Hemorrhage during surgery
You are performing a laparoscopic right salpingo-oophorectomy on a 40 yr old woman for pelvic pain collateral to right tubo-ovarian abscess. The operative field is uncertain due to extensive adhesions and distorted anatomy. During dissection of the suspensory ligament of the ovary from the ureter, you suddenly notice active, brisk bleeding at the level of the pelvic brim, which rapidly fills the pelvis.
Attempts to secure adequate visualization of the source of bleed with suction irrigation were insufficient due to continuous & profuse bleeding.
- Active intra-op hemorrhage
- No source of bleeding localized
- Apply pressure with a sponge
- Activate bipolar energy
- Place ‘figure of 8’ stitch
- Bilateral internal iliac artery ligation
- Thrombin hemostatic agents
Apply pressure with a sponge
Intraoperative hemorrhage is defined as surgical blood loss of more than 1 L, or one that necessitates a blood transfusion. A detailed preoperative evaluation and the adoption of safe surgical techniques are detrimental in reducing the risk of complications. Nonetheless, it may not be possible to prevent the occurrence of all complications, and intraoperative hemorrhage is among the most common to occur.
The initial step to control hemorrhage would be tamponade. Applying pressure to the area of bleeding will allow the patient to stabilize, while more definitive measures are arranged for. During laparoscopy, atraumatic grasapers may be utilized to tamponade the bleeding blood vessel. Gauze sponges could be introduced through a port for application over.
diffuse areas of bleeding, or in cases where the exact source of bleed is elusive. If the tamponade is not effective, or the defect perceived to be beyond the capacity of laparoscopic repair, a vertical midline incision should be promptly created to allow adequate access the major blood vessels.
Electrosurgery, sutures, and surgical clips can be used to control small-vessel bleeding. However, these measures can only be taken following clear identification of vital structures, and isolation of the bleeding vessels. The limited visualization described in the case, and the retroperitoneal nature of the surgery, should defer the surgeon from mass stitches or the indiscriminate use of electrosurgery, in fear of unintentional injury to surrounding structures.
If initial attempts to control the hemorrhage are ineffective, the next step would be to reduce pelvic blood flow. Bilateral internal iliac artery ligation would lower the rate of blood flow to the pelvis by half, and the pulse pressure of the vasculature by 85%. The system would thus be transformed into a low-pressure system, one that is more responsive to clot formation. This procedure should not be the first-line approach, and should only be performed by experienced surgeons.
Topical hemostatic agents, such as thrombin, aid in control of diffuse, low-volume venous bleeding. They are not as effective for intraoperative hemorrhage described as fairly ‘brisk’.
- SP Y, JG C, WH P. Management of Hemorrhage During Gynecologic Surgery. Clin Obstet Gynecol . Available from: https://pubmed.ncbi.nlm.nih.gov/26398297/
- WH P, WH W. Gynecologic surgery and the management of hemorrhage. Obstet Gynecol Clin North Am . Available from: https://pubmed.ncbi.nlm.nih.gov/20674784/