(1501) Fatal Hemorrhagic Shock After Panniculectomy Procedure: An Unusual Complication

Introduction: Rapid weight loss often leaves patients with a residual pannus, which can impair hygiene and limit mobility. Panniculectomy is a surgical procedure to remove the pannus (excess skin and tissue from the lower abdomen). Post-operative hematoma can occur in about 5-10% patients, however fatal hemorrhagic shock from postoperative bleed is rare. We present a rare case with fatal hemorrhagic shock after panniculectomy procedure.

Description: A 74-year-old male with history of morbid obesity and Roux-en-Y gastric bypass underwent an elective panniculectomy. Pre-procedure hemoglobin was 12.6 mg/dL. Procedure was uneventful with about 15 ml blood loss. 3 hours post-procedure, he endorsed dizziness, diaphoresis, and pallor. Vitals showed blood pressure 52/39mmHg, pulse 89 bpm, and respiratory rate 28/min. Exam revealed a firm abdomen, clean incision, and cool extremities. Surgery team was consulted, appropriate labs and massive transfusing protocol was ordered, and patient was transferred to the ICU. Repeat hemoglobin was reported as 6.8 mg/dL and unfortunately patient went into PEA arrest and expired despite all resuscitative efforts. The autopsy showed 2 large surgical site hematomas deep in the subcutis dissecting the subcutaneous fat down toward the hips and glutes.

Discussion: Post-operative bleeding is a well-known complication of panniculectomy however fatal hemorrhagic shock is rare. Bariatric surgery patients are at an increased risk of bleeding due to nutritional deficiencies and associated coagulopathy. Post-operative bleeding may pose a diagnostic challenge due to pooling of blood in dependent portions of abdominal cavity and relatively unremarkable physical examination. Hemodynamic instability may the first sign of ongoing post operative bleeding. The lethal triad of hypothermia, acidosis, and coagulopathy can further worsen ongoing hemorrhage leading to irreversible hemorrhagic shock and eventually death. Timely diagnosis and management can avoid progression to the lethal triad. 


Conclusion:

This case highlights a rare fatal complication of panniculectomy and the importance of early detection and management of post-op hemorrhage. Timely resuscitation with appropriate interventions to control post-operative hemorrhage is key to improving perioperative mortality.