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COMPLICATIONS 451
of the proximal colon that is beyond the size of any available stent.
Rectal anastomoses are best suited for stenting because of their size,
diameter, and access. However, the stent can cause tenesmus if any
part of it is 5 cm or less from the anal verge.
Fibrin glue (combined thrombin and brinogen) or other types of
nonbiologic glues have been used during anastomosis creation and
for leaks and stulas. Despite the early success showing an 85% healing rate of anal stulae, recent studies have failed to replicate these
numbers. It has also been shown that brin glues are less eective
in treating rectal complications compared with other areas such as
the esophagus. Fibrin glue has a 25% to 33% success rate as a single
agent for treating rectal anastomotic complications. e two benets
in using brin glue are the speed and ease of application and the fact
that it will not prevent the use of any other method if it fails.
It is sometimes possible to reapproximate a so anastomotic
staple line that has separated less than 1 cm, using clips or sutures.
Beginning at each end of the separation and moving to the middle to
place the clips reduces tension on the closure. e cost of this closure
is almost prohibitive when multiple clips are used. e endoscopist
also requires experience and extraordinary skill to be successful.
TRANSANAL REPAIR TECHNIQUES
Transanal repair techniques are best used in chronic leaks or stulas with minimal inammation or infection. E-VAC therapy could
potentially be used to provide resolution of inammation and infection and thus allow for earlier and more eective treatment with
transanal repair.
Leaks located in the distal rectum can be amenable to repair
through an open transanal approach. Leaks located more proximally
in the rectum have the potential to be repaired though transanal minimally invasive surgery for persons experienced with the technique.
Simple suturing is prone to fail even for small defects with minimal
inammation.
Expanding the small opening of a long-standing, almost chronic
leak in the posterior area of a very distal rectal anastomosis to
uncover a large presacral sinus, known as “unroong or marsupialization,” permits better drainage and healing that can result in complete
resolution of the sinus in a few months through re-epithelialization.
“Laying open” can be performed endoscopically using an Olympus
triple-lumen needle knife (Olympus, Hamburg, Germany), or with
the proctoscope and the laparoscopic electrocautery scissors. Our
preferred method is to use a laparoscopic Endo-GIA stapling device,
and we have achieved good results. e stapling device is placed
through an anoscope in the anus. e thin anvil arm of the EndoGIA device is inserted through the opening of the leak, and the staple
cartridge arm is le within the rectal lumen. e resulting staple lines
provide hemostasis and provide “marsupialization” by sealing the
edges of the chronic stula and exposing the chronic abscess cavity
to the rectal lumen. is becomes a pseudo-diverticulum from the
back of the rectum, which eventually becomes epithelialized and part
of the rectal wall.
Flap advancement can be used for any anastomotic stula near the
anal verge. e repair involves excising the stula opening and mobilizing the adjacent tissues, allowing for the approximation of healthy
tissues without tension. All of these transanal techniques will need
proximal diversion to have any chance of success.
TURNBULL-CUTAIT PULL THROUGH
Sometimes a surgeon will be faced with a rectal anastomosis that
has not healed with use of other modalities and appears to be unsalvageable. Repeat surgery to resect a low rectal anastomosis associated with chronic inammation can interrupt locally derived
neovascularization and may be associated with undue tension on
the new coloanal anastomosis. e combination of poor blood
supply and tension can easily result in a leak. e use of a TurnbullCutait pull through of the le colon can eliminate these risks. is
technique requires adequate mobilization of the le and transverse
colon to allow the bowel to be pulled though the short rectal stump.
e mucosa of the rectal stump is stripped to the dentate line and
the bowel is pulled through the anus to leave 7 to 10 cm hanging
out. A 34 F mushroom catheter, which is long enough to drain the
colon above the pelvic oor and bulky enough to passively remain
above the pelvic oor, is secured within the lumen of the bowel
using an encircling umbilical tape around the portion of the colon
pulled through the anal canal. e catheter hangs out of the anus
and is placed to closed drainage. e externalized bowel is wrapped
with Betadine-soaked Kerlix and continually kept moist with fresh
Betadine for 7 days. On day 7 the patient is taken back to the operating room and the external segment of bowel is amputated. A handsewn, coloanal anastomosis is then created at the dentate line or
the top of the cu of rectal mucosa. e downside of the TurnbullCutait procedure is the poor function that oen follows closure of
the diverting stoma.
SUMMARY
A surgeon working with GI anastomoses must be familiar with
a broad range of options to diagnose and manage leaks. Until we
have a perfect way to prevent leaks, the true skill of the GI surgeon is the ability to salvage a failed anastomosis in an imperfect
biologic system. As techniques of endoscopic closure, placement
of stents, vacuum-assisted dressing with an intraluminal sponge,
and transanal suture techniques improve with time and experience, the need for a large operative procedure to rescue anastomoses will diminish. Even so, adherence to surgical principles in
the management of intra-abdominal sepsis is particularly important. In the future, early diagnosis or detection of an impending
leak may allow intraluminal treatment before the complications of
contamination occur.
S u g g e S t e d R e a d i n g
Alves A, Panis Y, Trancart D, etal. Factors associated with clinically signi-
cant anastomotic leakage aer large bowel resection: multivariate analysis
of 707 patients. World J Surg. 2002;26(4):499–502.
Blumetti J, Chaudhry V, Cintron JR, etal. Management of anastomotic leak:
lessons learned from a large colon and rectal surgery training program.
World J Surg. 2014;38(4):985–991.
den Dulk M, Noter SL, Hendriks ER, etal. Improved diagnosis and treat-
ment of anastomotic leakage aer colorectal surgery. Eur J Surg Oncol.
2009;35:420–426.
Fraccalvieri D, Biondo S, Saez J, etal. Management of colorectal anastomotic
leakage: dierences between salvage and anastomotic takedown. Am J
Surg. 2012;204(5):671–676.
Hirst N, Tiernan J, Millner P, Jayne D. Systematic review of methods to pre-
dict and detect anastomotic leakage in colorectal surgery. Colorectal Dis.
