1. Surgical Pearls (Beads) Mark K. Dodson, M.D. Professor Department of OB/Gyn Division of Gynecologic Oncology University of Utah

2. I have no financial interests to disclose.

3. Controlling Pelvic Bleeding Developing Pelvic Spaces to Identify Blood Supply Packing Increase Abdominal Pressure

4. Pelvic Spaces and Boundaries Paravesicle Space Medial:Obliterated Umbilical A. Lateral: External Iliac V. Inferior: Bladder Superior:Cardinal Ligament Pararectal Space Medial: Ureter Lateral:Iliac Vessels Inferior:Cardinal Ligament Superior:Sacrum

5. Management of Intraoperative Hemorrhage PRESSURE

6. Intraoperative Control of Oozing During Laparoscopy Increase Abdominal Pressure to 20 mmHg Normal: 5 - 7 mmHg Morbid Obesity: 9 - 14 mmHg Intraabdominal Hypertension: > 15 mmHg Abdominal Compartment Syndrome: > 25 mmHg Transient Increases Appear to be Safe

7. Refractory Intraoperative Hemorrhage Pelvic Pressure Pack Sterile Plastic Bag Laparotomy Towels IV Tubing Container of Fluid

8. Pelvic Pressure Pack

9. Umbrella Pack

10. Pelvic Pressure Pack 11 Patients Life Threatening Hemorrhage 10 Obstetrics, 1 Gynecologic 9/11 Successful (82 %) Post-Op Fevers (Antibiotics) Dildy et al Obstet Gynecol 2006

11. Berci Fascial Closure Device Closing Laparoscopic Port Site Controlling Abdominal Wall Bleeding

12. Berci Fascial Closure Device

15. Endo Close

16. Cost of Fascial Closure Endo Close$35 - $50 Berci$1090

17. Ureterolysis Enter Retroperitoneum Develop Pararectal Space Identify Ureter at Medial Leaf of Broad Ligament (At Common Iliac Artery) Dissect Free From Medial Leaf Dissect Parallel Along Ureter

18. Removing CO 2 From Abdominal Cavity To Assess for Bleeding at Low Pressure Decrease Postoperative Shoulder/Upper Abdominal Pain and Nausea/Vomiting

19. Reducing Laparoscopic-Induced Shoulder and Abdominal Pain RCT (116 Patients) Passive Deflation thru Cannula Trendelenberg Position (30°) Pulmonary Recruitment Maneuver 5 Manual Inflations of Lungs Significant Improvement in Shoulder/Upper Abdominal Pain, Nausea/Vomiting (>1/2) Phelps, et al. Obstet & Gynecol, May 2008

20. Placement of Adhesive Sponge for Anti-Fog Place in Most Efficient Site Possible

21. Dimpling at Laparoscopic Port Site When Superficial SubQ Tissue is Tethered to Fascia Even Heavy Women Do Not Like Dimples Undermine with Index Finger

22. Closing Fascia with No Tension at Knot Weakest Site of Suture is the Knot Corners of Incision Have Least Tension Prevents Direct Tension at Knot

23. Difficult Dissection at Level of Bladder Fill Bladder with Fluid to Evaluate Contour Allow Foley to Curl in Bladder Tape Foley to Leg to Prevent Tension Use 10cc of Fluid at Bulb