title: Massive intraoperative bleeding after laparoscopic assisted abdominoperineal resection: a case report and systematic review of the literature.
abstract: BACKGROUND
  The laparoscopic-assisted abdominoperineal resection (LAPR) has been proved to be associated with a shorter postoperative recovery, with equivalent oncological results and similar survival when compared with conventional open surgery, for patients with low rectal cancer.
  
  
  METHODS
  Case report of a massive intraoperative bleeding during LAPR and systematic review of the English language literature, using PubMed Medline, ISI Thopmson, OVID and EMBASE databases.
  
  
  RESULTS
  58 years old patient admitted in emergency setting or rectal bleeding. Rectal examination revealed a protruding,frail tumor, located 2 cm from the anal verge. Total colono scopy revealed an infiltrative, protruding tumor, situated at 2 cm from the anal verge, with a 5 cm cranial extension,without any additional colonic lesions. Computed Tomography showed a 4,5 cm circumferential rectal wall thickening, without any enlarged mesorectal or abdominal lymph nodes. The patient was transported to operating room for a LAPR. During final hemostasis, at the level of perineal surgical wound, an acute massive bleeding occurred from the presacral vessels with severe blood loss. This bleeding couldnot be managed laparo scopicaly and conversion to laparotomywas decided, with pelvic packing. At 48 hours after the initial surgical approach, the tamponing packs were removed, without signs of active bleeding. There were applied haemostatic agents and the perineal wound was sutured, without further rbleeding during in-hospital stay.
  
  
  CONCLUSIONS
  A rapid and effective control of the presacral bleeding is mandatory to prevent a fatal outcome. Pelvic packing remains a life-saving procedure and the treatment of choice in severe cases.
authors.forename: M
authors.initials: M
authors.lastname: Beuran
authors.forename: B
authors.initials: B
authors.lastname: Stoica
authors.forename: I
authors.initials: I
authors.lastname: Tănase
authors.forename: I
authors.initials: I
authors.lastname: Negoi
authors.forename: S
authors.initials: S
authors.lastname: Păun
mesh_terms: D014408:Biomarkers, Tumor / Q000097:blood; D016063:Blood Loss, Surgical; D002272:Carcinoembryonic Antigen / Q000097:blood; D003082:Colectomy / Q000009:adverse effects*; D061887:Conversion to Open Surgery; D006801:Humans; D007432:Intraoperative Period; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010502:Perineum / Q000601:surgery*; D012004:Rectal Neoplasms / Q000175:diagnosis / Q000601:surgery*; D016896:Treatment Outcome
chemical_list: D014408:Biomarkers, Tumor; D002272:Carcinoembryonic Antigen