rectus sheath hematoma. surgical aspect

Rectus sheath hematoma (RSH) is a collection of blood within the rectus sheath due to injury or rupture of the superior or inferior epigastric arteries or rectus muscle.

1. Rectus Sheath Hematoma Done by: Isuru Rajaguru Group: 9 Sem: 11

2. Introduction Definition: Rectus sheath hematoma (RSH) is a collection of blood within the rectus sheath due to injury or rupture of the superior or inferior epigastric arteries or rectus muscle. Rare but often underdiagnosed cause of acute abdominal pain.

3. Anatomy of Rectus Sheath

4. Causes of RSH Blunt Abdominal Trauma : Direct impact (e.g., falls, motor vehicle accidents, sports injuries). More common in elderly or those with weakened abdominal muscles. Post-Surgical Complications : Laparoscopic or open abdominal surgeries can cause accidental injury to the epigastric vessels. Anticoagulation and Coagulopathies Anticoagulant Medications : Warfarin (increased INR leads to spontaneous bleeding). Heparin, Low Molecular Weight Heparin (LMWH), Direct Oral Anticoagulants (DOACs). Increased risk in patients with excessive INR (>4.0) or low platelet count . Pregnancy Hormonal Changes & Increased Abdominal Pressure : Progesterone-induced vascular relaxation can increase vessel fragility. Third trimester: Expanding uterus increases intra-abdominal pressure, predisposing to rectus sheath hematoma. Labor & Delivery : Straining during vaginal delivery or caesarean section may rupture rectus muscle capillaries.

5. Causes of RSH Chronic Coughing (e.g., COPD, tuberculosis, chronic bronchitis). Severe Vomiting (e.g., hyperemesis gravidarum, gastroenteritis). Heavy Lifting & Strenuous Exercise : Weightlifting, resistance training, or core-intensive workouts can stress the rectus muscle. Malignancy & Underlying Pathologies Intra-Abdominal or Retroperitoneal Tumors : Invasive malignancies (e.g., pancreatic, colorectal cancer) may erode nearby blood vessels. Connective Tissue Disorders : Ehlers-Danlos Syndrome, Marfan Syndrome → Weakened vessel integrity, increased bleeding risk.

6. Berna Classification of RSH

7. Clinical Features Symptoms: Acute-onset abdominal pain: (most common symptom) Sudden and sharp pain, often unilateral. Worsens with movement, coughing, or sneezing. May be localized (often in the lower abdomen) but can radiate. Firm mass in the rectus sheath: Tenderness over the lower abdomen. Found in moderate to severe cases. Located between the umbilicus and pubis (below arcuate line). More common in larger hematomas (Type II and III). Bruising or ecchymosis: Visible discoloration over the lower abdomen or flanks. Develops over 24–48 hours (indicative of expanding hematoma). Ecchymosis Cullen’s sign (periumbilical bruising) – suggests deeper bleeding. Grey Turner’s sign (flank bruising) – severe cases with retroperitoneal extension. Fox’s sign (bruising over the inguinal ligament) – suggests lower extension. Nausea & vomiting - Local Signs

8. Specific Clinical Tests Fothergill’s Sign Ask the patient to tense the abdominal wall (by lifting their head or legs while lying down). A rectus sheath hematoma remains palpable and does not shift , unlike intra-abdominal masses. Carnett’s Sign Press the painful area while the patient lifts their head or contracts the abdominal muscles. If the pain increases , it suggests anterior abdominal wall pathology (RSH). If the pain decreases , the source is likely intra-abdominal (appendicitis, peritonitis). Systemic Signs (In Severe Cases) Tachycardia & Hypotension Seen in large hematomas leading to hypovolemia. Pallor & Cold Sweats Indicates significant blood loss . Reduced Haemoglobin (Anaemia) Suggests ongoing haemorrhage in chronic or expanding hematomas . Peritoneal Signs (Rigid Abdomen, Guarding, Rebound Tenderness) Seen in Type III hematomas that rupture into the peritoneal cavity. May mimic surgical emergencies (appendicitis, bowel perforation).

