Major Pelvic Bleeding Following a Stapled Transanal Rectal Resection: Use of Laparoscopy as a Diagnostic Tool

Abstract

Stapled transanal rectal resection (STARR) and stapled hemorrhoidopexy (SH) are well-established techniques for treating rectal prolapse and obstructed defecation syndrome (ODS). Occasionally, they can be associated with severe complications. We describe the case of a 59-year-old woman who underwent STARR for ODS and developed a postoperative pelvic hemorrhage. A computed tomography (CT) scan revealed a vast pelvic, retroperitoneal hematoma and free gas in the abdomen. Laparoscopy ruled out any bowel lesions, but identified a hematoma of the pelvis. Flexible sigmoidoscopy showed a small leakage of the rectal suture. The patient was treated conservatively and recovered completely. Surgeons performing STARR and SH must be aware of the risk of this rare, but severe, complication. If the patient is not progressing after a STARR or SH, a CT scan can be indicated to rule out intra-abdominal and pelvic hemorrhage. Laparoscopy is a diagnostic tool and should be associated with intraluminal exploration with flexible sigmoidoscopy.

Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR—A Proposal for a Decision-Making Algorithm

“…Seven studies were excluded based on reasons listed in Table 1 [ 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Cumulatively, 17 articles (15 case reports and two case series) were considered relevant, and 38 patients were included ( Figure 1 , Table 2 ) [ 3 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”

“…Seven papers reported perirectal hematoma [ 3 , 17 , 18 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. In seven articles, intraabdominal bleeding was described [ 28 , 29 , 30 , 31 , 32 , 33 , 34 ], two reported retroperitoneal hematoma [ 19 , 25 ]. In some cases, the first sign of perirectal bleeding was the intra-abdominal hemorrhage [ 28 , 29 , 31 , 32 ].…”

“…The data about hemodynamic status were reported in all case reports and the case series [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]: a hemodynamic instability was reported in a few cases (18.9%, 7/37) and a hemodynamic stabilization and resuscitation were needed.…”

“…The laparoscopy is useful for both a diagnostic and therapeutic approach. It allows an assessment of the retroperitoneal hematoma, ruling out associated intra-abdominal injuries, washing out the abdominal cavity, draining the hematoma, and suturing of peritoneal lacerations if presented [16,19,20,25,26].…”

Common operation, uncommon complication. Bleeding from superior haemorrhoidal artery after minimally invasive procedure for hemorrhoids – a case report

“…The bleeding rate decreased from 12.9% to 4.4% with the increasing experience of the performing surgeon. 1,6,7 Only in one case have we encountered pseudo aneurysm, in a series of 28 MIPH cases done with the Chinese stapler guns. Although these are still very popular in India, in our unit we have given up the low cost stapler for MIPH.…”