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Journal of Postgraduate Medicine, Vol. 47, Issue 2, 2001 pp.143 Letter to Editor Near Fatal Haemoperitoneum of Rare Origin Following Laparoscopic Sterilisation Guleria K, Manjusha, Suneja A Guleria K, Manjusha, Suneja A University College of Medical Sciences & GTB Hospital, Shahdara, Delhi - 110 095, India Code Number: jp01042 Sir, A 27-year-old, multiparous lady underwent laparoscopic tubal sterilisation under local anaesthesia at a camp. She was sent back home two hours after the procedure. Later in the day, she developed giddiness and fainting and then presented herself to the gynaecological emergency unit of our hospital, five hours after the procedure. At initial examination, her pulse and blood pressure were not recordable and profound pallor was evident. Abdomen was distended and four quadrant abdominal paracentesis revealed free blood. Immediate laparotomy was performed with a midline vertical infraumbilical incision. At laparotomy, despite a 4000 ml haemoperitoneum, the uterus, adnexa, bowel and the great vessels were found to be normal and the Fallope rings were well applied. Examination of the anterior abdominal wall revealed a completely severed actively bleeding aberrant vessel, which was ligated at both the ends. This was a 6-mm wide unpaired branch of right inferior epigastric artery, coursing along the medial border of rectus muscle, between the muscle and the posterior lamina of rectus sheath. No other anomalies were detected. She made an uneventful recovery. Laparoscopic tubal sterilisation is a widely accepted method of contraception with a complication rate of less than 1% and almost no operative mortality.(1) Performed under local anaesthesia using a single midline intraumbilical entry, it is generally a safe procedure and is often performed on large number of patients in camps, on outpatient basis. But, anatomical variations can catch the surgeon unaware and lead to life threatening complication as in the present case. Laparoscopic sterilisation is only rarely associated with abdominal wall vessel injuries, probably because the trocar is introduced through the abdominal wall in the relatively avascular midline.(2) On searching the literature, we could not find any record of such anomalous vascular connections being encountered during diagnostic or operative laparoscopies for any indication, although such a possibility has been recognized.2 Vascular injuries sustained during diagnostic or operative laparoscopy usually results in haematomas of the anterior abdominal wall or the retroperitoneum, and only minimal free blood in the peritoneal cavity. Occurrence of massive haemoperitoneum as noted in the present case is quite rare. Only three cases of haemoperitoneum following laparoscopic procedures have been reported in the literature, but none was related to sterilisation.(2-4) It has however been noted that life-threatening haemoperitoneum may occur secondary to the injury of dilated paraumbilical and recanalised umbilical vein in patients of portal hypertension undergoing laparoscopy, probably because of deranged coagulation profile, but this possibility is irrelevant in the present case. Generally, the signs of bleeding are acute and the injury is recognized during or immediately after the procedure.(3,5) Failure to recognise the injury during the laparoscopic procedure itself can be attributed to the intra peritoneal gas pressure compressing the bleeding vessel and good preoperative condition of the healthy young subject. To conclude, a rare anatomical aberration as noted in the present case makes an occasional vascular injury unavoidable. This also strongly emphasises the need to follow the guidelines for Laparoscopic sterilisation issued by Government of India. These state that a client should be discharged at least four hours after the procedure if the vital signs as evaluated by the doctor are stable and should be followed up by a health worker within 48 hours at their homes. References
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