2014;16(2):95–109.
Nagell CF, Holte K. Treatment of anastomotic leakage after rectal resec-
tion with transrectal vacuum-assisted drainage (VAC). A method
for rapid control of pelvic sepsis and healing. Int J Colorectal Dis.
2006;21(7):657–660.
Phitayakorn R, Delaney CP, Reynolds HL, etal. Standardized algorithms for
management of anastomotic leaks and related abdominal and pelvic abscesses aer colorectal surgery. World J Surg. 2008;32(6):1147–1156.
Snijders HS, Wouters MW, van Leersum NJ, etal. Meta-analysis of the risk
for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol.
2012;38:1013–1019.
ornton M, Joshi H, Vimalachandran C, etal. Management and outcome of
colorectal anastomotic leaks. Int J Colorectal Dis. 2011;26:313–320.
Weidenhagen R, Gruetzner KU, Wiecken T, etal. Endoscopic vacuum-
assisted closure of anastomotic leakage following anterior resection of the
rectum: a new method. Surg Endosc. 2008;22:1818–1825.
C
C
Rhodri J. Codd and Peter M. Sagar
INTRODUCTION
Colonoscopy remains the gold standard for colonic investigation. It
is a sensitive diagnostic tool and provides a nonsurgical approach for
the removal of colonic and rectal polyps. However, colonoscopy is
invasive. It can be a challenging procedure to perform and is associated with infrequent but potentially serious complications. Most of
these complications occur aer therapeutic procedures have been
performed. Potential complications are listed in Box 86-1.
Adverse events can occur before, during, or aer a procedure.
Postprocedure complications can occur immediately, within days,
or sometimes years aer the procedure (e.g., a stricture related to
previous endoscopic mucosal resection). Knowledge of the potential
complications together with early recognition and appropriate management of the situation will help improve patient outcomes.
RISK MANAGEMENT
Perhaps the most important aspect of colonoscopy is minimizing
risk for the patient, which starts with a targeted history that includes
cardiac and respiratory risk factors, history of renal impairment, the
presence of diabetes or bleeding disorders, drug history (particularly
antiplatelet and anticoagulant agents), and a history of allergies. e
patient’s comorbidities are balanced against the possible benets of
colonoscopy to determine whether the procedure should be performed at all. Comorbidities also inuence choice of bowel preparation (renal function status) and the depth and duration of conscious
sedation (respiratory function).
Although the skill and experience of each colonoscopist varies,
every colonoscopy should be performed or supervised by an endoscopist with adequate training as dened by the various supervising
societies. e complication rate is highest for inexperienced colonoscopists who have performed a low volume of procedures. e risk of
complications can be up to three times higher aer a polypectomy
performed by a “low-volume” colonoscopist (i.e., an endoscopist
who has experience with 1 to 141 colonoscopies) when compared
with a “high-volume” colonoscopist (i.e., an endoscopist who has
experience with 379 to 1225 colonoscopies). Inherent in the better
outcome of experienced endoscopists is experience and knowledge
of the equipment, including the electrocautery generator and the
various adjuncts. A poorly functioning scope and lack of familiarity with equipment will place the patient at an unnecessary risk. It is
also important that colonoscopists be aware of their own limitations
because overambition may lead to adverse events. As the complexity of polypectomy increases, the risk of complications also increases.
Using lower risk procedures when appropriate, or referring patients
BOX 86-1: Potential Complications
Bowel preparation complications
Sedation complications
Hemorrhage
Perforation
Diastatic serosal tears
Bacteremia
Vasovagal reex
Postcolonoscopy distension
Splenic trauma
Cardiac events
Missed disease
Death
to “high-volume” endoscopists, can reduce the risk of perforation
and gastrointestinal bleeding.
In this chapter we will concentrate on the management of two
potentially life-threatening and surgically important complications
of colonoscopy: perforation and hemorrhage.
HEMORRHAGE
Hemorrhage is a rare complication of diagnostic colonoscopy because
clinically signicant bleeding from mucosal biopsy sites is uncommon. However, hemorrhage is the most common complication associated with endoscopic polypectomy. Hemorrhage can be dened as
acute blood loss aer a polypectomy that is severe enough to mandate
admission to the hospital.
Steps Prior to Colonoscopy
It is important to ascertain whether the patient has a history of a
bleeding disorder or is undergoing anticoagulant or antiplatelet therapy. Use of anticoagulant and antiplatelet agents should be stopped
for a sucient period before a polypectomy is performed. A comprehensive guide to the management of anticoagulant and antiplatelet
therapy in patients undergoing endoscopic procedures is available in
a document published by the working party for the British Society of
Gastroenterology (see Suggested Reading).
e patient and his or her family need to be warned about the
possibility of postpolypectomy bleeding. Patients should not travel to
areas remote from medical care for the next 2 weeks.
452
COMPLICATIONS 453
Risk Factors for Bleeding
Postpolypectomy bleeding rates between 0.16% and 6.1% have
been reported. Factors associated with an increased risk of bleeding
include patient age (elderly persons have a higher risk), size of the
polyp, location of the polyp (right colonic polyps have a higher risk
of bleeding), number and structure of the polyps (sessile and thickstalked polyps are more likely to bleed) and the use of anticoagulant
drugs. Some series report bleeding rates aer polypectomy of up to
10% for large (>2 cm) right-sided colonic polyps. In addition to these
factors, the type of diathermy setting can aect the risk of postpolypectomy bleeding. e use of pure-cut diathermy is associated with
a higher rate of immediate bleeding, whereas blend and coagulation
diathermy settings are associated with lower rates of hemorrhage.
Prevention of Bleeding
e European Society of Gastrointestinal Endoscopy has concluded that the placement of detachable loop ligating devices for
large pedunculated polyps and the submucosal injection of diluted
(1:10,000) epinephrine for sessile polyps are eective strategies to
reduce postpolypectomy bleeding. e ecacy of other measures,
including endoclip placement and argon plasma coagulation, has not
been proven. A helpful strategy in a high-risk patient with multiple
polyps is to remove the largest polyp and leave the others, so that if
bleeding occurs, the site is already known.
