Abdominal Wall: Rectus Sheath Hematoma

Basics

• Hematoma within the Rectus Sheath
• Most Common Cause: Injury to Epigastric Vessel Branches
  • Most Are Spontaneous & Not from Trauma
• Risk Factors: Female/Elderly (Smaller Muscle) & Anticoagulation

Presentation

• Painful Abdominal Mass
• Fothergill’s Sign – Does Not Cross Midline & Does Not Change with Flexion
  • Hernias are Generally More Painful/Prominent with Rectus Flexion
• Carnett’s Sign – Point of Maximal Tenderness Does Not Change from Supine to Sitting

Types Mn

• Type I – Small, Confined to Rectus, Does Not Cross Midline
• Type II – Confined to Rectus, Crosses Midline
  • Dissects Along Transversalis Fascial Plane
• Type III – Large, Not Confined
  • Usually Below Arcuate Line (Severe Bleeding – No Aponeurosis to Contain)
  • Often See Blood in Prevesical Space of Retzius

Diagnosis

• Dx: CT or US

Treatment

• Stable: Observation
• Unstable or Enlarging: IR Angioembolization
• Surgery Indications:
  • Skin Necrosis
  • Unstable or Enlarging with Failure of Angioembolization
• *Remember to Reverse Anticoagulation as Needed

Surgery

• Procedure: Surgical Evacuation & Vessel Ligation
• Incision: Midline or Paramedian to Expose the Posterior Sheath (Avoid Entering the Peritoneum)
• Inferior Epigastric Artery Ligation:
  • Incision: Oblique Over the Groin
    • Carried Down to the Inguinal Ligament
  • Inferior Epigastric Found Branching Off the Medial Aspect of the Distal External Oblique
  • Rarely Required Only for Persistent Bleeding that Cannot Be Controlled