Bleeding control in laparoscopic pelvic surgery

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Bleeding   control   in   laparoscopic   pelvic   surgery

Authors
J Leroy, J Marescaux
Media type
Duration
06'15''
Publication
2006-09
Popular
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Audio
en tw
Subtitles
en
E-publication
WeBSurg.com, Sept 2006;6(09).
URL: http://www.websurg.com/doi-vd01en1827.htm

Bleeding   control   in   laparoscopic   pelvic   surgery

1. First case 00'15''
Bleeding is a risk to any kind of surgery. This video demonstrates the control of pelvic bleeding during rectal surgery. The first case is a bleeding episode during pelvic dissection for rectal cancer. What can be seen here is injury to the left pudendal vein during total mesorectal excision for cancer. Compression using an atraumatic forceps represents the first operative manoeuvre. As we are reaching the end of the procedure, dissection is continued in order to better expose the pelvis. It should be noted that if conversion is required at this time in the procedure, it should be carried out at once. In this case, hemostasis is attempted through suturing. Here it is done almost in a blind fashion. Though risky as it may be, it should not be performed whatsoever; the risk of nerve injury is high. The use of a clip is also an option as an extremity of the vessel seems to be visible. Its use must not be done in a blind manner. Therefore, it should be avoided to not worsen the injury. As a result, compression use is highly recommended and we use it here. A hemostatic gauze pad is introduced into the abdominal cavity. Compression is carried out while the procedure comes to an end or if the surgeon feels uncomfortable with compression. After 20 minutes of compression, the gauze pad is removed. No bleeding can be observed at this stage. Compression is then continued; it is combined with the application of biological glue and oxidised cellulose widely used for intraoperative hemostasis. The manoeuvre inherent to rectal surgery is brought to an end and the postoperative outcome is fairly uneventful without any further bleeding.
2. Second case 02'47''
The following case shows a bleeding event that occurs during rectovaginal resection for endometriosis. During dissection of the left lateral pelvic region, a venous branch is accidentally divided. We don’t know the origin. Bleeding seems to be fairly minor as aspiration helps to control it. The branch seems noticeable. Bipolar cautery is tried but bleeding seems to be increasingly important. At this stage, cautery should be discontinued if the origin of bleeding remains unknown. Compression is then performed as shown in the previous case; it is maintained all the way through the rest of the surgical procedure. Here we can see that the recto-sigmoid dissection is being continued with removal of the lower portion of the sigmoid colon, rectal and vaginal wall. Meanwhile, compression is maintained with the use of a forceps introduced through a supra-pubic port. It took the surgeon about 20 minutes to perform the procedure and apply complete hemostasis. Unfortunately, bleeding continues. To better understand the origin of bleeding, dissection is continued using a vascular approach. Here we can see the internal iliac vessels, common iliac vessels and external iliac vessels as the bleeding site is just unidentified; dissection is required for a better understanding and to identify both the common iliac vein and internal iliac vein. Here we can see that bleeding originates from a branch of the internal iliac vein which can be ligated and divided between two clips. Hemostasis is achieved electively without any major risk of pelvic nerve injury or vascular or urethral injury.