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18 The Failed Anastomosis
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Pelvic Bleeding
Amit Merchea and Bruce G. Wolff
Key Points
• Intraoperative presacral hemorrhage is a rare but
potentially lethal complication.
• Most frequently, hemorrhage can be controlled by
simple local means such as compression, electrocautery, or ligation.
• In laparoscopic cases, if control cannot be achieved,
conversion to an open procedure should be expeditious and defi nitive.
• Surgeons should have an algorithm for treating
bleeding that they and their operative team are comfortable enacting quickly and defi nitively.
1 9
potential sites of hemorrhage include the presacral space,
iliac vasculature, retroprostatic or retrovaginal region, and
gluteal vessels.
Presacral venous bleeding has a reported incidence in the
literature of 3–9 % [ 1 , 2 ]. The presacral venous plexus is
covered by the presacral and pelvic fascia over the anterior
sacrum. It is formed by two lateral sacral veins, the middle
sacral vein, and many communicating veins. These ultimately communicate with the internal vertebral venous system via the basivertebral veins, which may be large-caliber
and high-pressure vessels (Fig. 19.1 ) [ 3 , 4 ]. It has been dem-
onstrated that the adventitia of the presacral veins is adherent
to the periosteum of the sacrum where the veins enter the
sacral foramina – these areas are particularly vulnerable to
tearing [ 5 ]. Mobilization of the rectum during proctectomy is
Introduction
Key Concept: Hemorrhage is rare, but can be life- threatening.
It is imperative to know the anatomy, remain calm, be meticulous, and know when to call for help.
Hemorrhage during pelvic surgery is a rare but potentially
life-threatening phenomenon. The internal iliac (hypogastric) arteries supply the majority of blood fl ow to the pelvis.
This vessel divides into anterior and posterior branches, with
the anterior division providing the majority of the vascular
supply to the pelvis and the posterior division largely
providing collateral circulation. Areas of the pelvis that are
A. Merchea , MD
Division of Colon and Rectal Surgery ,
Department of Surgery, College of Medicine, Mayo Clinic ,
4500 San Pablo Rd, Jacksonville , FL 32224 , USA
e-mail: merchea.amit@mayo.edu
B. G. Wolff , MD (
Division of Colon and Rectal Surgery,
Department of Surgery , College of Medicine,
Mayo Clinic , 200 First Street SW , Rochester , MN 55904 , USA
e-mail: wolff.bruce@mayo.edu
*)
presacral fascia is breached, signifi cant hemorrhage may
ensue from the underlying presacral venous plexus or basivertebral veins [ 2 , 4 ]. When the basivertebral veins are
injured, these may retract into the sacral foramen making
control diffi cult. Moreover, in the lithotomy position, the
hydrostatic pressure in the sacral veins can be signifi cantly
higher than that of the inferior vena cava – thus increasing
the potential rate of hemorrhage [ 4 – 6 ]. One must remember
that it is very rarely necessary to violate the presacral fascia
or to dissect upon the surface of the sacrum. Another caveat
is careful placement of sutures in the presacral fascia during
rectal rectopexy. During rectopexy, the presacral fascia is
exposed and sutures are placed through this into the underlying periosteum. If bleeding is noticed with placement of
these sutures, one can tie these down in an effort to ligate the
injured vessel.
The overall incidence of vascular injury during pelvic
operations is low (~1–2.3 per 100,000) [
planes are often readily apparent in the normal patient; however, body habitus, previous surgery, large tumors, infl ammation, radiation, and other factors may alter them and make
these planes more diffi cult to discern. Adequate preoperative
preparation, complete understanding of anatomic relations
7 , 8 ]. Dissection
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_19, © Springer Science+Business Media New York 2014
305
306
A. Merchea and B.G. Wolff
Fig. 19.1 The presacral venous plexus with communicating veins and
basivertebral veins (With permission from Mayo Foundation for
Medical Education and Research. All rights reserved)
Certain other patient factors may portend an increased
risk of intraoperative hemorrhage. The re-operative pelvis
requires a number of particular considerations. The surgeon
must realize that anatomy may be altered or displaced secondary to adhesions and fi xation of structures, including vasculature. Large, vascular tumors may pose a signifi cant
challenge for the surgeon [
9 ]. Preoperative planning and
potential coil embolization in these cases may temper the
risk of intraoperative hemorrhage during resection. An intralesional resection may even be necessary in large tumors
that may distort the anatomy , although in cases of malignancy this would be oncologically inappropriate [ 10 ].
