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Massive postmastectomy hemorrhage caused by a suction drain
Letters to the editors Use of laparoseopic instrumentation to quickly stretch the a b d o m i n a l wall in r e p a i r o f giant i n g u i n a l hernias
Massive postmastectomy hemorrhage caused by a suction d r a i n
To the Editors: The repair of giant abdominal wall hernias has always put the patient at risk of acute respiratory insufficiency because the newly reduced organs displace the diaphragm upward a n d impair breathing. Moreno I solved this problem by gradually enlarging the abdominal cavity by progressive distention before operation with p n e u m o p e r i t o n e u m . Although this m e t h o d works, it is time-consuming and painful. Obtaining more skin by slowly stretching it is a wellknown trick of plastic surgeons, 2 and because recent research in that field demonstrated that quick stretching was also possible, 3 we recently successfully quickly stretched the abdominal wall in one patient immediately before repairing the hernia. The patient was a 62-year-old mail with a giant inguinal hernia present for more than 10 years. It h a d been irreducible for more than 5 years. Preoperative chest x-ray film revealed interstitial fibrosis, and respiratory function studies were compatible with small airway disease. U n d e r general endotracheal anesthesia the a b d o m e n and scrotum were prepped a n d draped in the usual fashion. By use of the techniques of laparoscopy a Veress needle was inserted at the umbilicus a n d CO2 gas was insuffiated. A total of 5.9 L was used, a n d maximum pressure achieved was 29 m m Hg. The pressure was allowed to stay up for about 5 minutes, and then the needle was removed. Although we feared that m u c h of the insufflated gas would go into the hernia and distend the scrotum rather than the abdomen, this did n o t happen, and there was no appreciable increase in the hernia size. T h r o u g h a standard groin incision the hernia was mobilized, easily reduced, and repaired with a large sheet of polypropylene mesh (Lichtenstein repair). The postoperative course was uneventful except for slight reddening of the wound edges without fever or leukocytosis. The patient was discharged on postoperative day 3. Bert Myers, MD Professor of Surgery Louisiana State University Medical Center Mail Stop 112 i601 Perdido St. New Orleans, LA 70146
To the Editors: Surgical tradition dictates closed suction drainage to prevent seroma formation after mastectomy and axillary node dissection for breast c a n c e r ) Postoperative h e m o r r h a g e after mastectomy is rare, with a reported incidence of 1.3%.2 We recently encountered a case of massive arterial h e m o r r h a g e caused by a closed suction drain. A 48-year-old woman underwent a mastectomy with axillary dissection for breast cancer with the insertion of two closed suction drains. One was placed in the axillary dead space, and one was placed medially, deep to the u p p e r skin flap. The patient h a d an uneventful recovery with a gradual decrease in drain output. Because the drainage was greater than 50 ml per day, the drains were left in place until postoperative day 7. At that time the drainage became bloody, a n d the flap turned blue. O n exploration of the wound, a 500 gm blood clot was found. In addition, a hole was present in a perforating b r a n c h of the internal thoracic artery where it came into contact with a side port of the nonaxillary drain. The arterywas ligated, and the suction drains were removed. The total blood loss was 1100 ml. Her recovery from the second operation was uneventful. There have b e e n three reports of intraabdominal visceral injury but n o descriptions of arterial bleeding caused by suction drainage. 35 The mechanism of this complication appears to be pressure necrosis of the arterial wall. Surgeons should be aware of this potential complication when placing drains. Tatsuya Nomura, MD Yoshio Shirai, MD Haruhiko Okamoto, MD Katsuyoshi Hatakeyama, MD Department of Surgery Niigata University School of Medicine 1 Asahimachi-do~i Niigata 951, Japan
References 1. Moreno IG. The rational treatment of hernias and voluminous chronic eventrations: preparation with progressive pneumoperitoneum. In: Nyhus JB, editor. Hernia. Philadelphia: JB Lippincott, 1978:536-52. 2. Radovan D. Tissue expansion in soft-tissue reconstruction. Hast Reconstr Surg 1984;74:482. 3. Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin stretching device for the harnessing of the viscoelastic properties of skin. Hast Reconstr Surg 1993;92:260-70.
