdominal pressure, resulting in intra-abdominal hypertension (IAH). IAH is defined as sustained levels of intra-arterial pressure greater than 12 mm Hg.…”

Open Ischiofemoral Impingement Decompression

“…[18][19][20][21][22] Several complications have been reported with the endoscopic approach, including temporary sciatic nerve injury, hematoma, permanent nerve injury of the posterior femoral cutaneous nerve, 23 and intra-abdominal fluid extravasation. 24 This method does incur a steeper learning curve as well as less direct visualization of the important surrounding neurovascular structures; consequently, entrapment of the sciatic nerve is the leading reported cause of revision surgery. 23 Complications from an endoscopic approach can be severe, and an open approach may reduce the risk of several of these complications.…”

FAST exam for the anesthesiologist

“…A positive FAST exam correlates with a minimum of 300 to 500 mL of free fluid in the peritoneal space,13,14 which can indicate ongoing hemorrhage if found following abdominal surgery. Of note, intra-abdominal fluid extravasation (IAFE) following hip arthroscopy occurs up to 15% to 30% of the time and is associated with increased pain 15–17. In severe cases, IAFE can result in hemodynamic instability and abdominal compartment syndrome (ACS) 18.…”

“…Of note, intra-abdominal fluid extravasation (IAFE) following hip arthroscopy occurs up to 15% to 30% of the time and is associated with increased pain. [15][16][17] In severe cases, IAFE can result in hemodynamic instability and abdominal compartment syndrome (ACS). 18 However, unlike free fluid or blood, as seen after abdominal surgery, if the patient is hemodynamically stable postoperatively, there is no longer a risk of ongoing hemorrhage with hip arthroscopy.…”