Preoperative radiotherapy can increase the risk of bleeding
compared to non-radiated cases [ 11 ]. Radiation therapy can lead
to fi brosis and scarring, making identifi cation of, and dissection
in, appropriate tissue planes diffi cult. Tissues may become fi xed
and immobile, increasing the risk of inadvertent injury.
Limited literature exists concerning the characteristics
and management of operative vascular injury. Oderich et al.
have published a retrospective review spanning 18 years
from the Mayo Clinic examining iatrogenic operative injuries of the abdominal and pelvic venous system. Of the 44
venous injuries identifi ed, 30 involved the pelvic vasculature
(most commonly, the external iliac vein). Perioperative mortality was 18 %, all attributed to the venous injury [ 7 ].
Prevention
within the pelvis, along with meticulous surgical technique
and appropriate exposure, is essential to limit the risk of pelvic hemorrhage.
Risk Factors for Major Bleeding
Key Concept: Appropriately and completely evaluate the
patient preoperatively and attempt to anticipate and plan for
patients that may have an increased risk of bleeding.
The patient must be appropriately screened and examined
preoperatively. Among the goals of this evaluation is to identify any comorbid condition that may infl uence the operative
outcome. Within the context of bleeding, the patient must be
screened in terms of their hematologic system – in particular,
examining for any acquired or congenital coagulopathy (from
inherited/acquired platelet disorders, factor defi ciency, organ
dysfunction, medications, etc.). In addition to a complete medication administration history, any prior kidney or liver dysfunction or malnutrition may impact the body’s ability to form
clot. Routine coagulation studies should be carried out prior to
any procedure with the potential for blood loss. If a patient has
an identifi ed coagulation disorder, perioperative management
of this may be best managed in concert with a hematologist.
Key Concept: Maintain adequate exposure (do not compro-
mise safety for cosmesis) and have meticulous surgical
technique.
Secondary to preoperative patient preparation, operative
conduct is important in preventing hemorrhage. Adequate
exposure and meticulous surgical dissection are essential.
For open operations, a generous incision should be made to
adequately visualize the anatomy. Laparoscopic or robotic
approaches may improve visualization and dissection, particularly in a narrow pelvis, but control of hemorrhage once
it occurs may be technically challenging.
Fundamental surgical principles of tension and countertension facilitate the identifi cation and dissection in avascular
planes. Eight avascular planes and spaces within the pelvis
have been previously described (Table 19.1 ) [ 12 ]. Dissection
Table 19.1 Avascular planes and potential spaces of the pelvis
Retropubic space
Vesicovaginal space
Rectovaginal space
Retrorectal space
Pararectal spaces (two)
Paravesical spaces (two)
19 Pelvic Bleeding
307
Fig. 19.2 The eight avascular planes of the pelvis (With permission
from Mayo Foundation for Medical Education and Research. All rights
reserved)
within these spaces can be expeditious and is generally safe
(Fig. 19.2 ). When performing proctectomy, bluntly dissecting
the posterior mesorectum from the sacrum with one’s hand
has been reported to be a common cause of presacral venous
trauma and, in general, should be avoided [ 4 ].
Controlling Bleeding
Key Concept: Stay calm, have a stepwise algorithm for
approaching various bleeding scenarios, and use the techniques you are comfortable with.
When a signifi cant vascular injury occurs or brisk bleeding is evident, rapid and purposeful action must be taken to
achieve control. Fundamental to achieving this is maintenance of composure and calm for the surgeon. Equally
important is open communication with the anesthesiology
team to alert them of signifi cant hemorrhage so that more
intensive monitoring can be initiated (hemodynamics, blood
loss, urinary output, etc.) and blood products can be acquired
from the blood bank. Methods of hemorrhage control include
manual compression, electrocautery [ 13 ], vascular ligation,
suture repair, use of topical coagulants [
control techniques [
5 ], and radiologic intervention.
