A Case of Delayed Inferior Epigastric Artery Damage due to Overextension of the Abdominal Wall during Laparotomy

Abstract

A 76-year-old man who had undergone surgery for Stage IIIC gastric cancer and was under observation in our department was also found to have cancer of the duodenal papilla. Therefore pancreaticoduodenectomy (PD) and D2 lymph node dissection were performed. The operation proceeded smoothly despite the presence of severe adhesions in the abdominal cavity due to previous surgery. Before abdominal closure, two drains were inserted from the right side abdomen and placed in the vicinity of the pancreas. The operating time was 5 hours 17 minutes. None of the usual complications of PD occurred, but sudden right lower abdominal pain appeared on the evening of postoperative day (POD) 4. Since there was no externally visible abnormality of the abdominal wall, and no change in the patient's vital signs or drainage fluid, his condition was monitored overnight. The following morning the patient's blood pressure had dropped, and blood tests also showed severe anemia. Contrast-enhanced computed tomography showed right inferior epigastric artery damage and an abdominal wall hematoma were observed. Hemostasis was achieved by interventional radiology. The patient was discharged home on POD 20. Since the drain insertion sites had enough distance from the location of the inferior epigastric artery, their placement was not thought to be the cause. Instead, it was thought that the inferior epigastric artery had been damaged when the abdominal wall was placed under traction with a retractor hook during exposure of the operating field. Since such case is very rare, we report here in case with a review of the relevant literature.