9. Investigations Complete Blood Count (CBC) – Detects anemia (↓ Hemoglobin in active bleeding). Coagulation Profile (PT, INR, aPTT ) – Identifies anticoagulation-related bleeding. Renal Function Tests (Urea, Creatinine) – Assesses kidney function before contrast imaging. Liver Function Tests (LFTs) – Evaluates coagulopathy from liver disease. Blood Type & Crossmatch – Prepares for transfusion in significant hemorrhage . Lactate & Arterial Blood Gas (ABG) – Elevated in shock and tissue hypoxia. Imaging Studies A. Ultrasound (USG) – First-Line Bedside Test Quick, non-invasive, and bedside accessible. Identifies hematoma but less sensitive than CT for deep or expanding bleeds . Doppler USG detects active arterial bleeding . B. CT Scan – Gold Standard Best diagnostic tool – Defines extent, severity, and active bleeding . Differentiates hematoma from tumors , abscesses, or ruptured aneurysms . Helps guide embolization and surgical decisions . C. MRI – For Complex Cases Alternative when CT contrast is contraindicated (e.g., kidney failure, allergy). Superior soft tissue resolution, useful for chronic hematomas or tumors . not ideal for unstable patients . D. Angiography – For Bleeding Control Detects active arterial bleeding and allows embolization (selective artery occlusion). Used when CT shows ongoing hemorrhage in hemodynamically unstable patients .

10. Non surgical Management Indications : Hemodynamically stable, small to moderate hematomas. Measures : Bed rest and observation. Pain control (NSAIDs or opioids if needed). Local ice application. Reversal of anticoagulation if necessary. Compression bandaging to minimize expansion. Follow-up : Serial imaging in selected cases. Indications for Surgical Management Absolute Indications : Hemodynamic instability unresponsive to resuscitation. Active extravasation on imaging. Large hematoma causing abdominal compartment syndrome. Peritoneal signs indicating rupture into the peritoneal cavity. Relative Indications : Failure of conservative management. Progressive enlargement despite treatment. Management

11. Surgical Management Angioembolization (Minimally Invasive) – First-line for Active Bleeding Preferred in hemodynamically stable patients with active bleeding on imaging. Selective embolization of the superior or inferior epigastric artery. Surgical Exploration (Laparotomy) – For Unstable Patients Indicated for massive, expanding hematomas or failed embolization . Allows direct control of bleeding and removal of large hematomas. Operative Steps : Incision – Midline or transverse laparotomy based on hematoma location. Hematoma Evacuation – Clots are removed with suction and irrigation. Bleeding Control :- Direct ligation of bleeding vessels (superior/inferior epigastric artery). Electrocautery or hemostatic clips if needed. Hemostatic agents ( Surgicel , Fibrin glue) for additional control. Inspection of Surrounding Structures – Ensure no bowel perforation or vascular injury. Drain Placement – In large hematomas to prevent reaccumulation . Closure – Layered closure of abdominal wall.

12. Surgical Management Laparoscopic Approach – Alternative to Open Surgery Minimally invasive option in select cases. Reduced post-op recovery time and lower infection risk . Indications : Localized rectus sheath hematomas. Hemodynamically stable patients requiring evacuation. Procedure : Port placement – Trocar insertion at suitable sites. depends on hematoma location : Umbilical port (10 mm) – Primary access for laparoscope. Two additional 5 mm working ports (placed under direct vision). Hematoma drainage – Suction and irrigation. Electrocautery or ligation of bleeding vessels. Haemostatic agents applied to the bleeding area. Drain placement if necessary .

13. Potential Complications of Surgery These can be categorized as early (within days) and late (weeks to months after surgery) . Early Post-Surgical Complications (Within Days) 1. Hemorrhage & Rebleeding Cause : Inadequate hemostasis , retraction of ligated epigastric vessels, or resumption of anticoagulation too early. 2. Wound Infection & Surgical Site Infection (SSI) Risk Factors : Contamination during surgery. Presence of necrotic hematoma tissue . Diabetes, obesity, or immunosuppression . 3. Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE) Cause : Reduced mobility post-surgery leads to venous stasis . 4. Paralytic Ileus (Postoperative Bowel Dysfunction) Cause : Handling of the bowel during surgery. Increased abdominal pressure from hematoma or post-op edema . 5. Seroma or Persistent Fluid Collection Cause : Incomplete hematoma evacuation or excessive dead space.