Whichever method is utilized, evacuation of blood from the
operative fi eld and securing adequate exposure of the bleeding site is imperative to accurately identify the source.
Caution must be taken to protect vulnerable structures in the
14 , 15 ], damage-
vicinity of the bleeding source as proximal and distal control
is achieved, if possible.
The initial maneuver in controlling bleeding is often simple packing of the pelvis with laparotomy sponges .
Laparoscopically, a smaller sponge, such as a Ray-Tec, may
be inserted through a 10/12 mm port and used to clear fi eld
or tamponade low-volume bleeding. In many cases of low-
pressure, low-volume bleeding, the hemorrhage will readily
cease. Clips (or sutures) on visible presacral vessels may be
feasible and must be placed on both sides of the vessel.
Sometimes further mobilization of the rectum or surrounding
structures is necessary in order to adequately visualize the
bleeding point. Other unique and novel techniques have been
described with varying success to halt presacral hemorrhage
that could not be stopped with more conventional means
(packing, electrocautery, suture ligature, clamping).
Many topical hemostatic agents have been described [
14 ].
In our practice bone wax, gelatin foams (Gelfoam), oxidized
cellulose (Surgicel), and thrombin with gelatin (FloSeal) are
most commonly used. Bone wax exerts its effect through
occlusion of bleeding orifi ces. This is not absorbed by the
body and may become a nidus for infection [
16 ]. Gelatin
foams and oxidized cellulose act by providing a matrix for
the initiation of coagulation [ 17 , 18 ]. These are best used to
control small vessel bleeding and are absorbed by the body
within weeks. Thrombin with gelatin requires contact with
blood to serve as the source for fi brinogen and can achieve
reasonable control of moderate arterial bleeding [ 19 ].
Argon plasma coagulation is another thermal method of
coagulation. In this modality, argon gas is ionized and used
to deliver thermal energy to tissue adjacent to the probe with
limited depth of penetration (2–3 mm). If readily available,
this may be an effective tool.
The use of titanium thumbtacks inserted into the bleeding
orifi ce of the sacrum has previously been reported (Fig. 19.3 )
[ 4 , 20 ]. These thumbtacks, however, may not be readily
available and a rare complication of erosion through the
bowel wall has been reported [
21 ]. Harrison et al. [ 22 ]
reported on eight patients with massive bleeding treated with
muscle fragment welding technique (Fig.
19.3 ), initially
described by Xu in 1994 [ 23 ]. In this method a segment of
rectus abdominis muscle is harvested from the patient’s incision and placed over the bleeding region. Electrocautery on
maximum is then applied to a forceps holding the muscle in
place to “weld” the bleeding site. In all of these patients,
hemostasis was successfully achieved after initial attempts at
control via tamponade failed. Remzi et al. [ 24 ] describe
securing a patch of harvested rectus abdominis to the bleeding point with absorbable sutures. While successful in their
reported patients, suturing in a narrow, bleeding pelvis may
be technically diffi cult and time consuming.
Other open surgical methods reported include the use of
secured hemostatic sponges [
1 , 15 ], tissue expanders [ 25 ,
308
A. Merchea and B.G. Wolff
a
bc
def
Fig. 19.3 Methods for control of hemorrhage. ( a ) Normal presacral
venous plexus anatomy, ( b ) electrocautery, ( c ) suture ligature or clip-
ping of transected vessels, ( d ) pelvic packing, ( e ) thumbtacks inserted
26 ], and saline bags [ 27 ]. Van der Vurst et al. [ 1 ] recently
described the use of an endoscopic helical tacker to secure a
sponge of Surgicel over the bleeding sacrum, thus eliminating the space beneath and providing tamponade. Tissue
expanders and saline bags employ the same concept as packing in arresting hemorrhage. Proponents of these methods
suggest that advantages include the ability to perfectly fi t the
concavity of the sacrum, the ability to increase the hemostatic pressure by increasing the fl uid infused, and the potential ability to remove the devices at bedside, under local
procedures [ 27 ]. While each of these alternative methods is
reportedly effective, it is of our opinion that the simplest and
most expeditious method that the operative team is comfortable with is initially chosen.
