14-05-2009, PUS Antwerpen Ph De Sutter Prevention & Management of Acute Intra- & Postoperative Bleeding in Gynaecologic Surgery 14-05-2009, PUS Antwerpen Ph De Sutter

Acute intraoperative bleeding Textbook knowledge….? Rare Sudden & Unexpected Rapid & massive Life-threatening & possible lethal Management can be challenging ….. Not 1 solution ! Master the situation Ph. De Sutter Intra- & Postoperative Bleeding

The seven surgeons of King’s: a fable by Aesop…… Presacral bleeding after rectal resection….. 10 UPC Coloproctologist Undersew bleeding sites Gynaecologist Used stainless steel clips Vascular surgeon Performed a bilateral internal iliac artery ligation Neurosurgeon Suggested a posterior approach?? Cardiothoracic surgeon Installed a cell saver and rapid transfusion system Orthopaedic surgeon Hammered some staples in the sacrum Transplant surgeon After 35 liter of transfusion! …………………….. King’s College London, BJOG; 1998 Ph. De Sutter Intra- & Postoperative Bleeding

Definition massive bleeding Estimated circulating blood volume (CBV) 60 ml/kg ~ 3600 ml / 60 kg ~ 4800 ml / 80 kg Transfusion of > 10 UPC / 24 h Loss of > CBV / 24 h Loss of 50% CBV in 3 h (~ 2000 ml) Loss of 150 ml / min Ph. De Sutter Intra- & Postoperative Bleeding

Complications of gynaecologic surgery Preoperative prevention History Current disease Intercurrent disease Medication !! Physical / gynaecological examination Laboratory Coagulation disorders Imaging Preoperative preparation Order PC / FFP Bowel preparation Antibiotic prophylaxe Thromboprophylaxe Ph. De Sutter Intra- & Postoperative Bleeding

Preoperative prevention Design the adequate procedure Experience in clinical judgement is more valuable then surgical experience! Choose the appropriate procedure for the right indication Anticipate Unexpected operative findings Complications Comorbidity Recognize and not exeed your limitations Refer to a collegue Ph. De Sutter Intra- & Postoperative Bleeding

Surgical prevention General Adequate exposure Laparotomy: extendable incision Laparoscopy: adequate material Optics / camera / insufflator… Vaginal surgery: sufficient access Positioning Trendelenburg Good relaxation Less packing Venous return Ph. De Sutter Intra- & Postoperative Bleeding

Surgical prevention Anatomy Thorough knowledge of pelvic anatomy Identify / restore anatomic landmarks Use extraperitoneal dissection Use avascular planes and spaces routinely Identify retroperitoneal structures routinely Ph. De Sutter Intra- & Postoperative Bleeding

Surgical prevention Hemostasis Continuous, meticulous hemostasis Clamp / suturing Monopolar cautery Other devices End with ‘dry’ operative field Drains? Ph. De Sutter Intra- & Postoperative Bleeding

Acute intraoperative bleeding Management Calm & stepwise approach Tamponade Inform anaesthetist Monitoring Order blood / FFP Evacuate blood Adequate exposure / dissection of the site Avoid indiscriminate clamping, clipping, suturing… Secure adjacent structures Identify and isolate bleeder Ph. De Sutter Intra- & Postoperative Bleeding

Vascular bleeding Arterial: pulse pressure Easy identified / prompt control Venous: low-pressure, high-volume Small Thumb forceps + coagulation Larger Vascular clip Proximal (+ distal) Clamp + ligature Major Vascular suture (prolene 4-6/0) Ph. De Sutter Intra- & Postoperative Bleeding

(Radical) Hysterectomy Potential sites of persistent bleeding Bladder pilars / posterior bladder Gonadal vessels Inferior vena cava Common and external iliac vessels Parametrial / paracervical varicosities Internal iliac venous tributaries Obturator vessels and venous plexus Presacral veins and plexus Ph. De Sutter Intra- & Postoperative Bleeding

During surgical procedure Bilateral internal iliac artery ligation Success 40-100% ?? Reduce Pelvic blood flow by 48% Mean arterial pressure by 24% Pulse pressure by 85%  Venous like system Collateral circulation Uterine / ovarian arteries Middle / superior vesical arteries Lumbar / iliolumbar Lateral sacral / middle sacral arteries Burchell: 1968 Ph. De Sutter Intra- & Postoperative Bleeding

Bilateral internal iliac artery ligation Bilateral internal iliac artery ligation Prophylactic or therapeutic procedure? Prophylactic ligation at radical hysterectomy With: 465 ml (300-850 ml) Without: 856 ml (300-2500 ml) P<0,0006 Therapeutic / selective No guidelines When important blood loss is expected When haemorrhage occurs Better early then late! Gharoro: J Obstet Gynaecol 2003; 23 Ph. De Sutter Intra- & Postoperative Bleeding