Treatment of Bleeding
Hemorrhage sometimes occurs despite adequate risk assessment and
good technique. In this situation, it is important to have an appropriate management strategy. A suggested approach is summarized in
Figure 86-1. Bleeding can occur immediately or can be delayed up
to 30 days aer the procedure. In most cases of immediate hemorrhage, it is possible to treat the bleeding endoscopically. A working
knowledge of endoscopic hemostatic techniques is important, and
use of a combination of these techniques can be helpful.
Injection of epinephrine (a 1:10,000 solution) via a exible injector needle causes vasoconstriction and controls most bleeding. e
aim is to form a bleb of the solution at the site of bleeding by injection
into the submucosal plane. Injection of several milliliters around the
bleeding site may be necessary to achieve the desired eect.
Should bleeding occur aer removal of a pedunculated polyp, hemostasis is achieved by snaring the stalk and holding it for at least 5 minutes.
Some snares are detachable and can be le in situ. Repeat transection of
the base of the polyp is not recommended because this maneuver can
make regrasping of the base impossible should the bleeding continue.
Hemoclips are safe to use to treat immediate bleeding. However, accurate
placement is sometimes dicult, and multiple clips are oen required.
Methods of direct-contact thermal treatment including the use of
a heater probe, electrocautery, and argon plasma coagulation can be
useful in the treatment of hemorrhage. Although these techniques
carry a risk of perforation, short bursts of light contact without excessive pressure will reduce the likelihood of perforation.
When endoscopic techniques prove unsuccessful in achieving
hemostasis, decisions must be made about further management.
e volume and ow of bleeding should be estimated and the likelihood of spontaneous cessation should be assessed at colonoscopy.
Should the ow of blood be brisk and continuous, then appropriate
resuscitation with blood products is oen necessary. Angiographic
transarterial embolization can be successful in achieving hemostasis. However, patients must be stable enough to be transferred to
the radiology department and must be aware of the signicant risk
(approximately 11%) of colonic ischemia requiring colectomy.
Surgery is a last resort. A laparoscopic approach is appropriate and
preferable to open surgery. In cases of immediate postpolypectomy
bleeding, the site of hemorrhage is usually known. is knowledge
can allow a segmental colonic resection and primary anastomosis
because the colon should be clean aer the bowel preparation used
for the patient’s colonoscopy. In unusual cases, depending on the
availability of angiography, a subtotal colectomy may be required
Immediate Hemorrhage
Assess site of bleeding
Endoscopic Treatment
Injection of epinephrine 1 in 10,000 sol
If possible direct pressure with sling
± Hemoclip application
± Direct contact thermal treatment
If unsuccessful consider CT angiography
with embolization
If unsuccessful consider segmental
resection/subtotal colectomy
FIGURE 86-1 Algorithm for postcolonoscopy bleeding. C T, Computed tomography.
n
Delayed Hemorrhage
If small volume and patient stable can
watch and closely monitor
or
Early colonoscopy/CT angiography to
identify site of bleeding and treat
If brisk bleeding or patient unstable
consider on table colonoscopy ±
laparoscopy/laparotomy
*In all cases, patients must be closely
monitored and resuscitated with blood
products when appropriate.
CompliCations of ColonosCopy454
when delayed hemorrhage occurs or if uncertainty exists about the
site of bleeding. On-table colonoscopy can be helpful in facilitating
potential endoscopic control of hemorrhage or can identify the site of
bleeding and allow segmental colonic resection.
Delayed bleeding oen can be managed expectantly if the volumes
of blood are relatively small and the patient is hemodynamically stable. However, should the bleeding be more profuse, then colonoscopy
has a role. In this situation, it may be safer to perform colonoscopy in
an operating room with an anesthetist and blood products available in
the event that the patient requires an emergency laparotomy. Usually
a bowel preparation can be administered at the same time that resuscitation is occurring, although repeat scoping of an unprepared colon
can be performed. e site of bleeding is oen marked by an adherent
clot, which must be removed by irrigation before hemostasis can be
obtained. Adrenalin injection, clips, or coagulation can be used.
PERFORATION
Perforation can be dened as the evidence of air, luminal contents,
or instrumentation outside the gastrointestinal tract. In general, the
incidence of postcolonoscopic perforation is low, with rates ranging from 0.1% to 0.6%. erapeutic procedures are associated with a
higher risk of perforation when compared with diagnostic colonoscopy alone.
In the United Kingdom, the National Health Service bowel cancer
screening program quality assurance guidelines suggest perforation
rates of less than 1 in 1000 cases for diagnostic colonoscopy and less
than 1 in 500 cases aer polypectomy.
Causes of Perforation
A perforation during diagnostic colonoscopy can be caused in several ways, the most common of which is the use of excessive force
when pushing through the tip of the colonoscope. Other mechanisms
include the use of manipulation such as the dangerous blind “slideby” technique, aggressive resolution of sigmoid loops, and excessive
force along the antimesenteric border associated with looping of the
scope. Overinsuation of the colon also can result in perforation as
a result of barotrauma.
Sometimes clues exist to an increased potential for perforation. For
instance, in patients with severe inammation or acute angulation of the
colon associated with adhesions from previous surgery, particular care
should be taken not to use excessive force. In patients with diverticular
disease, the endoscopist also should take special care not to inadvertently
push the scope through a diverticulum, mistaking it for the lumen, and
thereby perforating the colon. e risk for perforation also exists when
the colon is weak, such as in the setting of ischemic or Crohn colitis.
Scoping should be performed carefully in such patients, and the colonoscopist must be ready to retreat if the colon seems too fragile.
erapeutic procedures carry a particular risk of perforation.
e risk is increased aer removal of sessile polyps, particularly if
the polyp is large and right sided. Technique is important to avoid
excessive risk of perforation. e endoscopist should be careful
not to include any bowel wall within the snare during polypectomy
and not to use prolonged electrocautery that can result in thermal
necrosis and a transmural burn. Two centimeters is the maximum
polyp diameter that should be drawn into the snare. Appropriate use
of electrocautery is of particular importance when removing rightsided polyps because of the relative thinness of the colonic wall.