In the event of intractable pelvic hemorrhage, internal
iliac artery ligation can increase the likelihood of control by
decreasing the mean blood fl ow, mean arterial pressure, and
overall pulse pressure within the pelvis [ 28 , 29 ]. Care must
be taken to identify the other branches of the iliac system to
avoid inadvertent ligation of the common or external iliac
arteries and to avoid injury to the hypogastric vein, which is
deep and lateral, during ligation of the artery. These vessels
into the sacrum, and ( f ) muscle welding (With permission from Mayo
Foundation for Medical Education and Research. All rights reserved)
can be temporarily occluded with vessel loops or atraumatic
vascular clamps to determine the level of effectiveness of this
maneuver. Ligation does not generally cause pelvic ischemia
because of the extensive collaterals, unless the patient has
signifi cant peripheral arterial disease.
As laparoscopic and robotic methods are becoming more
prevalent, surgeons must become facile with managing intraoperative complications, including bleeding. Management
of this potentially lethal complication can be particularly
challenging. Many of the same (or similar) techniques that
are used in open approaches can be employed in laparoscopic operations [ 11 ]. However, if minimally invasive mea-
sures at controlling hemorrhage fail, the decision to convert
to an open procedure must be made rapidly and without
hesitation.
The initial maneuver laparoscopically often employs
electrocautery to coagulate small bleeding vessels.
Compression of the site with a gauze sponge inserted through
one of the trocars can aide in compression, visualization, and
exposure. Secondary to this, some authors have described
harvesting an omental patch or epiploic fat and subsequently
using bipolar cautery to “weld” this over the bleeding site,
19 Pelvic Bleeding
309
much like the rectus abdominis muscle patch. Bovine pericardial grafts have also been tacked to the bleeding site by
endoscopic helical tackers to achieve tamponade [
11 ].
Finally, argon beam coagulation is an alternative method that
may be used [ 30 ]. It must be noted, however, that there
should not be signifi cant delay in enacting any of these methods. Not just the surgeon but the operating room staff must
all be comfortable with the use of these tools. Given the
potential lethality of presacral hemorrhage, surgeon judgment is the most important of the available tools – there
should be no delay in converting to an open procedure if this
is necessary to achieve hemostasis. The key is to minimize
the blood loss – after control, set up remedial maneuvers
methodically.
Massive, ongoing hemorrhage leads to acidosis, hypothermia, and coagulopathy – the so-called lethal triad [ 31 ]. In
such circumstances the surgeon must consider “bailing out”
and resuscitating the patient out of the operating room – particularly when the patient develops ongoing coagulopathy,
despite blood product administration [ 5 ]. Originally described
in the trauma literature [ 32 , 33 ], the principles of “damage-
control surgery” can be applied to other circumstances.
Pelvic packing with later reexploration is one form of
damage control. Zama et al. [ 34 ] reported their experience in
93 patients with pelvic packing during abdominoperineal
resection or low-anterior resection where packing was kept
in place for up to 48 h. No patient in this series required any
further intervention after removal of the packs, and there
were no intra-abdominal or pelvic infectious complications
or rebleeding. Our method of pelvic packing and temporary
abdominal closure includes tightly packing multiple laparotomy pads within the pelvis; a sterile plastic drape is placed
overlying the bowel to protect it, followed by suction drains
and sterile towels. A sterile adhesive, occlusive drape is
placed over this and suction applied to the drains. The patient
is reexplored once physiologically stabilized in 24–48 h.
Should bleeding persist or rebleeding occurs, transcatheter
arterial embolization of the bleeding vessel can be attempted.
