A Case Report

Amriansyah Pranowo Imamsoedjana*, Amru Sungkar**

Suwardi***, Prasetyo Sarwono Putro***
*Resident of General Surgery, Faculty of Medicine, Sebelas Maret University Surakarta
**Consultant Plastic Reconstructive Aesthetic Surgery Dr.Moewardi Hospital Surakarta
***Consultant Paediatric Surgery Dr.Moewardi Hospital Surakarta
**** Consultant of Interventional Radiology Dr. Moewardi Hospital Surakarta
• Hemangiomas are benign vascular tumors with complication of giant
hemangioma.
• It is reported 60% is occurred in cervico-facial region and 1% in
abdominal wall.
• Hemangioma could be clinically diagnosed on physical examination
and patient’s history.
• Although medications are the most common therapy, but surgery
could replace to achieve better outcome in severe case of
hemangioma

Ojili V, et al. Abdominal hemangiomas: a pictorial review of unusual, atypical, and rare types. Canadian Association of Radiologists Journal
2013;64:18-27
Case Report
Girl 4 years old came to Dr.Moewardi Hospital accompanied by her
mother with chief complaints Swelling in the right abdomen region. A
painless red swelling and it growing progressively. The Urination &
defecation are in normal condition.
Physical Examination
• From the physical examination there were swelling in lower right
quadrant of abdomen to periumbilical, the size was 20 x 10 cm.
Some part in redness color and blue-colored. Tender in palpation.
There was compressible with no pain and no bruit.

Courtesy of Amru Sungkar, MD

 Figure 2.

CT-Scan

Courtesy of Amru Sungkar, MD

 Figure 3.

Arteriography

Courtesy of Amru Sungkar, MD

 Courtesy of Amru Sungkar, MD

laparascopy Diagnostic continued with

Figure 4.
Excision with harmony scalpel leaving skin defect 15 x 10 cm
 Figure 5. Figure 5.
Post Op Day 2 Post Op Day 6

Figure 5.
Post Op Day 13 Courtesy of Amru Sungkar, MD
Post Op Day 6 Post Op Day 14 Courtesy of Amru Sungkar, MD

Figure 4. Delayed Closured with STSG, Thickness ± 90 %

 The Operation

Laparascopy, Arteriography and embolization

Hemangioma excision

Leaving skin defect, size 15x10cm, fascia as the base

Delay closure with skin graft, thickness 90%

 • Most common
Infantile • Appear since birth
Hemangioma • Growing progressively in months
• Spontaneously involutes

Congenital • Growing completely after birth

Hemangioma • Could involute or remain the same.

In this case

• The skin defect appeared since birth → Infantile Hemangioma

Liang MG Frieden IJ. Infantile and congenital hemangiomas. Seminars in Pediatric Surgery Volume 23, Issue 4, 2014, Pages 162-167
 Mostly affected skin → cervicofacial (60%) &
extremities (25%)

Visceral organs → liver, spleen, intestinum,

heart, brain

Abdominal wall → 1%

Frieden IJ, et al. Infantile hemangiomas: Current knowledge, future directions. Proceeding of a research workshop on infantile hemangiomas.
Pediatr Dermatol 2005;22(5):383-406
 • Low birth weight
• Prematurity
• Advanced maternal age
• Placenta previa
• Preeclampsia
• Amniocentesis & villi chorionic sampling
• Fertility drugs, erythropoietin
• Breech presentation
• First pregancy

Darrow DH, et al. Diagnosis and management of infantile hemangioma: executive summary.PEDIATRICS; 2015; 136 (4):
786-91.
 Abberation of
Uncontrolled vascular
angiogenesis and
element proliferation
vasculogenesis process

Frieden IJ, et al. Infantile hemangiomas: Current knowledge, future directions. Proceeding of a research workshop on infantile hemangiomas.
Pediatr Dermatol 2005;22(5):383-406
 Varied in size, location, depth & clinical stage

