Prevention & Management of Acute Intra- & Postoperative Bleeding in Gynaecologic Surgery

1. Prevention & Management of Acute Intra- & Postoperative Bleeding in Gynaecologic Surgery 14-05-2009, 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….. 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

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 surgeryPreoperative prevention • History • Currentdisease • Intercurrent disease • Medication !! • Physical / gynaecologicalexamination • Laboratory • Coagulation disorders • Imaging • Preoperativepreparation • Order PC / FFP • Bowelpreparation • Antibioticprophylaxe • Thromboprophylaxe Ph. De Sutter Intra- & Postoperative Bleeding

6. Preoperative prevention Design the adequate procedure • Experience in clinicaljudgementis more valuablethensurgicalexperience! • Choose the appropriateprocedure for the right indication • Anticipate • Unexpectedoperativefindings • Complications • Comorbidity • Recognize and not exeedyour 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, meticuloushemostasis • Clamp / suturing • Monopolarcautery • Otherdevices • End with ‘dry’ operativefield • Drains? Ph. De Sutter Intra- & Postoperative Bleeding

10. Acute intraoperative bleeding Management • Calm & stepwiseapproach • Tamponade • Informanaesthetist • Monitoring • Orderblood / FFP • Evacuateblood • Adequateexposure / dissection of the site • Avoidindiscriminateclamping, clipping, suturing… • Secure adjacent structures • Identify and isolatebleeder 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 • Bladderpilars / posteriorbladder • Gonadalvessels • Inferiorvena cava • Common and externaliliacvessels • Parametrial / paracervicalvaricosities • Internaliliacvenoustributaries • Obturatorvessels and venous plexus • Presacralveins and plexus Ph. De Sutter Intra- & Postoperative Bleeding

13. 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

14. 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

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 (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

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 • Bilateralinternaliliacarteryligation … • Pelvicsidewall / Parametria / Obturator / Presacral fascia • Retractedveins • 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: + 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

23. Pelvic packing • Whenanyotherattemptfails….. • ….itcanbe the last successfulway to control life-threateninghaemorrhage • Stop surgery • 5 large laparotomy laps + Hemostaticproducts • 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