11/59/79605
References 1. Aitken DR, Minton JP. Complications associated with masteetomy. Surg Clin North Am 1983;63:1331-52. 2. Budd DC, Cochran PC, Sturtz DL, Fouty WJJr. Surgical morbidity after mastectomy operations. AmJ Surg 1978;135:218-20. 3. Benjamin PJ. Faeculent peritonitis: a complication of vacuum drainage. BrJ Surg 1980;67:453-4. 4. Gray AJ, Copeland GP. Small bowel perforation following vacuum suction drainage. J R Coll Surg Edinb 1985;30:324-5. 5. Reed MWR, Wyman A, Thomas WEG, Zeiderman MR. Perforation of the small bowel by suction drains. BrJ Surg 1992;79:679. 11/59/79604
Angiographic localization with m e t h y l e n e b l u e and radiopaque microcoil To the Editors: Angiographic localization with methylene blue or anglographic embolization with microcoil 1 is successful in locating SURGERY
477
Massive postmastectomy hemorrhage caused by a suction d r a i n
To the Editors: The repair of giant abdominal wall hernias has always put the patient at risk of acute respiratory insufficiency because the newly reduced organs displace the diaphragm upward a n d impair breathing. Moreno I solved this problem by gradually enlarging the abdominal cavity by progressive distention before operation with p n e u m o p e r i t o n e u m . Although this m e t h o d works, it is time-consuming and painful. Obtaining more skin by slowly stretching it is a wellknown trick of plastic surgeons, 2 and because recent research in that field demonstrated that quick stretching was also possible, 3 we recently successfully quickly stretched the abdominal wall in one patient immediately before repairing the hernia. The patient was a 62-year-old mail with a giant inguinal hernia present for more than 10 years. It h a d been irreducible for more than 5 years. Preoperative chest x-ray film revealed interstitial fibrosis, and respiratory function studies were compatible with small airway disease. U n d e r general endotracheal anesthesia the a b d o m e n and scrotum were prepped a n d draped in the usual fashion. By use of the techniques of laparoscopy a Veress needle was inserted at the umbilicus a n d CO2 gas was insuffiated. A total of 5.9 L was used, a n d maximum pressure achieved was 29 m m Hg. The pressure was allowed to stay up for about 5 minutes, and then the needle was removed. Although we feared that m u c h of the insufflated gas would go into the hernia and distend the scrotum rather than the abdomen, this did n o t happen, and there was no appreciable increase in the hernia size. T h r o u g h a standard groin incision the hernia was mobilized, easily reduced, and repaired with a large sheet of polypropylene mesh (Lichtenstein repair). The postoperative course was uneventful except for slight reddening of the wound edges without fever or leukocytosis. The patient was discharged on postoperative day 3. Bert Myers, MD Professor of Surgery Louisiana State University Medical Center Mail Stop 112 i601 Perdido St. New Orleans, LA 70146
To the Editors: Surgical tradition dictates closed suction drainage to prevent seroma formation after mastectomy and axillary node dissection for breast c a n c e r ) Postoperative h e m o r r h a g e after mastectomy is rare, with a reported incidence of 1.3%.2 We recently encountered a case of massive arterial h e m o r r h a g e caused by a closed suction drain. A 48-year-old woman underwent a mastectomy with axillary dissection for breast cancer with the insertion of two closed suction drains. One was placed in the axillary dead space, and one was placed medially, deep to the u p p e r skin flap. The patient h a d an uneventful recovery with a gradual decrease in drain output. Because the drainage was greater than 50 ml per day, the drains were left in place until postoperative day 7. At that time the drainage became bloody, a n d the flap turned blue. O n exploration of the wound, a 500 gm blood clot was found. In addition, a hole was present in a perforating b r a n c h of the internal thoracic artery where it came into contact with a side port of the nonaxillary drain. The arterywas ligated, and the suction drains were removed. The total blood loss was 1100 ml. Her recovery from the second operation was uneventful. There have b e e n three reports of intraabdominal visceral injury but n o descriptions of arterial bleeding caused by suction drainage. 35 The mechanism of this complication appears to be pressure necrosis of the arterial wall. Surgeons should be aware of this potential complication when placing drains. Tatsuya Nomura, MD Yoshio Shirai, MD Haruhiko Okamoto, MD Katsuyoshi Hatakeyama, MD Department of Surgery Niigata University School of Medicine 1 Asahimachi-do~i Niigata 951, Japan
References 1. Moreno IG. The rational treatment of hernias and voluminous chronic eventrations: preparation with progressive pneumoperitoneum. In: Nyhus JB, editor. Hernia. Philadelphia: JB Lippincott, 1978:536-52. 2. Radovan D. Tissue expansion in soft-tissue reconstruction. Hast Reconstr Surg 1984;74:482. 3. Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin stretching device for the harnessing of the viscoelastic properties of skin. Hast Reconstr Surg 1993;92:260-70.
11/59/79605
References 1. Aitken DR, Minton JP. Complications associated with masteetomy. Surg Clin North Am 1983;63:1331-52. 2. Budd DC, Cochran PC, Sturtz DL, Fouty WJJr. Surgical morbidity after mastectomy operations. AmJ Surg 1978;135:218-20. 3. Benjamin PJ. Faeculent peritonitis: a complication of vacuum drainage. BrJ Surg 1980;67:453-4. 4. Gray AJ, Copeland GP. Small bowel perforation following vacuum suction drainage. J R Coll Surg Edinb 1985;30:324-5. 5. Reed MWR, Wyman A, Thomas WEG, Zeiderman MR. Perforation of the small bowel by suction drains. BrJ Surg 1992;79:679. 11/59/79604
Angiographic localization with m e t h y l e n e b l u e and radiopaque microcoil To the Editors: Angiographic localization with methylene blue or anglographic embolization with microcoil 1 is successful in locating SURGERY
477