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Malignant Disease:
Special Procedures

Staging of Gynecologic
Oncology Patients With
Exploratory Laparotomy

Subclavian Port-A-Cath 

Peritoneal Port-A-Cath

Application of Vaginal
Cylinders for Intracavitary
Radiation Therapy

Application of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy  

Pelvic High-Dose Afterloader

Abdominal Injection of Chromic Phosphate
()

Supracolic Total Omentectomy

Omental Pedicle "J" Flap

Tube Gastrostomy

Total Vaginectomy

Radical Vulvectomy
With Bilateral Inguinal
Lymph Node Dissection

Reconstruction of the
Vulva With Gracilis Myocutaneous Flaps

Transverse Rectus
Abdominis Myocutaneous
Flap and Vertical Rectus
Abdominis Myocutaneous
Flap

Radical Wertheim
Hysterectomy With
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina

Anterior Exenteration

Posterior Exenteration

Total Pelvic Exenteration

Colonic "J" Pouch Rectal
Reservoir

Kock Pouch Continent Urostomy

Omental "J" Flap Neovagina

Ileocolic Continent Urostomy (Miami Pouch)

Construction of Neoanus
Gracilis Dynamic Anal
Myoplasty

Skin-Stretching System Versus Skin Grafting

Gastric Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina

Control of Hemorrhage in Gynecologic Surgery

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

Presacral Space Hemorrhage Control

Bleeding from the presacral space arteries and veins, particularly branches of the middle sacral artery, can be copious and difficult to control. This is particularly true if the venous or arterial structures retract into the foramen of the sacrum. Surgeons can become frustrated by attempting electrocoagulation, suturing, clamping, and tying.

Technique

The sacrum is shown with arteries and veins in the periosteum.

The finger is placed over the lacerated artery and vein. Conservative methods such as fulguration and suturing can be tried but are often unsuccessful.

A thumbtack from the bulletin board grasped in a straight Kocher clamp can be placed in the laceration of the vessels in the presacral space. It is inserted through the vessel wall and embedded into the bone of the sacrum. It remains permanently in the bone.

Thumb pressure is used to drive the thumbtack firmly into the sacral bone, occluding the lacerated artery.

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