Bilateral internal iliac artery ligation Collateral circulation Ligation proximal to posterior devision Lumbar /iliolumbar arteries Middle sacral / lateral sacral arteries Ligation distal to posterior devision Superior / middle hemorrhoidal arteries Ph. De Sutter Intra- & Postoperative Bleeding

Bilateral internal iliac artery ligation Technique Identify iliac bifurcation and external iliac artery Retract ureter medially Dissect internal iliac artery at 2-3cm from the bifurcation Beware laceration underlying vein Place suture distal to the posterior division Ph. De Sutter Intra- & Postoperative Bleeding

Aortic clamping Prophylactic procedure Routine AC at radical pelvic surgery Max clamp time 1h Distal inferior mesenteric artery / cranial bifurcation Randomized 3x19 posterior exenterations for ovarian cancer No: 749 ml (300-1500 ml) BIIAL: 698 ml (250-2500 ml) AC: 208 ml (100-1100 ml) Mean clamp time 32 min (18-60 min) P<0,001 Eisenkop: Int J Gynecol Cancer 2004; 14 Ph. De Sutter Intra- & Postoperative Bleeding

Aortic clamping Prophylactic procedure? Aortic plaques / calcifications Periferal vascular disease (excluded from randomization) Vascular injury Risk of thromboembolism Heparin / protamine Limited time Hypotension at clamp release Delayed bleeding Ph. De Sutter Intra- & Postoperative Bleeding

Aortic clamping Therapeutic procedure Compression or clamping Sudden massive haemorrhage Unstoppable bleeding Temporary measure while: Restoring CBV & Coagulation Requesting assistance Ph. De Sutter Intra- & Postoperative Bleeding

Prolonged bleeding at end of surgical procedure Origin not identifiable Bilateral internal iliac artery ligation … Pelvic side wall / Parametria / Obturator / Presacral fascia Retracted veins Venous plexus Art sacralis media Haemostats & sealants Tamponade (Thumbtacks) Ph. De Sutter Intra- & Postoperative Bleeding

The seven surgeons of King’s: a fable by Aesop…… Presacral bleeding after rectal resection Coloproctologist Undersew bleeding sites Gynaecologist Used stainless steel clips Vascular surgeon Performed a bilateral internal iliac artery ligation Neurosurgeon Suggested a posterior approach?? Cardiothoracic surgeon Installed a cell saver and rapid transfusion system Orthopaedic surgeon Hammered some staples in the sacrum Transplant surgeon After 35 liter of transfusion! ……… Said to pack the pelvis and ……….called his anaesthetist Ph. De Sutter Intra- & Postoperative Bleeding

Massive bleeding The role of the anaesthetist Establish large-bore vascular accesses Maintain: Circulating volume First 25% loss of CBV: + crystalloids / colloids O² transport >25% loss of CBV: + erythrocytes (PC) Haemostasis > 4-6 PC: + 1 FFP / 2PC PTT, APTT, Plat, Fib < 50%: + cryoprecipitate, fibrinogen Temperature Monitoring & support AP, CVP, ventilation, urinary output, acidosis…. Ph. De Sutter Intra- & Postoperative Bleeding

Pelvic packing When any other attempt fails….. Stop surgery ….it can be the last successful way to control life-threatening haemorrhage Stop surgery 5 large laparotomy laps + Hemostatic products Stabilise patient ICU Hemodynamically / CBV Coagulopathy Remove packs after 1 – 5 days Re-laparotomy Vaginal Ph. De Sutter Intra- & Postoperative Bleeding

Angiographic embolisation Advantages Diagnostic Non invasive Identification of bleeding source Therapeutic More selective and distal occlusion Compared to surgical ligation Occlusion of collateral circulation Anatomic variability Ph. De Sutter Intra- & Postoperative Bleeding

Angiographic embolisation Disadvantages Not widely available Facilities Expertise Patient Haemodynamically stable Closed abdomen Not 100% effective But can be repeated Ph. De Sutter Intra- & Postoperative Bleeding

Ligation or embolisation? Dilemma or practical choise? Difficult after ligation of int iliac artery But not impossible No consensus on algorithm Ligation  embolisation Embolisation  ligation Intraoperative bleeding Different situation compared with PPH Atony Preservation of uterus Not necessarely CS / surgical exploration Postoperative bleeding Ph. De Sutter Intra- & Postoperative Bleeding

Postoperative bleeding Early & acute (< 6-12h) Sudden haemorrhagic (pre-)shock Arterial bleeding unsecured vascular pedicle Immediate surgical revision Delayed (> 12-24h) Gradual symptomatic Small arterial or venous bleeding / hematoma Evaluate / Compensate Revision if not stabilised 12-24h Surgical exploration Consider arteriographic embolisation Ph. De Sutter Intra- & Postoperative Bleeding