Diagnosis of Perforation
When a perforation happens, early diagnosis is essential. Perforation may be obvious during the procedure when intra-abdominal
fat or viscera can be seen through the scope, but in many cases the
symptoms and signs are more subtle. Other signs of perforation that
may be noted during the procedure include irreducible abdominal
distension, a sudden inability to maintain insuation of the colonic
lumen, or a sudden increase in patient discomfort.
Apart from persistence of the abdominal distension, immediate
postprocedure signs may be subtle. e presentation of peritonitis
may be delayed because the patient usually has undergone bowel
preparation, and the degree of contamination is therefore minimal.
Localized or generalized peritonitis may take time to develop and in
many cases will not occur at all. Similarly, fever, leukocytosis, and
other signs of sepsis can take hours or days to develop.
In the event of any suspicion of a perforation, a plain abdominal
and erect chest radiograph will likely show evidence of free or retroperitoneal air. e amount of free air may bear little relationship to
the clinical picture and should not be used as a marker of severity.
In patients with “benign pneumoperitoneum,” radiologic evidence of
free gas is recognized in an asymptomatic patient aer colonoscopy;
this condition has been identied in 1 of 100 consecutive abdominal
radiographs. One likely mechanism is a pneumatic serosal split as a
result of the use of air as an insuating gas and a tight sigmoid preventing distal decompression, which causes distention of the proximal colon and splitting of the serosa. Gas can escape the bowel, but
no frank perforation exists. e presence of postcolonoscopy free
intraperitoneal air does not mandate surgical exploration. Nonoperative management, which usually consists of close observation under
the care of gastroenterologists and surgeons, is successful in many
patients. Patients initially should take nothing by mouth in case surgical intervention becomes necessary. Intravenous uids and broadspectrum intravenous antibiotics should be administered, including
adequate anaerobic coverage. Close monitoring and regular surgical
review is required to identify any evidence of deterioration, which
may be an indication for surgery.
e ndings at colonoscopy can be helpful in determining the risk
of fecal peritonitis and the need for surgery. e adequacy of bowel
preparation can provide clues as to the risk of immediate fecal soiling.
If the bowel has been well prepared and is clean, the immediate risk is
lower than in a patient with poor bowel preparation and liquid stool
within the colon. e latter patient is more likely to require surgical
intervention aer an iatrogenic perforation because spillage of feces
into the peritoneal cavity is more likely.
Should the colonoscopist identify intraperitoneal viscera or fat
during the procedure, then an operation is warranted, because the
defect will be sizeable and will not heal with conservative measures
alone. Endoscopic closure of iatrogenic perforations of the colon
using endoclips has been reported in the literature. However, these
studies are mainly small case series or case reports, and attempting
endoscopic closure would depend on the prior experience and skill
of the endoscopist involved.
Management of Perforation
In patients with generalized peritonitis and sepsis, decision making is
easy because surgery is usually warranted. Similarly, patients who are
asymptomatic oen can be managed conservatively. However, some
patients have more subtle signs such as localized peritonitis, a lowgrade fever, tachycardia, and/or leukocytosis (postpolypectomy syndrome). ese patients may respond to bowel rest and intravenous
antibiotics but require very close monitoring for any deterioration
that would warrant surgery.
Should surgery be necessary, preoperative localization of the perforation operatively may be desirable. Usually the likely site is obvious
from the colonoscopy report and from the early symptoms, but if the
patient underwent multiple polypectomies, the site of interest may be
unclear. In this situation, a water-soluble enema may be requested but
should not delay surgical treatment.
Traditionally, patients requiring surgical intervention for iatrogenic colonic perforation would undergo laparotomy with either
If perforation noted at colonoscopy, then assess
adequacy of bowel preparation and size of defect
Consider endoclip if endoscopist is appropriately trained
Early postprocedure patient assessment—
history, examination, plain films ± CT
COMPLICATIONS 455
Asymptomatic or
mild symptoms
Closely monitor
NBM, IV fluid, broad
spectrum antibiotics
FIGURE 86-2 Perforation management algorithm. C T, Computed tomography; NBM, nothing by mouth.
Localized peritonitis
(Postpolypectomy
Syndrome)
Consider nonsurgical
approach with regular
reassessment and a
low threshold to proceed
to surgery if deterioration
suture repair of the defect or colonic resection. A proportion of
patients will require formation of a stoma in the form of a defunctioning loop ileostomy or an end colostomy (Hartmann procedure). In
recent years, it has been recognized that patients can be safely treated
laparoscopically aer colonoscopic perforation. is approach is preferred because patients can benet from minimally invasive surgery
while undergoing either suture repair with washout and drainage or
segmental colonic resection. A well-prepared colon with minimal
fecal soiling should allow safe suture repair and drainage or segmental resection with primary anastomosis. In a small proportion of
patients, clinical reasons for avoiding primary anastomosis may exist.
If signicant fecal soiling, perioperative instability, or major comorbidity is present, the risk of anastomotic leakage may be deemed too
high and colonic diversion is preferred. Restorative surgery can then
be considered once the patient has recovered from the acute event.
A management algorithm for patients with colonic perforation aer
a colonoscopy is provided in Figure 86-2. is algorithm should be
considered a guide and not a denitive management strategy because
ultimately each case is dierent and the surgeon should adopt an individualized approach to patients with iatrogenic colonic perforation.
S u g g e S t e d R e a d i n g S
Chukmaitov A, Bradley CJ, Dahman B, et al. Association of polypectomy
techniques, endoscopist volume, and facility type with colonoscopy com-
plications. Gastrointest Endosc. 2013;77:436–446.
