Robot-Assisted Laparoscopic Application of Fibrin Sealant Patch for Repair of Inferior Vena Cava

We present a 36-year-old female with a history of stage IV endometriosis and recurrent catamenial pneumothorax, as well as a surgical history of an ovarian cystectomy five years prior and two unsuccessful thoracoscopic lung decortications two years earlier. During her second thoracoscopic decortication, multiple diaphragmatic fenestrations were plicated with staples, however, despite surgical intervention, the patient continued to experience recurrent pneumothorax, requiring multiple chest tube placements. She presented to our clinic with a right-sided chest tube and worsening symptoms, including bloating, vomiting, intestinal cramping, and hematochezia. The patient consented to the surgical plan, which included robotic-assisted laparoscopic bowel resection, adenomyomectomy, liver mobilization, excision of endometriosis, and repair of the right diaphragm. A multidisciplinary team, consisting of gynecologic, thoracic, and hepatobiliary surgeons, was assembled for the procedure. A laparoscopic view of the pelvis revealed extensive scarring and stage V endometriosis, along with a prominent diaphragmatic defect. After completing pelvic endometriosis resection and ileocecal bowel resection, liver mobilization commenced in a lateral-to-medial direction following the transection of the right triangular ligament. At the start of the thoracic portion of the procedure, it became clear that prior thoracic interventions, combined with the presence of endometriosis, had significantly distorted the normal anatomy of the region, particularly at the central tendon of the right hemidiaphragm. Extensive fibrosis over previous suture lines at the central tendon and liver dome made it difficult to identify a clear surgical plane. The fibrosis had caused proximal displacement and tenting of the IVC, which was not immediately apparent to the surgical team. The surgeon proceeded with dissection from a lateral-to-medial direction, using a harmonic vessel sealer to mobilize tissues below the fenestration for tension-free closure. At this point, the tip of the vessel sealer caused a 2-mm defect in the anterior wall of the suprahepatic vena cava, inadvertently breaching the vessel due to its entrapment in dense scar tissue ( Figure 1 ). This breach led to sudden and substantial venous hemorrhage, rapidly filling the upper dome above the liver ( Figure 2 ). Prompt application of compression using the robotic arm temporarily achieved hemostasis, and the patient remained normotensive. Conversion to an open approach for vena cava suture repair was considered. However, while considering alternative methods for achieving definitive hemorrhage control and repair of the vena cava, the use of a fibrin sealant patch emerged as a viable option. The fibrin sealant patch was applied with pressure at the lesion site for 20 minutes, successfully achieving temporary hemostasis and avoiding the need for open conversion ( Figure 3 ). Intraoperative view of the injury to the IVC by robotic laparoscopic instruments. Hemorrhage prior to fibrin sealant patch application. Intraoperative view of the application of fibrin sealant patch followed by 20 minutes of instrument compression to the area. The procedure resulted in a total blood loss of 250 mL. The patient prophylactically received 1 unit of packed red blood cells (PRBCs) intravenously and was infused with 2,000 mL of Plasmalyte and normal saline throughout the operation. She remained hemodynamically stable, with no further bleeding observed once the pressure was relieved. The initial chest tube, already in place upon arrival, was maintained to allow for appropriate drainage of the injury, and no additional chest tube was placed. A diaphragmatic fenestration, likely responsible for the pneumothorax, was identified during the procedure at the medial aspect of the diaphragm. The defect was effectively patched with the fibrin sealant patch, though this was not the device's primary intended use. Given the intraoperative complication and successful stabilization of the defect, no additional endometriosis lesions were excised, and the procedure was concluded after stabilization. Postoperatively, she remained stable, with no evidence of bleeding or hemoglobin drift. The chest tube was maintained for three months. At the 1-year follow-up, the patient showed no recurrence of pneumothorax and remained asymptomatic, indicating successful resolution of her condition.