Early sign → blue-red colored patch on the

skin

Pain in ulcerative hemangioma

Warm on palpation

Bruit → sign of blood vessels→ involution

phase

Frieden IJ, et al. Infantile hemangiomas: Current knowledge, future directions. Proceeding of a research workshop on infantile hemangiomas.
Pediatr Dermatol 2005;22(5):383-406
 Morphology

•Localized
•Segmental
•Intermediate
•Multifocal

Bruckner AL, Frieden IJ. Infantile hemangioma. J Am Acad Dermatol 2006;55:671-82.

 Superficial Combined (capillary
Deep (cavernosus)
(capillary) cavernosus)
• in 50-60% cases • in 15% cases • In 25-35% cases
• Appears on skin • spongy, can be • Red-colored skin
• soft, nodule or seen as a swelling with blue colored
red-purple plaque • warm and in the base
• Present since compressible in • Red-colored
birth, or soon after palpation subcutaneous
born, grow rapidly, mass
and spontaneously • arteriovenous
regress fistula sometime
• Salmon patch, Port appear
wine stain

Bruckner AL, Frieden IJ. Infantile hemangioma. J Am Acad Dermatol 2006;55:671-82.

 Hemangioma Classification
Type 1 Neonatal staining
Intradermal capillary hemangiomas
A.Salmon patch
Type 2
B. Port wine stain
C. Spider angiomas
Juvenile hemangiomas
A. Strawberry mark
Type 3
B. Stawberry capillary hemangioma
C. Capillary cavernous hemangioma
Arteriovenous fistulae
Type 4 A. Arterial hemangiomas
B. Hemangiomas giantism
Type 5 Cirsoid angioma (racemose aneurysm)
Bruckner AL, Frieden IJ. Infantile hemangioma. J Am Acad Dermatol 2006;55:671-82.
 Differential diagnosis of hemangioma in baby
Tumors and other vascular abnormalities
Capillary malformation
Venous malformation
Lymphatic malformatin
Arteriovenosus
Uninvoluted congenital hemangioma
Nonprogressive congenital hemangioma
Rapid involution hemangioma
Lobular capillary hemangioma (pyogenic
granuloma)
Tufted angioma
Spindle cell hemangioendothelioma
Hemangioendothelioma caposiform
Fibrosarcoma
Rhabdomyosarcoma
Miofibromatosis (include hemangioperisitoma)
Nasal glioma
Lipoblastoma
Dermatofibrosarcoma protuberants
(and giant-cell fibroblastoma)
Neurofibroma
Frieden IJ, et al. Infantile hemangiomas: Current knowledge, future directions. Proceeding of a research workshop on infantile hemangiomas.
Pediatr Dermatol 2005;22(5):383-406
In this case

• A 4 years old female came to Dr Moewardi Hospital accompanied by the

parent with chief complaint of lump in the right abdomen. A painless
tender compressible red lump grow progressively as the size of 20x10 cm
with reddish and bluish appearance. There was no bruit on the physical
examination on the right lower region umbilical region to periumbilical
region. Normal urination & defecation were found in the patient.
Swelling with the size of 20x10 cm in lower right quadrant of abdomen
to periumbilical. Some part in redness color and blue-colored. The defect
appeared since birth, with initially small red patch then grow
progressively. Bruit/sound of blood flow (-) → not in the involution
phase. Ulcer(-), pain (-), Palpation compressible (+). Based on the history
taking and physical examination, the patient was diagnosed with
infantile hemangioma segmental type, cavernosum hemangioma
 • Steroid (triamcinolone) effective on
MEDICAL proliferation phase
THERAPY • β-blocker (propanolol)
• Interferon