Generalized peritonitis or
significant sepsis
Laparoscopy/laparotomy
± suture repair or colonic
segmental resection
Consider stoma formation,
depending on the status of
the patient, the degree of
contamination, and the
health of the bowel
Gatto NM, Frucht H, Sundararajan V, etal. Risk of perforation aer colo-
noscopy and sigmoidoscopy: a population based study. J Natl Cancer Inst.
2006;95:230–236.
Grupka MJ, Benson J. Endoscopic clipping. J Dig Dis. 2008;9:72–78.
Kapetanos D, Beltsis A, Chatzimavroudis G, Katsinelos P. Postpolypectomy
bleeding: incidence, risk factors, prevention, and management. Surg Lapa-
rosc Endosc Percutan Tech. 2012;22:102–107.
Kim HS, Kim TI, Kim WH, etal. Risk factors for immediate postpolypec-
tomy bleeding of the colon: a multicenter study. Am J Gastroenterol.
2006;101:1333–1341.
Rabeneck L, Paszat LF, Hilsden RJ, etal. Bleeding and perforation aer outpa-
tient colonoscopy and their risk factors in usual clinical practice. Gastro-
enterology. 2008;135:1899–1906.
Rotholtz NA, Laporte M, Lencinas S, etal. Laparoscopic approach to colonic
perforation due to colonoscopy. World J Surg. 2010;34(8):1949–1953.
Rutter MD, Chilton A. Quality assurance guidelines for colonoscopy. NHS
BCSP Publication. 2011;6:24.
Sivak MV Jr., ed. In: Gastroenterologic Endoscopy. 2nd ed. Philadelphia:
Saunders; 2000.
Tytgat GNJ, Classen M, Waye JD, Nakazawa S, eds. Practice of erapeutic
Endoscopy. 2nd ed. London: Saunders; 2000.
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M
H
P S
John H. Marks and Grace A. Montenegro
INTRODUCTION
Pelvic dissection is inherent to the management of many rectal, urologic, and gynecologic conditions, and operating deep in the pelvis requires an intimate knowledge of the anatomy of this region.
Whether performed in an open, laparoscopic, or robotic manner,
surgery must be precise to avoid violating cancer planes and to prevent nerve damage and pelvic bleeding. e greatest challenges are
posed by reoperative pelvic surgery and surgery in the presence of
pelvic inammation or bulky ultra-low rectal cancers, or when extensive pelvic brosis and obliteration of planes is present as a result of
recurrent tumors or treatment with radiation.
Presacral hemorrhage is one of the most feared complications of
pelvic surgery. An incidence of 9.4% and a mortality of 4.3% have
been reported. When discussing the prevention and management of
hemorrhage that occurs during pelvic surgery, it is helpful to outline
the relevant anatomy, as well as the principles of pelvic bleeding and
tactics for controlling it.
PERTINENT ANATOMY
e pelvis is a bony and muscular cone, bounded posteriorly by the
sacrum and coccyx and the piriformis and coccygeal muscles; anteriorly by parts of obturator internus, levator ani and the pubic bone;
laterally by the ilium and ischium, obturator internus, and superior
part of levator ani; and inferiorly by the levator ani muscles. e pelvis contains the rectum, distal sigmoid colon, bladder, and distal ureters, as well as ovaries, fallopian tubes, uterus and vagina in women
and seminal vesicles, ductus deferentes, ejaculatory ducts, and prostate in men.
e taeniae coli coalesce to form a complete longitudinal muscle
coat of the rectum as the sigmoid terminates. e rectum lacks epiploic appendices, haustrae, and a well-dened mesentery. e posterior rectal wall lies in the sacral hollow and is entirely extraperitoneal,
whereas the upper rectum is invested by peritoneum anteriorly and
laterally and the middle third only anteriorly. e lower third of the
rectum is entirely extraperitoneal because the anterior peritoneal
reection is found at 7.5 to 5.0 cm from the anal verge in women and
at 9.0 to 7.0 cm from the anal verge in men. Anteriorly, the rectum is
in close proximity to the cervix and posterior vagina in women and is
closely related to the prostate, seminal vesicles, and bladder in men. It
is separated from these structures by the fascia of Denonvilliers. e
fascia propria of the rectum is an extension of the parietal endopelvic
fascia that lines the oor and walls of the pelvis and encloses rectum,
adipose tissue, and blood and lymphatic vessels. It is more obvious
laterally and posteriorly. e lateral ligaments of the rectum contain
connective tissue and nerves and, in 25% of patients, branches of the
middle rectal artery. It is important to note that the middle rectal
arteries and pelvic plexus run underneath the lateral ligaments. e
456
presacral fascia covers the concavity of the sacrum and coccyx, and
the presacral nerves, middle sacral artery, and presacral veins run
behind it (Fig. 87-1).
During posterior rectal dissection, it is important to keep in the
avascular plane between fascia propria of the rectum and the presacral fascia, anterior to the hypogastric nerves. Dissection deep to
the presacral fascia can cause life-threatening venous bleeding. e
venous plexus is particularly at risk deep in the presacral hollow
when, in taking the dissection posteriorly down to the pelvic oor,
the surgeon does not recognize the anterior curve of the sacrum and
enters the presacral veins. e presacral venous plexus is formed by
the two lateral sacral veins, the middle sacral vein, and communicating veins (Fig. 87-2). ese veins have no valves and communicate via
the basivertebral veins in the internal vertebral venous system. e
adventitia of the basivertebral veins is xed to the sacral periosteum
at the margins of the sacral foramina mainly at the level of S3-S4.
In the lithotomy position, presacral veins can reach hydrostatic pressures up to three times the normal pressure of the inferior vena cava.
Retraction of the cut end of the vein into a sacral foramen also can be
a problem when the presacral fascia is violated, preventing control by
simple tie or suture ligation.
e visceral pelvic fascia of Denonvilliers is a fascial layer that
separates the extraperitoneal rectum anteriorly from the prostate
and seminal vesicles or vagina. e mesorectal plane represents the
continuation of the same plane of posterior and lateral dissection of
the rectum. is natural anatomic plane is located between the parietal and visceral pelvic fascia and is the embryologic basis of a total
mesorectal dissection (Fig. 87-3). Sharp and precise dissection in this
plane should be bloodless. Bleeding should raise the question of an
improper plane of dissection. Blunt dissection, particularly with a
hand in the presacral space, runs the risk of tearing the mesentery
and avulsing vessels, causing both bleeding and an inadequate total
mesorectal excision.