Robotic surgery is increasingly used for common surgical procedures, with the adoption rate in hospitals rising significantly from 2012 to 2018. 1 However, during such minimally invasive procedures, there is a risk of iatrogenic vascular injuries, which often require conversion to laparotomy. A systematic review of minimally invasive surgical studies in gynecology (n = 66) reported a vascular injury rate of 0.09% during robotic-assisted laparoscopic surgery (n = 27,971), with approximately half (55%, 95% CI 46–63) requiring conversion to laparotomy for repair. 2 A multicenter study of patients with diaphragmatic and thoracic endometriosis (n = 50) demonstrated that 2% (n = 1/50) suffered a superior vena cava injury. 3 The current recommendations for treating major vessel injury during minimally invasive procedures with life-threatening hemorrhage are to perform a rapid laparotomy and control the bleeding with direct pressure until a vascular surgeon can provide appropriate management. 4 For example, a retrospective study of 40 patients with venous injuries during abdominal and pelvic operations demonstrated that 64% of operations used venography, 14% utilized end-to-end anastomosis, 20% used interposition graft placement, and 2% used vessel ligation. 5 However, there may be alternative techniques that manage bleeding while still facilitating a minimally invasive approach. We present a case of an iatrogenic injury to the suprahepatic IVC repaired by the application of a fibrin sealant patch via compression with a robotic arm. The fibrin sealant patch is composed of human fibrinogen and human thrombin, embedded in a cellulose matrix which, once hydrated, forms a stable clot barrier. 6 It is indicated for use in adult patients as an adjunct to hemostasis during surgery, particularly when conventional methods like sutures, ligatures, or cautery are ineffective or impractical. 7 However, its use is limited in cases of major arterial or venous bleeding and is not recommended for laparoscopic or minimally invasive surgeries where manual compression is difficult to perform. 7 Despite these limitations, numerous studies highlight the efficacy of fibrin sealant patches for controlling surgical bleeding in various settings, including liver surgeries as well as complex cardiovascular and thoracic interventions. 8 , 9

This is the first documented case of a suprahepatic IVC injury repaired using a fibrin sealant patch in a patient with DE undergoing robotic-assisted laparoscopic excision. Suprahepatic IVC injuries, as seen in this case, are among the rarest forms of IVC injuries and are associated with a high fatality rate. 10 , 11 The mortality rate of iatrogenic IVC injuries ranges from 16% to 32%. 5 , 12 A retrospective study of patients (n = 6) with iatrogenic IVC injuries during various surgical procedures demonstrated that the median estimated blood loss was 4,780 mL (range, 800–8,000 mL), which is significantly higher than the 250 mL experienced by our patient. 5 Other case reports have described off-label applications of fibrin sealant patches to control major venous bleeding in patients undergoing cardiac surgery and cesarean sections; however, these were not in the minimally invasive setting. 13 , 14 A retrospective study of 60 patients undergoing robotic-assisted laparoscopic excision of DE demonstrated that 1 patient (1.7%; 1 of 60) had a trocar-related liver injury, which led to conversion to laparotomy due to hepatic hemorrhage. 15 In our case, had the fibrin sealant patch not been utilized, a similar conversion to laparotomy would have been necessary. Additionally, a tremendous advantage of this product is its compatibility with standard 8-mm trocar placement while maintaining the product's integrity. The use of the fibrin sealant patch to control intraoperative bleeding from major vessels in robotic-assisted or minimally invasive surgeries warrants further investigation, as its proven safety and efficacy could enhance outcomes, reduce blood loss, and lower conversion rates to laparotomy. In a multicenter, prospective randomized controlled trial comparing the fibrin sealant patch (n = 50) to standard care (n = 52) for controlling bleeding during elective hepatectomy, the fibrin sealant patch, used to manage hemorrhage from hepatic veins, was associated with thrombotic events in a small subset of patients (n = 2/50). 16 Fortunately, for our patient, no such complications occurred during the postoperative period or follow-up examinations.