Download Laparoscopic treatment of traumatic iliopsoas hematoma

Laparoscopic treatment of traumatic iliopsoas hematoma
JING Jue-hua, QIAN Jun, TANG Jian, TIAN Da-sheng, ZHANG Ji-sen and CHEN Lei
Department of Orthopaedics, the Second Hospital of An Hui Medical University, HeFei, 230601,
China. ( JING Jue-hua.
Tel: 86-551-3869504.
Email: [email protected].)
(QIAN Jun,
TIAN Da-sheng, ZHANG Ji-sen and CHEN Lei )
Correspondence to : Dr. TANG Jian . Department of Orthopaedics, the First Affiliated Hospital
of An Hui Medical University, HeFei, 230032, China. (Tel: 86-551-3869506. Email:
[email protected] )
Key words: Iliopsoas hematoma; laparoscopy; surgery; MRI
Traumatic iliopsoas hematoma is rare in adolescents. Hematoma within the iliopsoas muscle
causes severe pain and dysfunction of the femoral nerve. Surgical treatment is often
recommended.
Some open surgeries lead to severe trauma and some minimally invasive
surgeries cannot completely clear the hematoma within the iliopsoas muscle. A new treatment
protocol for iliopsoas hematoma is discussed. This report introduces a laparoscopic method
as a successful treatment for removing iliopsoas hematomas. Laparoscopic surgery may be a
safe and effective alternative to open surgery for hematomas with a mixture of blood clots and
old liquid blood.
Iliopsoas hematoma is often seen in patients with hemophilia and in those taking anticoagulant
medications. 1
It also occurs following a closed injury of the iliopsoas muscle, such as hyperextension
of the hip joint during a fall.
Hematomas are more frequently seen in the iliacus muscle than in the
psoas. 2
An iliopsoas hematoma may have different symptoms varying in severity, from early local signs, such
as lower-abdominal or groin pain to massive bleeding and shock. 3, 4 Iliopsoas hematoma is commonly
associated with femoral nerve palsy which produces quadriceps paralysis and paresthesias in the
anterior region of the thigh. 5Iliopsoas hematoma has been treated successfully with conservative
methods or surgical evacuation, both with successful results.
Surgical methods that have been
previously reported include transcatheter arterial embolization, percutaneous drainage of the hematoma
and surgical decompression of the femoral nerve.
1, 3, 6
No published reports have described
laparoscopic hematoma removal to the best of our knowledge. We present two cases of successful
removal of iliopsoas hematoma using this technique.
CASE REPORTS
Case 1
A healthy, 14-year-old boy fell to the ground while riding a bicycle. He recalled that he hyperextended
his left hip joint during the fall.
He experienced increasing pain in the left groin and was admitted to
our hospital six days after the injury.
The pain was severe and the patient was unable to walk due to
weakness in the left lower extremity. There was no history of pain of the left hip joint before the injury.
On physical examination, the patient was found to have grade 3/5 strength in the left of the iliopsoas
and thigh muscles and hypoesthesia in the distribution of the left femoral nerve.
He had significant
pain while attempting active flexion and passive extension of the hip.
The patient’s prothrombin time-international normalized ratio (PT-INR) was 1.1;
the activated partial
thromboplastin time ( APTT ) was 38.4 seconds and the platelet count was 160.0×109 /l.
These were
all within normal limits.
The hemoglobin level was 9.2 g/dl. Radiographs of the lumbar spine, pelvis
and thigh were normal.
A pelvic magnetic resonance imaging ( MRI ) scan revealed a large,
well-defined mass of 21.0×5.3×8.0 cm3 in the left iliacus muscle and psoas major muscle ( Figure 1).
This mass was a mixture of low, intermediate and high signal intensities on both T1- and T2-weighted
images.
These suggested that the hematoma was a mixture of blood clots and liquid blood. The
patient was diagnosed with traumatic iliopsoas muscle hematoma.
The procedure to remove the
hematoma using a laparo- scopic technique performed under general anesthesia was scheduled on the
third day after admission.
The patient was placed in the lateral decubitus position for surgery.
skin.
