Bilateral Vulvar Ecchymosis after Laparoscopic Myomectomy

A 40-year-old female with a preoperative hemoglobin level of 10.4 g/dl received a smooth conventional laparoscopic myomectomy with intraoperative blood loss of 100 ml. However, the patient encountered profound shock (60/24 mmHg) with a heart rate of 77 bpm and decreased hemoglobin level (6.9 g/dl) 4 h later in the ordinary ward. The vital signs became stable (blood pressure: 108/70 mmHg and heart rate: 77 bpm) after intravenous fluid resuscitation with 500 ml of normal saline in 40 min without vasopressor. Physical examination showed a left lower abdominal mass starting from the left lower port site, suspecting hematoma, but no apparent internal bleeding was seen then over Morrison’s pouch under abdominal ultrasonography. We performed the compression techniques with gauze covered by 3M™ Multipore™ Elastic Cloth Adhesive Tape on the left lower abdominal mass. After 12 h, we removed the gauze to recheck whether the hematoma improved and repeated the procedure if it deteriorated. Moreover, the combination of ampicillin and sulbactam injection was administrated for preventing infection due to massive blood loss. We also monitored the hemoglobin level and ultrasound daily. There were no signs of ongoing intra-abdominal bleeding, but the anemia persisted; this needs further blood transfusion. However, the ecchymosis gradually extended to the left flank areas and bilateral vulvar in about 1 day. On postoperative day 3, pelvic examination showed obvious bilateral labia majora ecchymosis [Figure 1], and we assumed the abdominal wall vessel injury was a laparoscopic access-related complication. The vulvar and trunk ecchymosis regressed after compressing the abdominal wall and vulvar ice packing. We arranged the discharge for the patient’s stable vital signs.Figure 1: Pelvic examination showing bilateral labia major ecchymosisVulvar hematoma/ecchymosis is uncommon in the nonobstetrics group, even rare in gynecological emergencies, with an incidence of 0.8%.[1] Moreover, postlaparoscopic vulvar hematoma was seldom mentioned in the past. Despite limited literature on this postoperative complication, Tokmak et al. reported a similar scenario with two possibilities: (1) During a partial oophorectomy, there is a possibility of injuring the vessels within the round ligament and (2) the superficial epigastric artery branches from the femoral artery and runs superomedially, approximately 5 cm lateral to the midline, and was chiefly injured when the trocar accessed the abdominal wall, leading blood to accumulate between the superficial perineal pouch and superficial fascia of the anterior lower abdominal wall. The authors also suggested avoiding unnecessary adnexa vessel dissection, and thorough hemostasis under lower insufflation pressure may prevent this situation.[2] Clinicians should arrange pelvic computed tomography with contrast medium or magnetic resonance imaging for lesion detection if the hematoma deteriorates.[3] A recent meta-analysis concluded that single-port laparoscopic myomectomy has the potential to be less invasive and have a lower reduction of postoperative hemoglobin than conventional laparoscopic treatment in proper candidates.[4] Although the therapeutic plans for vulvar hematoma/ecchymosis remain controversial, surgical intervention for unstable clinical conditions reduces the risk of succeeding shock, infection, and even mortality if initial compression management or ice pack fails.[5] Tjokroprawiro et al. shared an experience of a case with a large trauma-induced vulvar hematoma after a single incision that recovered rapidly in one day, shortening the hospital stays.[6] Angiographic embolization may be another viable option because it is widely advocated in puerperal vulvovaginal hematoma patients with satisfactory outcomes.[7] To prevent this complication, the left lower entry point, 5 cm superior to the pubic symphysis and 8 cm from the midline, may be used with transillumination to avoid and minimize the risk of vessel injury.[8] Furthermore, much blood loss may raise the surgical site infection rate, so prophylactic antibiotics should be applied.[9] In conclusion, our patient suffered a trocar-related vulvar hematoma, which was relieved by conservative treatment. However, serious complications such as hypovolemic shock and infection should be cautioned to avoid further catastrophes. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Author contributions Liang-Ying Ke: Writing - Original Draft; Chang-Lin Yeh: Resources; Cheng-Yu Long: Writing - Review and Editing. All authors have read and agreed to the final version of the manuscript. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest Dr. Cheng-Yu Long, an editorial board member at Gynecology and Minimally Invasive Therapy, had no role in the peer review process of or decision to publish this article. All authors declared no conflicts of interest in writing this paper.