Management of inadvertent mesenteric hematoma during total radical colectomy

A 76-year-old man was diagnosed with rectal carcinoma along with simultaneous growths in the ascending and descending colon. He underwent a total radical colectomy without complications. However, immediately after removal of the breathing tube, there was significant fresh blood accumulation in the abdominal drain, indicating active bleeding. An urgent re-exploration revealed a substantial amount of blood in the abdominal cavity and active venous bleeding from the superior mesenteric vessels territory, which was successfully controlled with sutures.

During observation, a hematoma in the mesentery, measuring 5 × 5 cm, was noted at the suture site, which rapidly expanded to 10 × 10 cm within 20 minutes. This expansion occurred despite the absence of identifiable active bleeding, likely due to the bulky fat pad and hematoma. It was suspected that the arterial knot had slipped off, and the open end of the artery had retracted under the fat pad, making it difficult to locate.

The patient received blood products and required inotropic support. Once stabilized, he underwent urgent angioembolization in the cathlab, which revealed active bleeding from a branch of the right colic artery. The bleeding was successfully controlled with coil and glue embolization. Post-embolization angiography confirmed no further active bleeding. 

Following one day of intensive care unit monitoring, the patient was transferred to the ward. He was discharged on the seventh post-operative day without any complications. 

Mesenteric hematoma typically occurs due to blunt abdominal trauma or as a complication of various medical conditions. Most cases can be managed conservatively, but if the hematoma expands rapidly or causes hemodynamic instability, intervention such as angioembolization or surgery may be necessary. Angioembolization is particularly favored as it is less invasive and safer, especially in cases where the bleeding source is difficult to locate during surgery. 

In conclusion, urgent angioembolization is a preferred option in cases of mesenteric hematoma with expanding hematomas, where locating the bleeding artery is challenging due to hypotension and hemodynamic instability. 

Conflict of Interest Disclosure: All authors have declared financial and personal relationships that could potentially influence their work.

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