A 48 y.o. male presents several hours after discharge from a bilateral laparoscopic hernia repair.

He presents with a BP of 70 and abdominal pain, nausea and vomiting.

What is wrong?

Our patient had a large retroperitoneal bleed into the space of retzius. The retroperitoneum is divided in three zones,  Zone I falls between the two psoas muscles and contains the abdominal aorta, pancreas and duodenum.  Zone II begins lateral to the psoas muscles on either side and contains the kidneys and portions of the colon. Zone III includes the bladder and presacral veins. The space of Retzius is zone III and is a potential space between the pubic symphysis and the urinary bladder.

The space of Retzius

Retroperitoneal hematomas can be traumatic or spontaneous.  In our patient it was the result of his surgery. In addition to surgery, trauma from blunt injuries or penetrating trauma can cause a retroperitoneal hematoma. The majority of patients  with retroperitoneal hematomas from blunt trauma have renal injuries or pelvic fractures.

The blue shows where retroperitoneal blood travels around the kidney

Most retroperitoneal hematomas do well with supportive care and blood transfusion alone.  The rate of invasive management (IR or surgery ) is less than 20%. Those with active extravasation on CT are most likely to need intervention. In the case of blunt trauma, surgery is more common, 77% in some studies because of associated intra-abdominal injuries

So is the bleeding intraperitoneal or extraperitoneal?

 In the case of our patient the repair was done with  a tranaabdominal preperitoneal approach(using a port at the umbilicus)  instead of a totally extraperitoneal approach.   So could there be peritoneal blood?

Yes, since the surgeon enters the peritoneal cavity to place a mesh over the hernia.  There is also possible interfascial spread of blood. In the case of our patient you know the source of the bleeding starts in the retroperitoneum because the space of Retzius is involved.  This  leads to a concern for injury to the Corona Mortis which  is an arterial or venous  connection between the obturator artery and  the external iliac or inferior epigastric arteries or veins.  It is located behind the symphysis pubis.   Injury to this artery has been reported in significant bleeds post hernia repair.

The corona mortis “crown of death” has been reported to cause significant bleeding in hernia repairs.

Our patient was given blood in the ED. The  hematoma in the space of Retzius enlarged.  Angiogram did not show a culprit vessel.  Unfortunately he had a complicated course.   He remained in shock and was given 2u RBC, 2u FFP,  3 L fluid in IR but remained hypotensive and was placed on levo and vaso drips. He was given more blood and his Hgb stabilized at 8. He developed scrotal edema and hypoxia.  Gradually, he was weaned from the vent and from oxygen.  He was discharged after 7 days and is currently doing well.

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Baekgaard J, Eskesen T, Lee J, et al. Spontaneous retroperitoneal and rectus sheath hemorrhage management , risk factors and outcomes. World J Surg. 2019 Aug;43(8):1890-1897.

Wang F, Wang F. the diagnosis and treatment of traumatic retroperitoneal hematoma. Pak J Med Sci. 2013Apr;29(2):573-6.

Gupta A, Borgos M, Ramseyer M. Major bleed post minimally invasive surgical repair of inguinal hernia Cureus 2020 Aug;12(8):e9940. 

Xu X, Teng F, Li J, et al. Life-threatening hemorrhage from the corona mortis treased with balloon-assisted coiling technique. Case Reports Am J Emerg Med. 2018 Mar;36(3):527.e1-527/e3/

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