Massive hemorrhage is a potential complication of gynecological surgeries and prompt action is needed. The document discusses ways to prepare for and manage intraoperative bleeding through careful surgical techniques, understanding of pelvic anatomy, and use of hemostatic measures and ligation of blood vessels if needed. Internal iliac ligation can be a life-saving procedure to control bleeding when other methods have failed.

1. Tackling intraoperative bleeding during
Gynaecological Abdominal Surgeries
❖ Dr Rajesh Gajbhiye
❖ Consultant Gynaecologist
❖ Mauli Hospital & Alexis
hospital Nagpur

2. Massive pelvic hemorrhage is a potential complication in
any patient undergoing obstetric or gynecologic surgery.
Able to manage and know modalities
Knowledge of the anatomic distribution of the blood supply
to the pelvis and the coagulation system, is essential for
preventive measures.
Prompt action at the occurrence of pelvic hemorrhage can
significantly minimize life-threatening complications.

3. Intraoperative haemorrhage is generally defined as blood loss exceeding
1000 mL or requiring a blood transfusion.
Massive haemorrhage refers to acute blood loss of more than 25 percent
of a patient's blood volume or bleeding that requires emergency
intervention to save the patient's life.2

4. ❖ Preoperatively
❖ Correction of anaemia
❖ Bleeding disorders

5. ❖ Patients at More risk for haemorrhage
❖ Large pelvic masses
❖ Adhesions-endometriosis & PID
❖ Malignancies
❖ Coagulation dysfunction
❖ Prior radiation

6. ❖ Prepare in advance for pelvic haemorrhage
❖ Availability of adequate blood
❖ Anesthesia team to monitor blood loss,output
❖ Call for assistance
❖ Bren stated-“Few gynaecologists have not had a routine
procedure abruptly transformed into a life threatening
drama”

7. To control any significant bleeding we need
Proper light
Proper visualisation of bleeding vessel
Manoeuvres and techniques to reduce bleeding
Proximal and distal control
Proper instrumentation
Avoid blind suturing and efforts
Have Confidence and patience
Keep a clear head even in presence of massive haemorrhage
Boost moral support of assistants and nursing

8. ❖ Proper Surgical Methods
❖ Exposure and incision
❖ Suction -less trauma to serial surface& calibration blood
loss
❖ Good Clamps
❖ Skeletonization
❖ Large pedicles, slipping
❖ No traction on vascular pedicles
❖ Transfixation,Double Ligation-Uterines,TO,IPL

9. ❖ Speed of surgery-cautious around deep pelvic veins
❖ Longer instruments-obese patients,deep pelvis
❖ Meticulousness in dissection,gentle handling of
tissues,accuracy in hemostasis
❖ Good suture material with tight knotting

10. Preventive measures
❖ Myomectomy for large myoma
❖ Uterine ligation
❖ vasopressin
❖ Tourniquets

11. Steps of haemorrhage
management
❖ Arterial bleeding -Spurters can be easily identified
❖ Isolated vessel-grasp with haemostat
❖ Ligation,electrosurgical coagulation
❖ Venous plexus haemorrhage is difficult
❖ Thin walled veins,fragile,tortuous
❖ Blood returning from deeper sources,unavailable for ligation
❖ Indiscriminate clamping -worsen the problem
❖ Large vein laceration -no cautery
❖ If vital structure retracted

12. ❖ Site compressed -Use of index finger pressure,tamponade
lacerated vessel as pressure is low
❖ Advantage-less tearing and trauma
❖ For 7 min,
❖ surrounding dissection -apply ligature
❖ suction out blood

13. Local Topical Hemostats
❖ Low pressure bleeding-veins capillaries and small
arteries
❖ Mechanical hemostat-Gelfoam
❖ Active hemostats-Human thrombin
❖ Fibrin sealents-Cryoprecipitate +Thrombin

16. ❖ Anaesthesist staff informed
❖ Nursing informed
❖ Fluid resuscitation
❖ Blood

17. ❖ Inscision incresed for adequate exposure
❖ Pfannenesteil -Cherny
❖ Adding retractors
❖ Second suctioning system
❖ Dissection of avascular plane around bleeding site
while protecting vulnerable structures

18. ❖ field not clutterd
❖ Adequate relaxation

19. Tranexamic Acid
❖ Massive haemorrhage may be complicated by
coagulopathy and uncontrolled microvascular
haemorrhage
❖ 1 gm IV

