1. 14-05-2009, PUS Antwerpen Ph De Sutter
Prevention & Management of Acute Intra- & Postoperative Bleeding in Gynaecologic Surgery
, PUS Antwerpen
Ph De Sutter

2. 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

3. The seven surgeons of King’s: a fable by Aesop……
Presacral bleeding after rectal resection… 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. (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

13. During surgical procedure Bilateral internal iliac artery ligation
Success % ??
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

14. Bilateral internal iliac artery ligation
Bilateral internal iliac artery ligation Prophylactic or therapeutic procedure?
Prophylactic ligation at radical hysterectomy
With: 465 ml ( ml)
Without: 856 ml ( 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

15. 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

16. 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

17. 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 ( ml)
BIIAL: 698 ml ( ml)
AC: 208 ml ( 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

18. 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

19. 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

20. 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

21. 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

22. 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: FFP / 2PC
PTT, APTT, Plat, Fib < 50%: + cryoprecipitate, fibrinogen
Temperature
Monitoring & support
AP, CVP, ventilation, urinary output, acidosis….
Ph. De Sutter Intra- & Postoperative Bleeding

23. 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

24. 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

25. 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

26. 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

27. 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