A nulliparous woman aged 45 years was
referred to us with painful swelling in left lower limb. She
underwent laparoscopic hysterectomy for menorrhagia
12 days prior to the admission. The laparoscopic surgery
was completed in 90 min without blood loss and blood
transfusion. The size of the uterus was approximately
12 weeks. Duplex scan of the left lower limb confirmed
thrombosis of the left external iliac vein, femoral vein,
popliteal vein and tibial veins. On examination the laparoscopic puncture wounds healed well. She was hospitalized for initial anticoagulation with low molecular weight
heparin (Enoxapain 1 mg/kg body weight twice daily) and
compression bandages. Histological examination of the
hysterectomy specimen was noted to be benign (Adenomyosis and cervical Leiomyoma). She responded to anticoagulation therapy and was discharged with an advice to
attend the follow up clinic for long term anticoagulation
advice for the next 6 months to prevent recurrent thromboembolic episodes.
Keywords : DVT (deep vein thrombosis) Laparoscopy Hysterectomy
Hysterectomy is a common gynecological operation performed in women to solve the benign and malignant
problems of uterus. Abdominal hysterectomy is considered
to be a major operation and more risky than vaginal hysterectomy or laparoscopic hysterectomy. Venous thrombosis and pulmonary embolism are known to occur in
major abdominal surgeries which last longer than 2 h.
Schorge et al. [1] noted that clinically significant VTE
following gynecological surgery is rare in the absence of
malignancy, prolonged surgical anesthesia or hypercoagulable factors. Gynecological laparoscopic procedures are
considered to be less invasive and early ambulation is
possible. Ageno et al. [2] found that gynecological laparoscopy in non-cancer patients is a low risk procedure for
post operative VTE [2]. Here we are reporting extensive
deep vein thrombosis (DVT) after total laparoscopic hysterectomy in a nulliparous woman which is considered to
be uncommon complication.
A 45 year old woman was referred to us with painful
swelling of the entire left lower limb. She noticed pain in the left lower limb 8 days after total laparoscopic hysterectomy operation which was completed in 90 min. The
operation was done to treat menorrhagia. The size of the
uterus was slightly bulkier ([12 weeks). On the 12th post
operative day she noticed swelling of the left leg and
duplex scanning showed proximal DVT involving the
external iliac, femoral popliteal and tibial veins. She was
moderately built and moderately nourished. The uterine
biopsy showed adenomyosis and cervical polyp but there
was no malignancy. She was nulliparous and she took some
treatments for infertility when she was 25 years old. There
were no known hypercoagulable conditions in her or in her
family. She did not have any symptoms of pulmonary
embolism. She moved out of bed on first post operative day
following the laparoscopic hysterectomy. The pressure of
pneumoperitoneum was maintained 12–15 mm of Hg and
the patient was operated in semi lithotomy position. There
were no untoward events during the surgery. She was given
low molecular weight heparin (Enoxaparin 60 mg twice
daily) subcutaneously and observed for 2 days in the hospital. She applied compression elastic bandages. The
swelling and pain promptly decreased and she was discharged to go home on request after 2 days. She was
advised to continue medication and attend the out patient
clinic for follow up advice on regular anticoagulation
therapy. She is advised oral anticoagulation for the next
6 months to prevent the recurrent venous thrombosis or
embolism in the follow up clinic.
It is a common perception that DVT and pulmonary embolism are rare in gynecological abdominal non cancerous surgeries and laparoscopic surgeries in our country. In our patient who is moderately built and moderately nourished DVT was noticed 12 days after the laparoscopic hysterectomy though she started walking (actively mobile) on first post operative day. There was no malignancy in the biopsy and there was no history of prior DVT. In the multi center study performed by Ageno et al., screening for DVT was done with ultrasound on day 7 and day 14 after the surgery and none of the 266 non cancerous patients developed DVT.
When large uterine myomas are compressing the pelvic
veins they develop venous thrombosis which can be suspected and treated preoperatively [3]. In many studies
(12 studies/945 patients) control subjects without prophylaxis have shown 16% incidence of DVT after gynecological surgeries. The maximum relative reduction (56%)
of the DVT was noted with low dose unfractionated heparin therapy (LDUH) in gynecological patients. It is
interesting to note the natural course of post operative
venous thrombo-emboli in gynecological oncology from
the studies done with I121 labeled fibrinogen leg counting in
328 patients. In 52% of the patients DVT was noted initially in the calf and out of that 27% dissolved spontaneously, 4% progressed to proximal veins and 4% developed
pulmonary emboli. Only 9 out of 328 developed the femoral vein DVT without calf vein DVT and one patient had
PE from internal iliac vein [4]. Clinically significant lower
limb venous thrombosis may be relatively more common in
cancer surgeries but is rare after laparoscopic gynecological surgery for benign pathologies. It should be suspected
when ever leg swelling is noted within 2–4 weeks after
such surgeries and treated promptly
