Author Information
Pandey
Nihita*, Gupta AS**, Mirchandani A***, Chauhan AR****.
(* Third
Year Resident, ** Professor, ***Assistant Professor, **** Additional Professor.
Department of Obstetrics and Gynecology, Seth G.S. Medical College & K.E.M. Hospital,
Mumbai, India)
Abstract
A 29 year
old woman presented in a moribund condition with hemoperitoneum following
Shirodkar’s Sling surgery done through a Pfannensteil incision and a postoperative
exploratory laparotomy. She had been explored at the primary hospital of the
surgery and was referred in view of frank blood draining from the
intraperitoneal drain. Re-exploration was done and intra-operatively the right
inferior epigastric artery was found to be injured. She developed sepsis and
was revived after intensive treatment for a month. This case highlights why the
judgment of incisions is crucial for the outcome of the surgery and that
cosmetic outcomes should never receive priority over safety.
Introduction
Pfannensteil
incision is now the preferred route of access for pelvic surgeries.[1]
But before over-enthusiastic application of this incision, one should weigh the
risks and benefits. Although the merits of the Pfannensteil incision are many,
there are also several grave limitations like risk of vascular injury,
increased blood loss and the inability to extend the incision if the need so
arises, thereby restricting the surgical field.[1,2] Hence, it is
imperative that instead of universal application of this technique for every
pelvic surgery, one should make a choice specific to each case.
Case Report
A 29 year
old patient presented to the emergency room, transferred from a secondary care
hospital, on day 2 of an exploratory laparotomy done in view of a
hemoperitoneum following Shirodkar’s Sling surgery for uterovaginal prolapse.
Patient was operated through a Pfannensteil incision. On day 5 of Shirodkar’s
Sling surgery the patient had high grade fever and complained of acute pain in abdomen.
Ultrasonography showed hemoperitoneum for which the patient was explored
through the initial Pfannensteil incision in the primary hospital.
Intraoperatively there was a 150 ml hematoma on the rectus sheath, clots were
present over the left Psoas major muscle and 1000 ml hemoperitoneum was drained
out. The two tape fixation sites of sling surgery were healthy and there was no
active bleeding. Two units of whole blood were transfused. An intraperitoneal
drain was kept in situ. In view of her worsening condition, she was transferred
to our center.
On arrival
to our tertiary care center, the patient’s general condition was poor, vital
parameters were unstable with a pulse of 130/min and BP of 90/60 mm Hg. On
abdominal examination there was slight tenderness in the lower abdomen. The
intraperitoneal drain had drained 1520 ml of frank blood in 24 hours. Her Hb
was 4.6 g/dl, white blood cell count 25,000/cmm and a platelet count of
14,000/cmm. Coagulation profile was within normal limits. Broad spectrum antibiotics
were started in view of clinical picture of sepsis and blood and blood products
replaced. Computerized tomography (CT) of the abdomen and pelvis was done which
showed a moderate hemoperitoneum and the drain was seen to be abutting the
right inferior epigastric artery. In view of increasing pain in abdomen and CT
findings, a decision of re-exploration was taken. The drain was removed to
prepare the abdomen for the re-exploration. Re- exploration was started by
opening of sutures of the Pfannensteil incision and a vertical midline
extension was required as the access to the abdomen was restricted.
Intra-operatively there was hemoperitoneum of 1500 ml and a branch of the right
inferior epigastric artery was found to be bleeding. Hemostasis was achieved.
No other bleeding sites in the retroperitoneum, or in the peritoneal cavity or
in the abdominal wall were found. Two drains were placed- one intraperitoneal
and one between the rectus sheath and the muscle. In total 12 whole bloods, 18
platelets and 4 units of Fresh frozen plasma were transfused to the patient
peri-operatively and in the immediate postoperative period. Higher antibiotic (parenteral Meropenem) was
started and the patient was shifted to an intensive care unit for a brief
period. Complete blood count and coagulation profile were repeated periodically
which showed serial gradual improvement. The patient recovered but developed
acute post traumatic stress disorder and had to be started on anxiolytics.
