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Control of Hemorrhage
in Gynecologic Surgery

The gynecologic surgeon operating in the pelvis and abdomen is constantly performing surgery in the vicinity of large vital blood vessels. Occasionally, one of these large blood vessels will be accidentally entered, producing profuse hemorrhage.

Large abdominal and pelvic arteries should be repaired. Small defects in abdominal and pelvic veins should likewise be repaired with surgical suturing. Difficult laceration in large veins that cannot be repaired easily must be tied off. The only vein in the abdominal and pelvic cavity that cannot be tied off is the portal vein. Tying the vena cave may produce temporary bilateral leg edema until collateral circulation is established.

The basic of hemorrhage control should be mastered by all abdominal and pelvic surgeons. This topic has been divided into the following parts:

• Repair of the Punctured Vena Cava
• Ligation of a Lacerated Internal Iliac Vein and Suturing of a Lacerated Common Iliac Artery.
• Hemorrhage Control in Sacrospinous Ligament Suspension of the Vagina
• Presacral Space Hemorrhage Control
• What Not to Do in Case of Pelvic Hemorrhage
• Packing for Hemorrhage Control
• Control of Hemorrhage Associated With Abdominal Pregnancy.

Physiologic Changes. The typical 70-kg female will have approximately 5000 mL of blood before surgery. A blood loss of 1000-2000 mL, i.e., 40% of the patient's blood volume, may be tolerated without transfusion or potential hypovolemic shock. Patients with blood loss greater than this, however, must have immediate replacement of whole blood. Crystalloids are a poor substitute for whole blood.

An excellent rule to follow is that for every 6 units of packed red cells infused, 2 units of fresh frozen plasma should be infused to replace factor VIII, which is frequently diluted with large blood transfusions. This dilution can create a disseminated loss of blood from small punctures of blood vessels by needles as well as from sharp dissection. The total platelet count may be reduced; the prothrombin time (PT) and partial thromboplastin time (PTT) may be normal or elevated.

Points of Caution. If transfusion exceeds 10-12 units and bleeding is not under control by standard surgical techniques, a 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.