If the source of bleeding is unknown, apply pressure on the aorta using a hand, weighted speculum, or Conn aortic compressor (Pilling-branded, Teleflex Medical, Limerick, Pa).
Secure individual vessels with finetipped clamps and small-caliber sutures or clips, and minimize the use of clamps. Never place clamps or sutures blindly, and never use electrocautery for large lacerations.
If you choose to use packs to temporarily control bleeding, insert them carefully to avoid tearing veins, and place pelvic packs (hot or cold) in a stepwise fashion, from sidewall to sidewall. Leave packs in place for at least 15 minutes and remove them sequentially.
Great vessel injuries
The aorta, vena cava, and common iliac vessels are sometimes injured during removal of paraaortic nodes or when the inferior mesenteric vessels are avulsed during retraction of the sigmoid colon. In addition, needle or trocar injuries during operative laparoscopy occur in as many as 4 of every 10,000 procedures.3
Again, the first step in managing great vessel injuries is applying pressure. Then obtain blood components, and, if necessary, consult with a vascular surgeon or gynecologic oncologist.
In general, once the patient is hemodynamically stable, the affected vessel should be compressed proximally and distally. Use Allis or vascular clamps on the torn edges to elevate the lacerated area. My preference is to close these injuries with a running 5-0 or 6-0 nylon or monofilament polypropylene (MFPP) suture on a cardiovascular needle.
Replacing blood and its components
Be aware of the following replacement guidelines for catastrophic intraoperative hemorrhage:
- For every 8 U of red blood cells replaced, give 2 U of fresh frozen plasma.
- If more than 10 U of red blood cells are replaced, give 10 U of platelets, preferably at the end of the procedure.
- With prolonged PTT, give fresh frozen plasma.
- If fibrinogen is low, give 2 U of cryoprecipitate.1
When massive bleeding is anticipated or encountered, the Haemonetics Cell Saver (Haemonetics Corp, Braintree, Mass) is invaluable. This device, which requires a trained technician, removes blood from the operative field, anticoagulates it, and washes red blood cells, which are infused. It is accepted by many Jehovah’s Witnesses,4 and has been used safely in women with cesarean-associated bleeding.5 Relative contraindications include malignancy and bacterial contamination from a ruptured abscess or inadvertent injury to unprepared bowel.6 The Cell Saver may be used after heavy bleeding from hysterectomy or in patients with ruptured membranes.
STEP 3Try A Topical Hemostatic Agent
If hemorrhage contiues after arterial bleeders are secured, consider a topical hemostatic agent (TABLE 2). All such agents require pressure to be applied for 3 to 5 minutes.
My preferences are Surgicel (Johnson & Johnson, New Brunswick, NJ) and Gelfoam (Pharmacia, Kalamazoo, Mich). In general, Avitene Ultrafoam collagen hemostat (Davol, subsidiary of C.R. Bard, Murray Hill, NJ) works poorly in the presence of thrombocytopenia and should be used with caution near the ureter.
Fibrin glue has been widely used as a hemostatic agent in microvascular, cardiovascular, and thoracic surgery.
To prepare fibrin glue at my institution, we use a double-barrel syringe to apply equal amounts of cryoprecipitate and thrombin at the same time. One fibrin sealant, Tisseal VH (Baxter Healthcare, Deerfield, Ill), comes with a Duploject applicator. After the agent is thoroughly applied (it is sprayed), pressure is applied for 3 to 5 minutes.
The same manufacturer also produces Coseal, which is used in vascular reconstruction to achieve additional hemostasis by mechanically sealing off areas of leakage, and Floseal, to help achieve hemostasis when ligatures or clips are impractical.
TABLE 2
Topical intraperitoneal hemostatic agents
| AGENT | WHAT IT IS | HOW IT IS APPLIED |
|---|---|---|
| Avitene Ultrafoam | Absorbable collagen hemostat | Comes in powder; sprinkle on area |
Fibrin glue
| Equal amounts of cryoprecipitate and thrombin | Spray on affected area with double-barrel syringe or device supplied by Baxter Healthcare |
| Gelfoam | Absorbable gelatin sponge | Cut in strips of appropriate size and apply to area |
| Surgicel | Oxidized regenerated cellulose | Cut in strips of appropriate size and apply to area |
STEP 4Hypogastric Artery Ligation
SALLY’S CASE
Bleeding persists
Because of the hemorrhage, a gynecologic oncology consult is obtained and the hypogastric artery is ligated bilaterally, but bleeding continues. During further exploration, the left ureter is found to be ligated. Sally receives 65 U of packed red blood cells, platelets, and fresh frozen plasma. The Cell Saver also is used.
If pelvic oozing persists after application of a topical hemostatic agent, consider hypogastric artery ligation, which controls pelvic hemorrhage in as many as 50% of patients.7,8