21. Bleeding Continues
❖ Internal Illiac Ligation
❖ Ant supplies to central pelvic viscera
❖ Reduces Blood flow by 48%,Pulse pressure by 85%
❖ Promotes thrombosis to occur
❖ Collateral circulation
❖ No compromise to pelvic organ viability
❖ Normal post ligation fertility

26. Internal Illiac ligation
❖ pelvic peritoneum lateral to IPL or medial to IPL
❖ Indentify the external iliac and internal Illiac
❖ Mixter is placed under vessel 3-4 cm from bifurcation
❖ Lateral to medial avoid injury to ext illiac vein.
❖ Two 1 no sutures ligated
❖ Beneath int Illiac vein

27. Prophylactic ligation
1 Pelvic inflammatory disease: Operation for pelvic
inflammatory disease often is difficult, and bleeding is profuse.
Ligation may decrease the constant ooze.
2 Extensive endometriosis: Adhesions are frequently dense.
Diminished blood supply facilitates the operative procedure.
3 Wertheim's hysterectomy: Ligation of the hypogastric
arteries should be an integral part of Wertheim's operation.

32. TRANSCATHTER ARTERIAL
EMBOLOTHERAPY
❖ Selective aretrial embolization -After vaginal abdominal
hysterectomy and other gynaecological surgeries
❖ Ca Cx,GTT
❖ O’Hanlan -Six pt postop embolotherapy
❖ 3 controlled and 3 facilitated

33. ❖ Collaterals embolisation
❖ Saureacker et al reported direct intraoprative
embolisation of hypogastric artery on one or other side

35. Specific sites of bleeding
❖ Infundibulo pelvic ligament
❖ lacerated ovarian vessel hematoma
❖ Retroperitoneally the hematoma is explored till the
normal vessel identified
❖ Ovarian Ligated

36. Axilla of pelvis
❖ Bifurcation of common iliac artery and vein
❖ Hypogastric veins -risk during lymphadenectomy
❖ External iliac vein

37. Presacral venous plexus
❖ This area is called corona mortis
❖ Lacerated Sacrocolpopexy,presacral neurectomy,post. extenteration
❖ cut vessel may retract in bone
❖ inserting stainless steel thumbtacks
indirect coagulation through a muscle fragment
Multiple layers of Gelfoam and collagen is tightly sewn over
foramen

39. Parametrial and Paravaginal
vessels
“WEb”of paracervical tissue contains branches of hypogastric artery and vein
carefully ligated during radical hysterectomy
Hemorrhage from vaginal angles during or after abdominal hysterectomy:
With good reason, the vaginal angles are characterized as “coffin corners.”
Vaginal artery is not secured properly or becomes dislocated
Always anchor lateral to angle,so angle cannot slip
Mass sutures placed in this area frequently incorporate a ureter.
IIL

43. Major pelvic vessels Injury
❖ Common iliac,External & Internal
❖ IVC
❖ Aorta
❖ pressure applied
❖ vascular surgeon called
❖ blood products

44. Paraaortic LN
❖ Para aortic Lymph node -Lacerations to aorta/IVC
❖ Lacerations IVC ,sponge and two fingers suture with 5-0
proline
❖ Lacerations in Common illiac vein ,external iliac vein
should be repaired though can be ligated

45. ❖ Internal illiac ligation -no ischemia
❖ External repaired to maintain blood supply lower limb
❖ keep vascular clamps 2-3 cm distal & proximal
❖ close defect with 5-0 monofilament suture.

49. If transfusion exceeds 10-12 units
bleeding is not under control
Clear assessment must be made in consultation with the
anesthesiologist.
If the patient is cold, has metabolic acidosis, and continues to bleed,
it may be wise to totally pack off that portion of the abdominal cavity that
is bleeding; to close the skin of the abdomen, only not the rectus fascia; to
send the patient to the surgical intensive care unit for correction of all vital
signs, temperature, electrolytes, and clotting factors; and to return the
patient in 48 hours under good surgical conditions to remove the packs
and control any residual hemorrhage if found.

50. Packing
❖ Cases with intractable haemorrhage
❖ Poor access for suturing
❖ Failed medical management
❖ Internal illiac done
❖ Disseminated intravascular coagulation

57. Conclusions
❖ Prepare in advance for difficult cases
❖ Know the anatomy and vascular supply well
❖ Know the coagulation systems
❖ Know the danger areas well
❖ Internal illiac Ligation life saving procedure
❖ Arterial embolization is a good armamentarium in controlling
hemorrhage
❖ Packing can be used as rescue if nothing is responding

58. “Thankyou.”