1. VCU DEATH AND COMPLICATIONS CONFERENCE Sihong SuyApril 5, 2012

2. Brief Overview of Case  Diagnosis:  Presacral schwannoma  Procedure:  Resection of presacral mass  Complication:  Intraoperative hemorrhage

3. Clinical History  HPI:  64 yo woman with no signifcant PMH Presented to her PCP with vague abdominal pain, urinary frequency and some degree of vaginal prolapse Underwent CT scan which revealed a heterogenous mass measuring 10 x 28 x 12.6 cm CT guided biopsy was performed with pathology consistent with schwannoma Referred to Surgical Oncology for evaluation for possible resection

13. Medical History  PMH:  Chronic back pain  Hypercholesterolemia  Uterine bleeding  SurgHx:  TAH with BSO  Meds:  Celebrex  Simvastatin  Allergies:  Codeine  Labs:  WBC 3.6  Hemoglobin 13.3  Platelet 265  SocHx:  Nephrolithiasis  Parathyroidectomy GM, GGM

14. Hospital Course  March 14 th :  To OR for ex lap and resection of presacral mass Mass was noted to be deep in pelvis Partially dissected it out anteriorly and sidewalls Difficulty exposing the posterior plane so dissected out using finger fracture technique Hemorrhage was not excessive > irrigate for closure > pooling of venous blood was noted > presacral packing was performed > presacral space continued to well up with venous bleeding No obvious large source of bleeding was identified  Patient was hemodynamically stable SBP 90-120’s, HR 60-90’s, UOP 65 ml/2 hours  Intraoperative CBC obtained showed hemoglobin 6.5 > repeat 5.3 2 units PRBC given

15. Hospital Course  March 14 th - POD 0 :  Patient became hemodynamically unstable Massive transfusion protocol initiated Cell saver called into room Intraoperative Vascular Consult  Continued packing and waited for anesthesia to catch up with resuscitation  Upon removal of packing 1 side branch from left common iliac vein and two presacral sidewall branches were noted to be bleeding controlled with 3-0/4-0 prolene  Patient continued to ooze from presacral area  Decision was made to pack the abdomen, place wound vac transfer pt to ICU for resuscitation/monitoring  Intraoperative resuscitation 7400 ml crystalloid/500 albumin/ 10 units PRBC/10 FFP/2 Platelets/ 1630 cell saver EBL 2300/UOP 100 Factor VII administered in STICU

17. Hospital Course  POD 1 :  Patient was hemodynamically stable 700 ml serosanguinous fluid from abdominal wound drain 1 Unit PRBC  POD 2:  Taken back to OR for exploration  Packs removed – No surgical bleeding  Abdominal closed  POD 12:  Uneventful course  Discharged home

18. Analysis of Complication Was the complication potentially avoidable? – Maybe. – Pre-operative angiography – possible pre-operative embolization – However would have been difficult to embolize small side branch and presacral veins Would avoiding the complication change the outcome for the patient? – Yes. Limited transfusion. Second operation and long hospital course What factors contributed the complication? – Patient’s disease process. Difficult exposure