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Minimally invasive surgery?
  1. Alejandro Chavarriaga1,
  2. Amy Wyrzykowski1,
  3. David V Feliciano2
  1. 1 Department of Surgery, WellStar Atlanta Medical Center, Atlanta, Georgia, USA
  2. 2 Shock Trauma Center/Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr David V Feliciano, Shock Trauma Center/Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA; davidfelicianomd{at}

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A 43-year-old woman with a body mass index of 35.1 presented to an ambulatory surgery center for a laparoscopic sleeve gastrectomy. A Veress needle was used to access the peritoneal cavity. When the laparoscopic camera was inserted, massive hemorrhage was noted. Laparoscopic control of the bleeding was attempted but was unsuccessful, and the patient was converted to a laparotomy. Because of the massive hemorrhage, the source was unable to be identified. A total of eight non-vascular clamps were placed in the abdomen in an attempt to control bleeding. The estimated blood loss at the outside facility was reported to be 5 L. The patient’s abdomen was packed, she was transfused 2 units of packed red blood cells and fresh frozen plasma, and then transferred to a level 1 trauma center.


The most appropriate first step in the management of this patient in addition to resuscitation at the center is:

  1. Thoracotomy/X-clamp descending aorta.

  2. Call an endovascular surgeon.

  3. REBOA in the emergency room.

  4. Perform thromboelastography.


The patient arrived at the center on an intravenous drip of norepinephrine at 16 μg/min and with intermittent intravenous infusions of 1 mg epinephrine. As retrograde endovascular occlusion of the aorta (REBOA) was not available at the center at the time, the patient was taken directly from the ambulance bay to the operating room and the massive transfusion protocol was initiated. The patient’s blood pressure was 80/50, her arterial pH was 6.93, and the base deficit was −24.

At laparotomy, there was obvious hemorrhage from the distal infrarenal abdominal aorta just above the bifurcation. There was maceration of approximately 1 cm of the anterior aorta encompassing 50% of …

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