Just above its bifurcation, the aorta gives rise to the middle sacral
artery. e analogous middle sacral vein drains into the le common
iliac vein. e internal iliac arteries represent the main arterial supply
to the pelvis through posterior and anterior trunks. On the viscera,
these arteries anastomose with each other, providing collateral circulation between the le and right sides of the pelvis. e veins correspond to the branches of the artery. e posterior trunk is composed
of the iliolumbar, lateral sacral, and superior gluteal arteries. e lateral sacral artery supplies the vertebral contents and enters the rst
and or second anterior sacral foramen. e superior gluteal artery
courses posteriorly and leaves the pelvis through the greater sciatic
foramen. e anterior trunk of the internal iliac artery is long when
compared with the posterior trunk and is closely related to the lateral
pelvic wall.
e rst branch of the anterior trunk is the obturator artery. It
extends forward along the pelvic wall against the fascia over the
obturator muscle and leaves the pelvis via the obturator canal. e
COMPLICATIONS 457
PSVS
l
nerve
Nervi erigente
Fascia propria
of rectum
Seminal
vesicles
Fascia of
Denonvilliers
Middle
rectal artery
Lateral
ligament
Presacral
fascia
Presacral
veins
FIGURE 87-1 Presacral fascia. (From Church JM, et al. The surgical anatomy of the rectum--a review with particular relevance to the hazards of rectal mobili-
Bladder
Pelvic
plexus
Pelvic wall
Rectum
Mesorectum
Superior
rectal artery
Hypogastric
sation. Int J Colorect Dis. 1987;2:158-166.)
MSV
Rectum
Sacral
nerve S3
Visceral
pelvic fascia
Parietal
pelvic fascia
IIV
S2TVT
LSV
BVV
FIGURE 87-2 Presacral venous plexus.
FIGURE 87-3 Mesorectal plane.
BVV
IVVS
Bladder
Hypogastric
nerve
Internal iliac
artery
Middle
hemorrhoida
artery
Piriformis
muscle
Hypogastric
nerve plexus
S3
ManageMent of HeMorrHage during Pelvic Surgery458
vein, and nerve in pudendal
anal sphincter
Anal canal
Rectum
umbilical artery is the second branch. It runs parallel to or just
above the pelvic brim and turns onto the anterior abdominal wall
lateral to the bladder. e inferior vesical artery is typically the next
branch and supplies the bladder. e middle hemorrhoidal artery
is also a branch of the internal iliac anterior trunk; however, it is
present in only 10% to 60% of dissections and has variable contribution to the rectal blood supply. It traverses the pelvis on the
superior aspect of the levator ani. It does not travel directly through
lateral stalks, but its branches may run through them (Fig. 87-4).
e middle hemorrhoidal artery reaches the lower third of the rectum anterolaterally, close to the level of the pelvic oor and deep
to the levator fascia. It is prone to be injured during low anterior
resection, when anterolateral dissection of the rectum is performed
close to the pelvic oor and the prostate and seminal vesicles or
upper part of the vagina are being separated from it. e anterior
trunk of the internal iliac nally bifurcates into the inferior gluteal
and pudendal arteries. e internal pudendal courses down on the
anterior surface of the sacral plexus. e pudendal vessels then send
branches medially to the pelvic oor, anal sphincters (inferior hemorrhoidal artery), and genitalia.
e superior hemorrhoidal artery is the direct continuation of
the inferior mesenteric artery. It divides within the mesorectum at
the level of S3 into descending right and le branches to the rectum.
Within the submucosa of the rectum, these branches run straight
downward to supply the lower rectum and anal canal. As these
branches reach the rectal columns, they condense into capillary plexi
in locations corresponding to internal hemorrhoidal groups, right
posterior, right anterior, and le lateral positions.
BLEEDING
Avoiding pelvic bleeding without compromising the intended surgery is always the primary goal, but because of the complex anatomy
of the pelvis, bleeding may occur even during procedures performed
by the most experienced of surgeons. Preparation for this eventuality
is hence the key to containing it. In preoperative planning, one must
consider the challenges of the procedure, disease, and body habitus.
Dicult dissections are anticipated in patients with recurrent or
bulky tumors, morbid obesity with bulky peritoneal fat, tumors in
the distal third of the rectum, and a narrow pelvis in men. Typing
and cross-matching of blood should be performed for any pelvic surgery. e anesthesiologist should have good venous access prior to
the start of the procedure.
When major pelvic bleeding is encountered, several points are
important. e need for additional trocars or hands to aid in retraction must be anticipated. Good communication with the operating
room sta and the anesthesia team is essential, and extra suction
catheters may be necessary. e best initial management is direct
pressure, either with a nger, a sponge on a stick, or a pack at the
site of bleeding. Once direct pressure is applied, the anesthesia team
should be notied of the blood loss and the potential for further loss,
and time is required for the loss to be caught up and for further products to be made available. Delivery of the specimen with the packing
in place should be performed if possible because it allows better visualization of the presacral region.
TACTICS FOR CONTROL OF PELVIC
BLEEDING
Major Vessel Bleeding
Iliac Vessels
Bleeding from the common iliac or internal iliac arteries or veins is
usually massive. It may occur in very slim patients in whom dissection is deceptively easy, or very stuck patients in whom absence of
tissue planes can hide a vessel. Major arterial bleeding is obvious;
major venous bleeding is a rapid welling up of a pool of blood in
the surgical eld. Immediate packing and a request for a vascular
surgery consultation can be followed by optimizing exposure for the
attempt at control. If a vascular surgeon is not available, the bleeding
Superior rectal
artery and vein
Sigmoid colon
Rectosigmoid
junction
Rectal ampulla
Anorectal
junction
Levator ani
muscle
Pudendal
canal
Anal column
Puborectalis
muscle
Internal anal
sphincter
Intersphincteric groove
(anocutaneous line)
Deep
Superficial
Subcutaneous
FIGURE 87-4 Lateral stalks with pelvic plexus and mid rectal arteries.