Summary Pearls
Pelvic and presacral bleeding is a rare and sometimes lethal
event. The risk is limited by exquisite anatomic knowledge
and careful dissection. However, they can occur and you
need to be prepared that this may occur every time you perform a pelvic dissection. While you, as the surgeon, should
have a stepwise algorithm to treat such episodes, you must
have the instruments either readily available or nearby.
Asking for tacks when no one is aware of where they are is
futile. Finally, be comfortable with the techniques they
employ, and do not hesitate in seeking assistance of more
experienced colleagues, if necessary.
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Part IV
Anorectal Disease
Hemorrhoidal Disease: Postoperative Complications
Stefan D. Holubar and David E. Rivadeneira
Key Points
• In the United States, governmental and medical
society recommendations suggest that Americans
should ingest at least 25 g of dietary fi ber (12 servings of fruits and/or vegetables per day). Many
patients fi nd this a diffi cult-to- obtain goal and is the
basis for recommendations for supplemental soluble fi ber to allow soft, bulky stool, which minimizes
hemorrhoidal tissue trauma.
• When considering any operative approach to internal hemorrhoidal disease, proper patient selection is
the crucial fi rst step in avoiding complications. A
complex interplay of factors such as age, gender,
continence, comorbidities, and expected survival all
play an important role in deciding on the optimal
treatment.
• Despite the degree to which hemorrhoidal disease
impacts patients’ lives, surgeons and patients must
be aware that postoperative complications may
result in permanent quality of life consequences.
S. D. Holubar , MD, MS, FACS
Section of Colon and Rectal Surgery , Dartmouth-Hitchcock
Medical Center, Geisel School of Medicine at Dartmouth,
The Dartmouth Institute for Health Policy Research ,
One Medical Center Drive, Level 4C , Lebanon , NH 03756 , USA
e-mail: stefan.holubar@dartmouth.edu , http://www.dhmc.org
D. E. Rivadeneira , MD, MBA, FACS, FASCRS (
Division of Colorectal Surgery , Huntington and Southside
Hospitals Northshore/LIJ Health System , Hofstra University
School of Medicine, 755 New York Avenue, Suite 108 ,
Huntington , NY 11743 , USA
e-mail: drivadeneira@nshs.edu,
http://www.drdavidrivadeneira.com
*)
2 0
The Hemorrhoidal Consult
Key Concept: When patients are referred to you with symptoms due to hemorrhoids, it is not hemorrhoidal pathology
until you make the diagnosis.
“Hemorrhoids” are without a doubt the most common
indication for referral to a colorectal surgeon. Due to several
factors ranging from lack of experience to lack of a complete
examination, you will often fi nd that less than half of the
patients referred for that indication actually have hemorrhoidal disease and only a minority (~10 %) of which will
require intervention more than lifestyle modifi cation [ 1 , 2 ].
While this is more likely a refl ection of improper training, it
serves notice that you are the expert and need to be very
familiar with anorectal anatomy and pathology. Given that
half of the population of the United States over 50 are estimated to have hemorrhoidal bleeding at some point, likely
due in part to lack of dietary fi ber in the Western diet, the
magnitude of the problem for both colorectal surgeons and
as a public health concern should not be underestimated [ 3 ].
When approaching the hemorrhoidal consultation, one of
the fi rst things you as the consultant should consider is the
patient’s age. Aging results in physiologic changes that
include pelvic fl oor laxity and constipation but also bring
about a more sedentary lifestyle and the need for medications that can lead to excess straining. Similarly, patient gender has important implications. For females this includes a
thorough gynecologic history focusing on prolonged labor,
number of vaginal deliveries, episiotomies, and lacerations,
as these can impact surgical decision-making and may contribute to otherwise avoidable complications. For example, a
female patient with grade 3 hemorrhoids who had a previous
third- or fourth-degree laceration may have an attenuated
rectovaginal septum (Fig.
ings, you may choose to perform a hemorrhoidectomy rather
than a pexy, due to the risk of an iatrogenic rectovaginal
20.1 ). Depending on your fi nd-
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_20, © Springer Science+Business Media New York 2014
313