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
  • Procedure: Surgical Evacuation & Vessel Ligation
  • Indications:
    • Skin Necrosis
    • Unstable or Enlarging with Failure of Angioembolization
  • Incision: Midline or Paramedian to Expose the Posterior Sheath (Avoid Entering the Peritoneum)