Inferior
epigastric artery
Obturator artery
Umbilical artery
Inferior vesicle
artery
Inferior gluteal
artery
Internal
pudendal artery
Superior vesicle
artery
Middle rectal
artery
Internal pudendal artery,
canal (in obturator fascia)
Inferior rectal
artery
Pectinate
(analrectal) line
Zones of external
COMPLICATIONS 459
site is controlled by mobilizing the vessel above and below and applying vascular clamps. e tear or cut is then repaired with a vascular
suture. Success depends on recognizing the approximate site of the
damage early to facilitate early control of bleeding.
Minor Vessel Bleeding
Arterial bleeders are easier to control than other sources of bleeding.
ey are obvious and can be controlled with suture ligation, hemoclips, endo ties, or electrocautery. e main challenge involves suturing deep in the pelvis and subsequently tying, when there is a risk
of avulsing the vessel. Care must be taken not to pull on the tie as
the knot is placed down. Dissection of the feeding artery with ligation may be necessary to control arterial hemorrhage. e last resort
of packing the pelvis and transporting the patient to interventional
radiology for the embolization of internal iliac branches is rarely necessary in an elective case; it is an excellent tactic but is generally used
in trauma patients and in persons with venous bleeding.
Presacral Bleeding
Violation of the presacral fascia and release of the venous pool from
its high hydrostatic pressure can lead to a life-threatening hemorrhage. Although prevention of this complication is a far better strategy than controlling it, it is imperative for the pelvic surgeon to be
armed with techniques for treatment. Communication with the
anesthesia team is essential. Blood should be available in the room,
and two large-bore intravenous lines should be in place. Decisions
regarding a blood warmer and the need for platelets and fresh frozen
plasma can be made on an evolving basis depending on the volume
of blood loss and the patient’s condition. A second suction device on
the operative eld is sometimes helpful. Tragic problems may occur
if the surgeon and anesthesiologist are not in close contact and if
hypotension is corrected with pressors rather than with volume, or if
the surgeon is not told of hemodynamic problems and forges ahead
rather than continuing to apply pressure to allow the anesthesia team
to catch up with the blood loss.
Pelvic Packing
Packing is always a safe technique when dealing with massive presacral bleeding, especially in a patient who is becoming hemodynamically unstable. It can be used at the initial time of bleeding in an eort
to gain control of the situation denitively, or as a fallback position,
with transport to the intensive care unit (ICU) when control of bleeding cannot be accomplished. When a decision has been made to leave
packs in place for control of bleeding, a return to the operating room
for removal of the packs within 24 to 48 hours is required. Although
recurrent hemorrhage is a risk at the time of the second look, oen the
prolonged pressure of the packs within the pelvis and the opportunity
for replacement of blood volume, normalization of coagulation, and
correction of patient temperature in the ICU result in a more controllable situation. orough soaking of the packing before it is removed
diminishes the likelihood of displacement of any coagulum with the
packing and a resultant resumption of bleeding. A modied packing
technique was described by Metzger in which a bowel isolation bag
is placed in the presacral space with its neck brought out through
a perineal wound. e bag is lled with gauze packing, which can
be removed at the bedside 2 to 4 days later, along with the bag. is
technique allows the surgeon to observe for any ongoing blood loss.
e surface of the bag allows the gauze to tamponade the bleeding,
but because it is not adherent, it can be removed without disruption
of the clot and rebleeding. e technique does not require a return to
the operating room for removal of the packing. However, the need for
a separate perineal wound, particularly in patients with a fresh anastomosis, is a disadvantage. Other devices that have been described
for tamponade include tissue expanders and saline solution bags.
Although avoiding another exposure to anesthetic is a consideration,
a return to the operating room may allow better exposure for ensuring hemostasis and anastomotic integrity.
Suture Ligation
Suture ligation has the potential for aggravating rather than controlling presacral bleeding. Although it can be eective, the needle oen
causes further injury to the fragile venous walls. More commonly,
the veins are injured as the suture pulls through the walls as they are
tied. If suture ligation is used, it is important that the suture includes
the presacral fascia, presacral veins, and deep connective tissue. Jiang
etal reported that circular suture ligation of the venous plexus in the
area with intact presacral fascia that surrounds the bleeding site is an
eective, simple technique. By incorporating additional tissue in the
suture, the veins are less likely to be injured when the suture is tied.
Thumbtacks
Sterile stainless steel or titanium thumbtacks can be placed directly
into a sacral foramen containing a bleeding presacral vein. is
approach allows direct pressure but avoids the risk of venous injury
that can occur with sutures. Although it is occasionally helpful, signicant limitations to this approach exist. umbtacks cannot be
applied to bleeding points originating from sacral neural foramen or
near vital structures such as the ureters. umbtacks are also ineective in cases of diuse bleeding. Additionally, authors of some case
reports have described thumbtack displacement, resulting in chronic
pain and anastomotic disruption (Fig. 87-5).
Wang etal described the use of a titanium table xation staple
with a cancellous bone gra at the site of bleeding in the sacrum. e
staple has four superne spiral spikes for xation and can vary in size
to t the size of the bleeding hole. e stapler has a specic driver and
hammer to make xation easy.
A less traumatic technique sometimes used to apply permanent
pressure for presacral hemorrhage control is the application of bone
wax. is technique is only helpful in very limited bleeding situations. Pressure with wax without coagulation in the presence of diffuse presacral bleeding will not be successful.