Three incisions were made in the
The first incision was in the posterior axillary line just inferior to the inferior margin of the 12th
rib; the second incision was in the midaxillary line superior to the iliac crest; the third incision was in
anterior axillary line vertically aligned with the first incision ( Figure 3 ). We accessed the retroperitoneal cavity by blunt dissection and placed a balloon in the retroperitoneal cavity. Then
approximately 500 ml of gas was pumped into the balloon to expand the retroperitoneal cavity.
The
laparoscopy lens and the operating handle were placed into the retroperitoneal cavity through three
trocars of different diameter.
After visually localizing the hematoma, we exposed it and removed
approximately 700 ml of clots and old liquid blood through a large-diameter suction catheter ( Figure
4).
We then placed a drainage tube in the hematoma cavity and fed it through the incision just
superior to the iliac crest, removed the trocars and closed the incisions.
Upon waking after surgery, the patient observed that his left groin pain felt immediately improved.
Two weeks after surgery, sensation in the femoral nerve distribution was improved and lower extremity
strength was restored to grade 4/5.
Six months later, the patient had full strength but sensation in the
femoral nerve distribution did not fully recover.
However,
he was able to return to unrestricted
activities without any previous symptoms or post-surgery functional limitations. A CT scan, performed
six months after surgery, showed the left iliacus and psoas muscles had been restored to their normal
shape ( Figure 2 ).
Case 2
A 13-year-old boy was examined that had a five day history of pain in his right thigh which worsened
when he extended his right knee.
The pain began while he was exercising and had hyperextended his
right hip.
On the sixth day after the onset of pain, he was unable to walk because of pain in the right
thigh and was admitted to our hospital.
Physical examination revealed extreme tenderness to palpation in the groin.
quadriceps was grade 4/5.
The power of the
Passive extension and active flexion of his right hip were painful.
Sensation along the anterior aspect of the right thigh was normal.
Blood tests, including coagulation time, prothrombin time, bleeding time, and platelet counts were
within normal limits. The hemoglobin level was 12.1 g/dl.
Radiographs of the pelvis were normal. A
pelvic MRI scan revealed a hematoma measuring 8.2×4.5×7.0 cm3 in the right iliacus muscle ( Figure
5). Using the laparoscopic technique described in Case 1, we removed approximately 240 ml of clots
and old blood from the hematoma.
eliminated.
A week after surgery, the patient's right thigh pain was completely
He was able to lie on his back with the hip and knee in full extension two weeks after
surgery and to walk without any limitations six weeks after surgery.
A CT scan performed at six
weeks showed that the right iliacus and psoas muscle had returned to their normal shape ( Figure 6 ).
CLINICAL OVERVIEW
Most cases of iliopsoas hematoma are caused by anticoagulant therapy or hemophilia but some are
secondary to trauma.
Iliopsoas hematoma originates from tears in iliacus and psoas muscle fibers and
capillary damage. 7, 8
Both of our patients had a clear history of trauma; their APTT, PT-INR and
platelet counts were normal.
Whether iliopsoas hematoma should be surgically or conservatively treated is debatable.
9
Treatment
decisions depend on the speed of onset, hematoma volume, and degree of neurological impairment. 10
Conservative treatments are suggested if the hematoma is relatively small and the neurological
symptoms slight.
11, 12
Conservative treatments include bed rest, analgesics, hemostatics, and
correction of deregulated anticoagulant therapy.
13
large and cause severe neurologic dysfunction. 14
Surgery is necessary if the hematomas are very
The surgical treatments including trans-catheter
arterial embolization, percutaneous drainage and surgical decompression of the femoral nerve have
been reported in the literature. 1, 3, 6
STRATEGIES
This paper describes two cases in which iliopsoas hematomas are removed using a laparoscopic
technique.
CT and MRI tests confirmed that both blood clots and old liquid blood are present within
the hematomas.
The clots and old liquid blood were removed through laparoscopic ports to achieve
surgical decompression.
The choice to use a laparoscopic approach was based on two factors.
the operation is minimally invasive and produces little tissue damage.
First,
Secondly, with this technique,
both blood clots and old liquid blood are removed resulting in a thorough decompression of the femoral
nerve.
In addition, the risk of infection associated with both old liquid blood and open surgery can be
reduced with this technique.
The laparoscopic technique, like open surgery, also allows identification
and cauterization of the bleeding source.
After using this technique, our patients experienced immediate relief from the pain they experienced
from their injuries before surgery.
