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

Introduction: There is a risk of iatrogenic vascular injuries during robotic-assisted laparoscopic excision of diaphragmatic endometriosis. Although studies are limited, the first reported case of a suprahepatic inferior vena cava (IVC) injury during robotic diaphragmatic endometriosis excision was successfully treated using a fibrin sealant patch, preventing exsanguination and conversion to laparotomy.

Case description: A 36-year-old female with a history of recurrent catamenial pneumothorax and two prior video-assisted thoracoscopic surgeries to treat diaphragmatic endometriosis presented to our clinic with right-sided shoulder pain and a chest tube in place. She underwent robotic-assisted laparoscopic pelvic and bowel resection for severe endometriosis and liver mobilization to repair the right diaphragm. During liver mobilization, the surgeon inadvertently caused a 2-mm defect in the suprahepatic IVC, resulting in 250 mL of venous hemorrhage. Hemostasis was achieved using robotic compression of a fibrin sealant patch, avoiding conversion to laparotomy. The chest tube was maintained throughout surgery and postoperatively for drainage. The patient experienced no thrombotic complications.

Discussion: This case illustrates the successful use of a fibrin sealant patch to control a major vascular injury in the robotic-assisted laparoscopic setting. While fibrin sealant patches are Food and Drug Administration-approved for soft tissue hemostasis, their application in major vascular repairs, including the IVC, is off-label. The blood loss (250 mL) and absence of thrombotic events highlight the safety and efficacy of the fibrin sealant patch. Further investigation is warranted to establish the efficacy of fibrin sealants in the repair of major vascular injuries in robotic-assisted and traditional laparoscopic surgeries.