P3490 - Clip to the Rescue: Unusual Case of Lower GI Bleeding After Laparoscopic Hysterectomy

Landon Kozai, MD¹, Chase Warashina, MD¹, Arvin Tan, MD², Traci T. Murakami, MD^3
1University of Hawaii, Honolulu, HI; ²University of Hawaii, John A. Burns School of Medicine, Honolulu, HI; ³Queen's Medical Center - West Oahu, Ewa Beach, HI

Introduction: Laparoscopic surgery is associated with shorter length of hospital stay, reduced pain, and shorter recovery times when compared to open abdominal surgery. A rare complication of laparoscopy is bowel injury due to laceration or electrocautery, leading to perforation. We present a case of lower GI bleeding due to a perforated rectum after laparoscopic surgery.

Case Description/Methods: A 43-year-old woman was admitted for rectal bleeding. She had a history of laparoscopic hysterectomy with bilateral salpingo-oophorectomy and lysis of adhesions for endometriosis and leiomyomata two days prior. She complained of tenesmus, small volume stool, hematochezia, and persistent lower abdominal discomfort associated with the passage of bowel movements since the surgery. Digital rectal exam revealed dark blood and no visible hemorrhoids. Mild diffuse abdominal tenderness was noted. CT abdomen and pelvis with IV contrast showed a 9 x 4 x 4.8 cm post-operative hematoma posterior to the bladder. Colonoscopy revealed a 7 mm ulcer in the rectum about 5 cm from the anal verge with a clot indicating recent bleeding. A perforation was noted once the clot was washed away with bubbles arising from the ulcerated area, indicating a fistulous tract. Using a trans nasal slim scope, the fistula was intubated, revealing a cavity containing a hematoma. The defect was repaired using an upper endoscope and re-approximated using an over-the-scope clip. She then underwent emergent diagnostic laparoscopy and evacuation of the pelvic hematoma. A rigid proctoscopy was negative for air leak post-endoscopic repair.



Discussion: Gastrointestinal tract injuries are a rare, but serious complication of laparoscopic surgery occurring in 0.13% of cases. Awareness of potential injury is critical, as little as one-third of bowel injuries are detected intraoperatively, and around 50% are detected postoperatively. This is due to a lack of typical symptoms of bowel injury such as fever, nausea, vomiting, ileus, and abdominal pain. Thus, the diagnosis is often delayed, which can lead to life-threatening peritonitis. Postoperative anemia, leukocytosis, benign residual post-laparoscopic pneumoperitoneum and abdominal discomfort can obscure the diagnosis. It was suspected that this patient sustained thermal injury related to electrocautery, leading to ulceration and perforation of the rectum. Bowel injury should be suspected in any patient with recent laparoscopy who presents with GI bleeding.



Disclosures:


Landon Kozai, MD¹, Chase Warashina, MD¹, Arvin Tan, MD², Traci T. Murakami, MD³. P3490 - Clip to the Rescue: Unusual Case of Lower GI Bleeding After Laparoscopic Hysterectomy, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.