Massive hemothorax caused by Gelpi retractor during posterior correction surgery for adolescent idiopathic scoliosis: A case report

Background context: Gelpi retractors are used in surgery because they can reduce paravertebral muscle damage during retraction. No pleural injuries associated with their use in posterior spine surgery have been reported. Purpose: To describe a patient who suffered a massive postoperative hemothorax caused by a Gelpi retractor used during posterior correction surgery for adolescent idiopathic scoliosis (AIS). Study design: Case report. Methods: A case report of a rare hemothorax complication due to a Gelpi retractor is reported. The relevant literature was reviewed. Results: A 12-year-old girl with Lenke type 2 AIS, with curves of 60° at T2-7 and 75° at T7-L1, underwent posterior correction and fusion surgery using a segmental pedicle screw construct placed between T2 and L2. Although the patient's vital signs were stable during and soon after the surgery, a chest x-ray taken one day later revealed a massive left hemothorax. Her hemoglobin concentration was decreased to 5.5g/dl, and SpO₂ remained as low as 92% even with oxygen administration. Thoracoscopy revealed subpleural hemorrhaging at several points in the left upper intercostal area (T3-6), and a penetration of the pleura between the left 4th and 5th ribs. Active bleeding had already stopped. The tip of the Gelpi retractor appeared to have penetrated the pleura. A chest tube was placed in the patient to treat the hemothorax. Conclusions: A pleural injury by the Gelpi retractor was determined to be the cause of the hemothorax in this case. The patient's prominent thoracic hump may have increased the risk of such an injury because the tip of a Gelpi retractor might easily have become stuck in the intercostal space rather than the paravertebral muscles.