Recovery of neurological function was incomplete in both cases at
the time of discharge from the hospital.
However, six weeks after surgery, the motor function was
completely recovered in both cases and the sensory disturbance remained only minimally impaired in
the case in which it was initially present ( Case 1 ).
CLINICAL DIFFICULTIES
Trans-catheter arterial embolization and percutaneous drainage can not clear the hematoma within
iliopsoas completely. Open surgery results in a major trauma for patients, especially for adolescents.
However, the laparoscopic surgery has the advantage such as minor trauma, removal of the hematoma
completely and cauterization of the hemorrhagic spots successfully.
AUTHORS’ PERSONAL OPINIONS
Traumatic iliopsoas hematoma is rare in adolescents 12 and should be suspected in patients with hip
pain and neurological dysfunction.
A CT scan or MRI are good diagnostic tools to further verify
other preliminary physical examinations 15 as these allow rapid identification and measurement of the
hematoma.
If the imaging demonstrates a hematoma with a mixture of blood clots and old liquid
blood, laparoscopic surgery may be a safe and effective alternative to open surgery.
REFERENCES
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therapy. Intern Med 2005; 44:641-643.
2. Nakao A, Sakagami K, Mitsuoka S, Uda M, Tanaka N.
Retroperitoneal hematoma associated with
femoral neuropathy: a complication under antiplatelet therapy. Acta Med Okayama 2001; 55:363-366.
3. Holscher RS, Leyten FS, Oudenhoven LF, Puylaert JB. Percutaneous decompression of an iliopsoas
hematoma. Abdom Imaging 1997 ;22:114-116.
4. Chevallier X, Parget-Piet B. Femoral neuropathy due to psoas hematoma revisited. Report of three
cases with serious outcomes. Spine (Philadelphia, PA, 1976) 1992;17:724-726.
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iliacus haematoma. J Neurosurg 2005;102: 382-385.
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caused by traumatic iliacus hematoma: a case report. J Orthop Sci 2002;7:713- 716.
7. Niakan E, Carbone JE, Adams M, Schroeder FM. Anticoagulants iliopsoas hematoma and femoral
nerve compression. Am Fam Physician 1991; 44:2100-2102.
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femoral nerve palsy after abdominal extension exercises: a case report. Am J Sports Med
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9. Qanadli SD, EI Hajjam M, Mignon F, Bruckert F, Chagnon S, Lacombe P. Life-threatening
spontaneous psoas hematoma treated by transcatheter arterial embolization. Eur Radiol 1999;9:
1231–1234.
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muscle: a case report and review of literature. Arch Orthop Trauma Surg 2002;122:109-111.
11. Maffulli N, So WS, Ahuja A, Chan KM. Iliopsoas hematoma in an adolescent Taekwondo player.
Knee Surg Sports Traumatol Arthrosc 1996;3:230-233.
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secondary to a traumatic iliacus hematoma in an adolescent. J Bone Joint Surg Br 2008;90:1380-1381.
13. Fealy S, Paletta GA. Femoral nerve palsy secondary to traumatic iliacus muscle hematoma: course
after nonoperative management. J Trauma 1999;47:1150–1152.
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femoral nerve. J Orthop Trauma 1992; 6:110-112.
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Figures
Figure 1. T2-weighted magnetic resonance images (a, c) and computed tomography scan (b) of the
pelvis before surgery in Case 1. Hematoma is observed in the left iliopsoas muscle.
Figure 2. Sites for laparoscopic ports in Case 1. (a) Preoperative photograph of right flank with
drawing of the surface anatomy of the right 12th rib, iliac crest, and three port locations.
Intraoperative photograph of right flank with three laparoscopic instruments in place.
(b)
Figure 3. Laparoscopic photographs from Case 1 showing the external view (a) and internal view (b)
of hematoma.
Figure 4. Sections (a,b) from the computed tomography scan of the pelvis in Case 1, six months after
surgery. Hematoma has disappeared on the CT scan after six months.
Figure 5. T2-weighted (a, b) and T1-weighted (c) magnetic resonance images of the pelvis before
surgery in Case 2. Hematoma is observed in the right iliopsoas muscle.
Figure 6. Sections (a,b) from the CT scan of the pelvis in Case 2, six months after surgery. Hematoma
has disappeared on the CT scan after six months.