Case Report: Laparoscopy; Expecting Complication Even When It Seems Uneventful

Abstract

To present an unexpected case of severe hemorrhage during laparoscopy pyelolithotomy. A 38-year-old man with a right staghorn stone underwent laparoscopic pyelolithotomy. During renal pelvis dissection, pyelotomy, stone extraction, and closing pyelotomy site, the surgeons did not notice anything wrong or unexpected. The stones were extracted in a lap endobag and through the extended pararectal trocar site. The extended incision was 4 cm. In a recovery room, the patient became pale and his systolic BP decreased to 80 mm Hg. The corrugate drain output was 50 cm³. On second look exploration, the source of hemorrhage was a branch of inferior epigastric artery, severed during trocar site extension. Injury to the inf. epig. vessels during laparoscopic surgery can cause troublesome and massive bleeding. It may occur in 2 circumstances: during trocar insertion or during specimen extraction. We present a case of bleeding after staghorn stone extraction through port incision which became life threatening. injury to the inf. epig. vessels during trocar insertion is almost always recognizable immediately. But injury to the inf. epig. vessels during specimen extraction could be missed and should always be in the mind of the astute surgeon. Off-center trocar sites and specimen extraction site should always be checked for bleeding in laparoscopy, especially when they are in the proximity of inferior epigastric vessel tributaries.