Discussion
The
Pfannensteil incision was first described by the German gynecologist in 1900.[3]
Since then this technique has been widely used by gynecologists and urologists
for pelvic surgeries.[1] This mode of incision is now recommended as
it is considered more physiological and many merits are attributed to it, which
include reduced postoperative pain, better healing, good cosmetic results and
reduced risk of incisional hernia formation.[4, 5, 6] However, it is
advised that in cases where the extent of the surgery cannot be predicted, it
is always better to opt for the midline vertical incision since it has
universal application.[1, 6] Also, the vertical midline incision can
be extended if required, allows access to the retroperitoneum besides the
entire pelvis and abdominal cavity, and has reduced blood loss and reduced
nerve injury.[1] A Pfannensteil incision on the other hand is a
restricted incision and is known to cause vascular injuries; the most common
being that of the inferior epigastric arteries, as was the case in this
patient.[1, 2] Shirodkar’s sling surgery is a posterior compartment
conservative surgery for uterovaginal descent which involves the creation of
artificial uterosacral ligaments by means of polyester tape or fascia lata and
fixing it to the anterior longitudinal ligament over the sacral promontory. In
this procedure the tape or fascia lata is hitched to the psoas major muscle on
the left side by help of a loop so as to prevent constriction of the sigmoid colon. This
procedure requires extensive dissection of the retroperitoneum and thereby
holds risk of injury to the great vessels, left ureter and the vessels of the
mesocolon. Hence, the vertical midline incision was recommended by Dr Shirodkar
in his monogram as it provided adequate exposure to the retroperitoneum as well
as the pelvis.[7]
In the
present case, the source of the initial bleeding could either have been from
the psoas hitch or the inferior epigastric artery which is a known complication
of the Pfannensteil incision or from both the sites. Inadequate length of the
Pfannensteil incision may make the exposure to the Psoas major muscle difficult
and injury to a vessel or the genitofemoral nerve coursing on it can be
injured. It is also a possibility that the initial bleeding was only from the
Psoas hitch which was controlled during the first exploration. As the first
exploration was done through the initial Pfannensteil incision, the epigastric
artery could have been injured in an attempt to extend the incision for better
exposure. The insertion of the drain could have caused the injury to the
epigastric artery as the exit of the drain was very close to the inferior
epigastric artery on the right side. The drain should have been placed more
laterally. This epigastric artery injury was either overlooked during the 1st
exploration or it occurred during this exploration.
Figure 1. CT
scan image. D is the drain. H is the
hemoperitoneum. Yellow arrow shows the exit of the drain.
This case
highlights the reason why Pfannensteil incision is inappropriate and harmful for
the purpose of Shirodkar’s Sling surgery and for an emergency exploratory
laparotomy.
Although
in recent times, the trend of performing Shirodkar’s Sling surgery through
either of the incisions is increasing; still studies have shown that vertical
midline incision is preferred, especially when the patient is short or stout.[8]
However, this Such trends need to be established only after well designed case
series studies establishing effectiveness and safety of either incision is
confirmed and documented. Since the
number of Shirodkar’s Sling surgeries in a gynecologist’s practice is very
small, gynecologists will not have sufficient training and experience to
perform this highly skilled surgery. So changing an incision for the surgical
approach can have dangerous repercussions that can threaten the physical and
the mental health of the patient as experienced by this patient.
It is thus
safe to conclude that gynecologists performing Shirodkar's sling surgery
through a Pfannensteil incision are compromising the safety of the patient and
should seriously reconsider prior to opting for a Pfannensteil incision for
performing Shirodkar's sling surgery.
Conclusion
This case
highlights the importance of a good choice of surgical incision. This simple
yet extremely important step has the potential of deciding the outcome of the
surgery as shown in this case report. A sound decision has to be made taking
into account multiple variables like the diagnosis, the surgery planned, the
possible complications and the patients’ physical parameters. Risk benefit
ratio always has to be considered before making such choices.
References
- Patnaik VVG, Singla R. K., Bansal V.K. Surgical Incisions—Their Anatomical Basis. Part IV- Abdomen. J Anat. Soc India. 2001;50(2):170-178.
- Meeks RG, Trenhaile T. Incision decisions: which ones for which procedures? OBG Management. 2002;14(3):16-33.
- Kisielinski K, Conze J, Murken AH, Lenzen NN, Klinge U, Schumpelick V. The Pfannenstiel or so called "bikini cut": still effective more than 100 years after first description. Hernia 2004;8(3):177-81.
- Grantcharov TP, Rosenberg J. Vertical compared with transverse incisions in abdominal surgery. Eur J Surg 2001;167(4):260-7.
- Luijendijk RW, Jeekel J, Storm RK, Schutte PJ, Hop WC, Drogendijk AC, et al. The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg 1997;225(4):365–369.
- Burger JW1, van 't Riet M, Jeekel J. Abdominal incisions: techniques and postoperative complications. Scand J Surg 2002;91(4):315-21.
- Shirodkar V.N. Contributions to Obstetrics and Gynaecology. 1st ed. Edinburg and London. E & S Livingstone Ltd. 1960; pp. 46-64.
- Lerona E, Stanton S.L. Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse. British J of Obstets and Gynaecol 2001;108:629-633.
Pandey N, Gupta AS, Mirchandani A, Chauhan AR. Hazardous Outcome of a Wrong Incision in Shirodkar’s Sling Surgery. JPGO 2014. Volume 1
Number 12. Available from: http://www.jpgo.org/2014/12/hazardous-outcome-of-wrong-incision-in.html