SURGICAL • embolization
THERAPY • Excision

Weiss, Enzinger. ‘Benign Tumors and Tumor Like Lesion of Blood Vessels’. In Soft Tissue Tumor. Mosby Elsevier,2008; pp. 633-63
Boyd VC, Bui D, Naik B, Levy ML, Hicks MJ, Hollier L. Surgery: the treatment of choice for hemangiomas. Seminars in Plastic Surgery; 2006;
20(3):163-8
 Surgical indication

• Tumor grows progressively

• Uncontrolled pain (ulcerated)
• Limitation in function
• Risk of necrotic skin
• Thrombocytopenia
• Defect in cosmetic aspect
• Suspected malignancy

Boyd VC, Bui D, Naik B, Levy ML, Hicks MJ, Hollier L. Surgery: the treatment of choice for hemangiomas. Seminars in Plastic Surgery; 2006;
20(3):163-8
 Operative

• Patients continue to present with lesions that

cause permanent disfigurement after
previous reassurances that the lesion would
not be problematic
• Families need to be counseled regarding
treatment of these lesions
• All parents of children with hemangiomas,
regardless of size or location, should be
offered the option of surgery

Boyd VC, Bui D, Naik B, Levy ML, Hicks MJ, Hollier L. Surgery: the treatment of choice for hemangiomas. Seminars in Plastic Surgery; 2006;
20(3):163-8
Embolization
• Therapeutic management to occlude the
blood vessel
• To arrest or prevent hemorrhaging
• To devitalize a structure, tumor or organ
• By delivering materials as embolic agents

Dasgupta R, Fishman SJ. ISSVA classification. Semin Pediatr Surg. 2014; 23(4):1588-61
 Curative
• To deliver the embolic material into the center of the
vascular anomaly. Used in extensive lesions or
inaccessible lesions.

Palliative
• Indicated for relief of symptoms, such as hemorrhage,
pain, or when the lesion cannot be totally resected.

Preoperative
• Employed to diminish blood loss and facilitation
surgery.

Medsinge A, et al. A Case-Based Approach to Common Embolization Agents Used in Vascular Interventional Radiology. AJR. 203:699-708. 2014.
Embolization procedure

Embolization is done under local

anesthesia, sedation or general
anesthesia.

Diagnostic angiography is performed as

a separate procedure to delineate the
arterial supply and venous drainage.

Percutaneous arterial access: either

femoral or radial artery.
 A guiding catheter, positioned proximally, is used
to study the vessels. A microcatheter introduces
through the guiding catheter to select the feeding
pedicle and to place the embolic material. For
preoperative purpose, embolization is done
usually 24 to 48 hours prior to surgery.

Control angiography is carried out to evaluate the

therapeutic end point.

Gart L dan Ferneini AM. Interventional Radiology and Bleeding Disorders What the Oral and Maxillofacial Surgeon Needs to Know. Oral
Maxillofacial Surg Clin N Am. 28: 533-542. 2016.
 Embolic Agents
Duration of Action Embolic Agents

Temporary Gelatin sponge (Gelfoam, Pharmacia &

Upjohn), oxidized cellulose, microfibrillar
collagen
Permanent
• Nonabsorbable PVA, TAGMs
microparticles
• Mechanical Coils (pushable, injectable, detachable),
agents detachable plugs

• Liquid agents Ethanol, sodium tetradecyl sulfate

o Sclerosants NBCA glue, ethylene vinyl alcohol (Onyx,
o Polymers Micro Therapeutics)

Medsinge A, et al. A Case-Based Approach to Common Embolization Agents Used in Vascular Interventional Radiology. AJR. 203:699-708. 2014.
Excision
• technique for small lesions is very straightforward and involves
removing the abnormal vascular tissue with a lenticular, or lens-
shaped excision, that results in a linear scar
• Recently, some surgeons have been advocating the use of an
elliptical, circular, or irregular incision shapes, followed by a purse-
string-type closure → result in a scar having radial (starshaped) ridges
that can take several weeks to flatten.
• If the hemangioma is large, the excision followed by skin
reconstruction, and the site is covered with a skin graft.

