Surgical Approaches for Abdominal Wall Hematoma Evacuation
The standard surgical procedure for evacuating a large abdominal wall hematoma is percutaneous mechanical thrombectomy, which allows for effective evacuation with minimal tissue trauma in a single setting. 1
Initial Assessment and Management
- Evaluate hemodynamic stability first, as large abdominal wall hematomas can cause substantial hemorrhage requiring fluid resuscitation 1
- Consider reversal of anticoagulation before surgical intervention for patients on anticoagulant/antiplatelet therapy, weighing risks and benefits 1
Surgical Options for Hematoma Evacuation
- Percutaneous mechanical thrombectomy is the primary surgical approach for evacuating persistent abdominal wall hematomas with minimal tissue trauma 1, 2
- Endovascular embolization is indicated when active bleeding is identified, particularly when the source is the deep or superficial inferior epigastric artery 3, 4, 5
- Open surgical evacuation may be necessary in cases where minimally invasive approaches are insufficient or when there are complications requiring direct visualization 6
Special Considerations
- For severely injured patients with hemorrhagic shock, signs of ongoing bleeding, coagulopathy, or hypothermia, damage control principles should be applied 1
- When definitive fascial closure cannot be achieved after hematoma evacuation, consider skin-only closure with delayed abdominal wall reconstruction 6, 1
Post-Procedure Management and Reconstruction Options
- For large defects following evacuation, consider component separation technique for reconstruction of abdominal wall defects 6, 1
- In cases with exceptionally large defects, microvascular tensor fasciae latae flap may be a feasible option 6, 1
- Ultrasound examinations can be used repeatedly to monitor the size of the hematoma after intervention 4
Common Pitfalls and Caveats
- Reduced surgical exposure in minimally invasive approaches may limit the ability to treat structural lesions or identify all bleeding sources 1
- Prolonged indwelling catheters in minimally invasive approaches may increase infection risk 1
- Conservative management may be sufficient for smaller hematomas without active bleeding, but persistent, recurrent, or symptomatic hematomas typically require intervention 2, 7
- Failure to identify the correct bleeding vessel (deep vs. superficial epigastric arteries) may lead to unsuccessful embolization attempts 3, 4