14. Late Post-Surgical Complications (Weeks to Months Later) 6. Abdominal Wall Hernia Cause : Weakening of the rectus sheath after surgical hematoma evacuation . 7. Adhesions & Chronic Pain Syndrome Cause : Fibrosis within the rectus sheath following surgery. 8. Skin Necrosis & Wound Breakdown Cause : Tension on wound edges post-surgery. Compromised blood supply from prior hematoma pressure. 9. Recurrence of Rectus Sheath Hematoma Cause : Resumption of anticoagulation too soon. Persistent hypertension or coagulopathy .

15. Differential Diagnosis Appendicitis Key Difference: No palpable rectus sheath mass ; pain is not localized within the rectus sheath . Diverticulitis Key Difference: No rectus sheath mass; pain follows bowel-related symptoms . Perforated Peptic Ulcer Key Difference: No ecchymosis or abdominal wall mass ; history of acid-related disease. Ruptured Abdominal Aortic Aneurysm (AAA) Key Difference: Pulsatile mass , severe hemodynamic instability, no rectus sheath tenderness. Retroperitoneal Haemorrhage Key Difference: No well-defined abdominal wall mass , hemorrhage is deep. Rectus Muscle Rupture (Without Hematoma) Key Difference: No palpable hematoma or discoloration .

16. Gynecological Causes (in Females) Ruptured Ectopic Pregnancy Key Difference: Gynaecological history, no rectus sheath hematoma , internal pelvic bleeding. Ovarian Torsion Key Difference: No abdominal wall mass, no ecchymosis. Musculoskeletal & Soft Tissue Causes Hernia Key Difference: Hernia is reducible , does not have ecchymosis . Abdominal Wall Abscess Key Difference: Abscess is fluctuant, may have pus drainage, no underlying bleeding. Differential Diagnosis

17. Prognosis Favourable Prognosis: Small, self-limiting hematomas (Type I & II) resolve with conservative management. Early diagnosis and non-operative treatment lead to full recovery in most cases. Most patients recover without long-term complications. Poor Prognostic Factors: Delayed diagnosis leading to large hematomas. Severe anticoagulation-related bleeding. Hemodynamic instability or ACS. Infection and abscess formation in untreated cases. Mortality Risk: Rare but can occur in elderly, anticoagulated, or critically ill patients. Mortality rates increase if surgical intervention is delayed in hemodynamically unstable patients.

18. Prevention Strategies Careful Use of Anticoagulation Therapy Monitor INR in warfarin patients to prevent over-anticoagulation. Use of DOACs (direct oral anticoagulants) in high-risk patients (lower bleeding risk vs. warfarin). If bleeding risk is high, consider adjusting dosage or switching medications. 2. Avoid Excessive Abdominal Strain Educate patients to avoid heavy lifting, violent coughing, or intense exercise . Use abdominal binders in post-surgical or at-risk patients. Caution in pregnancy (third trimester) to minimize strain.. 3. Early Identification of Risk Factors Screen high-risk patients (anticoagulated, hypertensive, elderly, pregnant). Regular monitoring for early signs of hematoma formation (bruising, tenderness). Bedside ultrasound can aid in early diagnosis in hospital settings. 4. Postoperative Monitoring & Gradual Mobilization Early detection of RSH in postoperative patients reduces complications. Gradual mobilization to prevent sudden muscular strain. Avoid NSAIDs in post-surgical patients with bleeding risk.

19. References - Berna, J. D. et al., AJR Am J Roentgenol, 2000. - Cherry, W. B., Medicine (Baltimore), 2006. - Hatjipetrou, A., Int J Surg, 2015. - Fitzgerald, J. E., Int J Surg, 2009. "Rectus Sheath Hematoma Treatment & Management" – Medscape Percutaneous Arterial Embolization in the Management of Rectus Sheath Hematoma" - American Journal of Roentgenology "Rectus Sheath Hematoma Associated with Low Molecular Weight Heparin" - The Annals of The Royal College of Surgeons of England "Rectus Sheath Hematomas" - Cleveland Clinic

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