Muscle Fragment Welding
e muscle fragment welding technique involves the use of a 1.5- to
2.0-cm square segment of rectus abdominis muscle harvested from
the incision and held in place with forceps over the bleeding area
while vigorous suctioning is implemented to expose the presacral
eld. Electrocautery at a high setting (100 Hz) is applied to the forceps and transmitted to the muscle fragment to weld it to the bleeding
site. Although the muscle fragment or coagulum may fall free from
the site, the source of the bleeding is welded closed. An advantage of
this technique is that no additional equipment is required and no foreign bodies are le in place for later removal. e rectus abdominis
muscle also can be used to control presacral bleeding. A 4 × 2 × 1 cm
piece of rectus is harvested as a free ap and sewn over the bleeding
area to tamponade the bleeding. Although no additional equipment
is necessary for this procedure, the need to suture the rectus in place
may in itself prompt further bleeding.
Bipolar Electrocautery
Electrocautery combined with forceps can be used for localized pelvic bleeding. It may not be successful in cases of diuse hemorrhage,
even with higher cautery settings. Filippakis etal described the use of
spray electrocautery to control presacral bleeding. e spray setting
for monopolar electrocautery generates a direct current that operates
between 200 kHz and 3.3 MHz, well above the range at which neuromuscular stimulation could occur. Tissue fulguration is achieved by
Ureter
Obturator
artery
Ductus
deferens
Prostatic
plexus
Dorsal
nerve
of peni
c
Perinea
nerve
Sympathetic
Umbilical
artery
Vesical
plexus
s
Lumbar
sympathetic
ganglia
ManageMent of HeMorrHage during Pelvic Surgery460
Hemostasis Step-by-Step Technique
trunk and
ganglia
Hypogastric
plexus
Hypogastric
nerve
Sacral
plexus
Pelvic
splanchnic
nerves
Pudendal
nerve
Inferior
hypogastric
plexus
Inferior
l
rectal nerve
D’Ambra et al described a hemostatic step-by-step technique
that utilizes local compression of the bleeding site with tampon
gauze or an absorbable knitted fabric hemostat (Tabotamp, Ethicon, Somerville, N.J.). When bleeding does not stop, an epiploic
appendage or omental scrap is localized and ablated by coagulating the pedicle with bipolar forceps and using it as a plug on the
tip of the grasping forceps. The plug is placed on the bleeding
site and monopolar coagulation is applied with use of electrified
dissecting forceps through interposed grasping forceps. This technique leads to progressive liquefaction of the fatty scrap but prevents the underlying presacral venous structure from tearing and
aids in denatured protein clotting of vessels, resulting in stable
hemostasis.
A third step is used if the fatty scrap does not work. A small scrap
of bovine pericardium gra is tacked to the bleeding site by endoscopic helicoidal protack. e biologic step was only used in two of
seven cases in which presacral hemorrhage was managed. Hemostatic
gauze, a collagen-like natural substance created from chemically
treated cellulose, is approved for use in China and has been described
to help control bleeding from open wounds and body cavities. Upon
contact with blood, the gauze expands to three to four times its size
and converts into a gel. It then dissolves into saline and glucose over
a period of 1 to 2 weeks.
Hemostatic Agents
Ureter
Hypogastric
nerve
FIGURE 87-5 Pelvic nerves.
Superior
hypogastric
plexus
Sacral
nerve
root
Inferior
hypogastri
plexus
using electrical arcs. e sparks jump from the electrode across the
air gap to the tissue, which causes clotting of blood and destruction of
tissue with no cutting eect. e benet of this approach is that with
the arcing, the coagulum is not formed and pulled o by the cautery
as it is moved. e correct method to achieve fulguration when using
coagulation is to hold the tip of the active electrode slightly above the
target tissue at a 90-degree angle. is technique can eectively reach
and coagulate nonvisible bleeding points when bleeding originates
from basivertebral veins that pass through the sacral foramen. e
use of the argon beam coagulator to control presacral bleeding during
an ultra-low anterior resection has also been described. e equipment, operated with a “point and shoot” method, does not require
additional training to use and works easily in connes of a narrow
pelvis during laparoscopic surgery. For this method to be eective,
however, the operative eld must be dry, and therefore ample, welldirected suction is needed.
Mechanical Hemostatic Agents
Mechanical hemostatic agents include porcine gelatin (Gelfoam
and Gelfoam Plus [Pharmacia and Upjohn Co., New York, N.Y.]
and Surgifoam [Ethicon]), cellulose (Surgicel and Surgicel NuKnit [Ethicon]), bovine collagen (Avitene sheets and Ultrafoam
collagen sponges [Davol Inc., Warwick, R.I.]), and polysaccharide
spheres (Arista [Davol Inc.]). These agents integrate an absorbable sponge, foam, pad, or other material with a topical hemostatic agent that is then applied to the affected area. They form
a matrix at the site of bleeding, activating the extrinsic clotting
pathway and allowing clotting to occur. These agents rely on fibrin
production to achieve hemostasis; therefore, they are only appropriate for patients with an intact coagulation cascade. Bovine collagen and polysaccharide spheres are the most effective; porcine
gelatins have improved efficacy when used with topical thrombin.
Typically these agents are suited for capillary, venous, or small
arterial bleeding.
Active Hemostatic Agents
Active hemostatic agents include bovine thrombin (ThrombinJMI [GenTrac, Inc., Middleton, Wisc.]), recombinant thrombin
(Recothrom [ZymoGenetics, Inc., Seattle, Wash.]), and pooled
human plasma thrombin (Evithrom [OMRIX Biopharmaceuticals, Ltd., Somerville, N.J.]). These agents are topical thrombins that stimulate fibrinogen at the bleeding site to produce a
fibrin clot; therefore, circulating fibrinogen is necessary. Active
hemostatic agents can be used effectively in patients with coagulation systems that are impaired. They are applied via pump or
spray kits or delivered via a saturated absorbable gelatin sponge
directly to the site of bleeding. Bovine thrombin is the most
common and least expensive active hemostat used in the United
States today. It is stored at room temperature and comes in powder form that is easily reconstituted with saline solution when
needed for use. Active hemostatic agents are suited for small
capillary and venous bleeding. Pooled human plasma thrombin is contraindicated in patients with a human blood product
allergy.