What is the recommended surgical approach for evacuating a large abdominal wall hematoma?

Surgical Approaches for Large Abdominal Wall Hematoma Evacuation

For large abdominal wall hematomas requiring evacuation, minimally invasive approaches such as endoscopic evacuation or percutaneous mechanical thrombectomy should be the first-line surgical intervention, with open surgical evacuation reserved for cases with active arterial bleeding or failed minimally invasive approaches. 1

Assessment and Initial Management

• Evaluate hemodynamic stability first, as large abdominal wall hematomas can cause substantial hemorrhage requiring fluid resuscitation 2
• Perform CT imaging to assess the size, location, and presence of active bleeding, which is crucial for surgical planning 3, 4
• Consider angiography for patients with evidence of active bleeding on CT scan to identify the bleeding vessel 3, 5

Surgical Approach Algorithm

First-Line: Minimally Invasive Techniques

• Percutaneous mechanical thrombectomy is effective for evacuating persistent post-surgical hematomas in a single setting with minimal tissue trauma 1
• Benefits include reduced operative time, possibility of performance under local anesthesia, and reduced tissue trauma 6
• This approach is particularly beneficial for deep lesions and can facilitate earlier evacuation than conventional open surgery 6

Second-Line: Endovascular Embolization

• For hematomas with identified active arterial bleeding (commonly from deep circumflex iliac artery or superficial/deep inferior epigastric arteries), angiography-directed therapeutic embolization should be performed 3, 5
• Embolization can be done using materials such as Spongel or Microcoils 3
• This approach helps avoid unnecessary surgical procedures while effectively controlling bleeding 3, 4

Third-Line: Open Surgical Evacuation

• Open surgical evacuation should be performed when:
  • Minimally invasive approaches fail 7
  • Active arterial bleeding continues despite embolization 7
  • Patient shows signs of hemodynamic instability 4
• The surgical approach involves:
  • Making an incision over the hematoma site 7
  • Evacuating fresh and clotted blood 7
  • Identifying and ligating any actively bleeding vessels 7
  • In some cases, resection of adjacent structures may be necessary to access the bleeding source 7

Special Considerations

• For patients on anticoagulant/antiplatelet therapy (common in abdominal wall hematoma cases), consider reversal of anticoagulation before surgical intervention, weighing risks and benefits 2, 4
• Damage control principles should be applied in severely injured patients with hemorrhagic shock, signs of ongoing bleeding, coagulopathy, or hypothermia 6
• When definitive fascial closure cannot be achieved after hematoma evacuation, consider skin-only closure with delayed abdominal wall reconstruction 6

Post-Procedure Management

• Monitor the size of the hematoma with ultrasound examinations after intervention 3
• For large defects following evacuation, consider component separation technique for reconstruction of abdominal wall defects 6
• In cases with exceptionally large defects, microvascular tensor fasciae latae flap may be a feasible option 6

Pitfalls and Caveats

• Unnecessary surgical interventions can worsen outcomes, especially in elderly patients with multiple comorbidities 4
• The reduced surgical exposure in minimally invasive approaches may limit the ability to treat structural lesions or identify all bleeding sources 6
• Prolonged indwelling catheters in minimally invasive approaches may increase infection risk 6
• Conservative management is successful in 90.6% of cases, so surgery should be reserved for specific indications 4