Nomura T, Osaki T, Ishinagi H, Ejiri H, Terashi H.Simple and easy surgical technique for infantile hemangiomas: intralesional excision and primary closure. ePlasty 2015; 15:9-16
Goals of abdominal wall
reconstruction

• Provide stable soft-tissue coverage

• Restore fascial integrity
• Prevent hernia
• Protect abdominal viscera
• Restore function if possible

Althubaiti G, Butler CE. Abdominal Wall and Chest Wall Reconstruction.Plast. Reconstr. Surg; 2014; 133(5): 688e-701e
Reconstructive Surgery

• Dead space should be eliminated as

much as possible during reconstruction
• Extensive undermining of the skin should
be avoided
• The surgeon should also choose a
method of reconstruction that minimizes
the chances of bowel adhesions,
fistulization, and perforation.

Althubaiti G, Butler CE. Abdominal Wall and Chest Wall Reconstruction.Plast. Reconstr. Surg; 2014; 133(5): 688e-701e
Stable skin coverage

• primary closure of the skin

• local or regional flaps
• skin grafts
• tissue expansion
• free tissue transfer
• Flap selection will depend on the
location, extent, and size of the defect

Althubaiti G, Butler CE. Abdominal Wall and Chest Wall Reconstruction.Plast. Reconstr. Surg; 2014; 133(5): 688e-701e
• A 47-year-old male was found to have a giant hemangioma of the liver
measuring 22cm in its greatest diameter upon preoperative MRI. The
patient underwent preoperative trans-arterial embolization (TAE) of the
hemangioma, followed by extended right hepatectomy for definitive
treatment. Once the specimen was removed , hemostasis was maintained.
There were no complications during the operation, and the estimated
blood loss was 750 mL. The patient was discharged on postoperative day 7
after an unremarkable postoperative course.

Carpizo DR, Tieniber AD, Shah MM, Eng OS, John LN (2017) Preoperative Trans-Arterial Embolization and Surgical Resection
for Giant Liver Hemangioma: A Multidisciplinary Approach. Gastroenterol Pancreatol Liver Disord 5(2):1-6
• A 29-year-old woman was diagnosed with a giant cavernous
hemangioma. embolization was performed with PVA embosphere via
microcatheter. The postembolization DSA showed almost complete
occlusion of the hemangioma’s supplying artery and its main
branches. Then the patient was transferred to the operating theater
and a right posterior sectorectomy was performed. The hemorrhage
from the hepatic raw surfaces was minimal and no blood transfusion
was required.

Vassiou, Katerina & Rountas, H & Liakou, Paraskevi & Arvanitis, Dimitrios & Fezoulidis, Ioannis & Tepetes, K. (2007). Embolization of a
Giant Hepatic Hemangioma Prior To Urgent Liver Resection. Case Report and Review of the Literature. Cardiovascular and
interventional radiology. 30. 800-2. 10.1007/s00270-007-9057-y.
• A 45-year-old female presented with an aggressive vertebral
hemangioma centered within the T-8 vertebral body with bony and
soft tissue extension into the spinal canal and right T8–9 neural
foramen. Surgery was therefore scheduled to resect the lesion with
preoperative embolization under the same anesthesia to minimize
the risk of blood loss. Patient recovered to her neurological baseline.
At her first follow-up appointment her symptoms were completely
resolved and she reported only a small area of numbness in the
distribution of the right T-8 nerve root, which had been sacrificed.

Vasudeva, V et al. Surgical treatment of aggressive vertebral hemangiomas. Neurosurg Focus 41 (2):E7. 2016
Conclusion
• We reported a 4 y.o. girl with abdominal hemangioma that was
performed excision post embolization to minimize bleeding
intraoperative. The abdominal defect post excision was closed with
skingraft. The aims of surgery was achieved to gain normal function
and aesthetic results.
Conclusion
TERIMA KASIH