Unexpected hemorrhage during robot-assisted laparoscopic prostatectomy: a case report

Abstract

BackgroundRobot-assisted laparoscopic prostatectomy is increasingly performed as a minimally invasive option for patients with organ-confined prostate cancer. This technique offers several advantages over other surgical methods. However, concerns have been raised over the effects of the steep head-down tilt necessary during the procedure. We present a case in which head-down positioning and abdominal insufflation masked the signs of an intraoperative hemorrhage.Case presentationA 73-year-old Asian man developed severe hypotension caused by an unexpected hemorrhage during robot-assisted laparoscopic prostatectomy for prostate cancer. Although our patient’s blood pressure steadily decreased during the procedure, his systolic blood pressure remained above 80 mmHg while he was tilted head downward at an angle of 28°. However, his blood pressure dropped immediately after he was returned to the horizontal position and abdominal insufflation – to create a pneumoperitoneum – was ceased at the end of surgery. We returned the patient to a head-down tilt to keep his blood pressure stable and began fluid infusion. Blood test results indicated that a hemorrhage was the cause of his hypotension. Open abdominal surgery was performed to stop the bleeding. The surgeons found blood pooling inside his abdomen from a longitudinal cut in a small arterial vessel in his abdominal wall, possibly a branch of his external iliac artery. The surgeons successfully controlled the hemorrhage and our patient was moved to our intensive care unit. Our patient recovered completely over the next few days, without any neurological deficits.ConclusionsWe suspect that blood began to pool in our patient’s superior abdomen during surgery, and that increased intra-abdominal pressure suppressed the hemorrhage. When our patient was returned to the horizontal position and insufflation of his abdomen was discontinued, the resulting increased rate of hemorrhage caused a sudden drop in blood pressure. Surgeons and anesthesiologists must understand the hemodynamic changes that result from head-down patient positioning and abdominal insufflation.

Stylistic features of case reports as a genre of medical discourse

“…Hence, MCRs are notable for their use of active sentences in the simple past tense (309 cases) [ 3 , 5 – 18 ]: “We maintained anesthesia with inhaled desflurane at 5% and intravenously administered remifentanil at 0.2 μg/kg/min in a fraction of inspired oxygen of 0.45 (…) At that moment, we administered 20 mg ephedrine, 300 μg phenylephrine, and 0.03 μg/kg/min norepinephrine to maintain adequate blood pressure (…) We did not detect any problems with his respiratory parameters (…) His systolic blood pressure remained at 40 mmHg for 10 min; we performed chest compressions to maintain his blood pressure” [ 5 ]; “We did not find cases with such an evolution in the literature, but we found some cases of spontaneous expulsion of ileal lipoma per rectum” [ 6 ]; “We found electrogram amplitude to be normal throughout the right ventricle (…) In this case we used cryoablation to avoid the pain associated with radiofrequency delivery” [ 7 ]; “An extraoral examination revealed a diffuse swelling of her left nasal alar base without tenderness” [ 8 ]; “Two patients with EHPVO presented with micrognathia, restricted mouth openings, and facial asymmetry” [ 9 ]; “Brain magnetic resonance imaging (MRI) did not identify any abnormalities, but an ophthalmic examination revealed vertical supranuclear gaze palsy (VSGP), and analysis of peripheral blood and bone marrow biopsies identified vacuolated histiocytes” [ 10 ]; “…we considered electroconvulsive therapy; clinicians may opt for electroconvulsive therapy at an earlier stage in similar psychiatric emergencies (…) We hypothesized that our patient’s poor clinical response was from a genetic polymorphism in the drug-metabolizing activity of cytochrome P450 enzymes” [ 11 ].…”

Unexpected hemorrhage of a rare vessel, a pubic branch of the external iliac artery, after laparoscopic radical prostatectomy

“…The pubic branch was thought to be transected during insertion of the laparoscope port at the beginning of surgery. [ 15 ] In this case, the repeated friction of the laparoscopic lens against the arcus pubis to achieve a clear field of view in the case of pelvic contraction may lead to bleeding, which could be easily overlooked in the ordinary course of events. Additionally, the condition of the patient's blood vessel was poor because of a 10-year history of diabetes and hypertension, resulting in an increased risk of hemorrhage.…”

Enhanced Laparoscopic Vision Improves Detection of Intraoperative Adverse Events During Laparoscopy

“…This loss of vision can be problematic, especially as surgical instruments can inadvertently encounter other structures. Blind spots can thus result in intraoperative complications such as bowel perforation [5] or hemorrhage [6,7] that may have severe consequences if not dealt with during the procedure. In addition, the lack of visibility of the surroundings may lead to the surgeon and their assistant losing the orientation of the endoscope with respect to the surgical horizon.…”