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40138 Management of Presacral/Pelvic Bleeding
stressed. The literature has consistently demonstrated that checklists improve outcomes in a
stressful situation [8]. As such, it is important to
have a structured plan.
Prior to engaging in specific technical manoeuvres described below, the situation first
needs to be acknowledged. Troublesome bleeding in the pelvis is a constant hindrance but does
not impede progress nor compromise the patient. Significant bleeding, however, should be
verbally acknowledged. This is important since
all members in operating room may not be able
to see the operation or may not be aware of the
gravity of the situation. It is possible that the fellow or resident either performing or assisting in
the operation may not have encountered significant pelvic haemorrhage before [9]. It will thus
be necessary for the surgeon to take over the
operation and organise the assistants in the most
useful position (e.g. opposite the surgeon or in
between the patient’s legs) as per their seniority.
An escalation in hierarchy should also be conducted with other members of staff in theatre.
The most senior nurse should take over as the
scrub nurse if not already involved, and multiple
unscrubbed nurses should be available as a number of uncommonly used tools may need to be
acquired expediently. Similarly, the anaesthesiologist should be informed directly.
Role of the Anaesthesiologist
Once the anaesthesiologist has been informed,
acute circulatory support can be considered to
have been delegated. Though the practical role of
the surgeon is to control the bleeding, it is important to be familiar with the strategies at the
disposal of the anaesthesiologist.
The focus of the anaesthesiologist will include
initial measures including ensuring optimal intravenous access and volume resuscitation. This
may lead to more intensive monitoring for the
acute period and also in anticipation of the likely
necessity of admission to the high dependency
unit or intensive care unit.
Volume replacement may include activation
of the massive transfusion protocol or component
blood replacement in line with institutional practice. Serial thromboelastograph measurements
may also be important to guide blood product
replacement alongside advice from a haematologist [10].
Tranexamic acid may also help limit the magnitude of bleeding. Recent evidence suggests that
tranexamic acid reduces bleeding in gastrointestinal surgery with no increase in the incidence of
thromboembolic events [11]. Anecdotal experience also suggests that use during pelvic exenteration decreases surgical ‘ooze’.
Role of the Surgeon
Once the operating team has been suitably organised, the pelvis should be packed. At this time,
more help should be obtained from a colleague if
possible. The importance of an experienced first
assistant and the potential advantage of a hitherto
uninvolved person cannot be overstated.
The injury now needs to be localised and illumination and proper exposure is crucial especially since a hallmark of this type of bleeding is
gushing blood form the pelvic floor with a nearundetectable bleeding point. A practical solution
to obtain optimal illumination is that the operating surgeon should utilise a headlight. Exposure
can also be facilitated by expedient removal of
the specimen whilst the area remains tamponaded with packs. If the bleeding point cannot be
reliably detected, pressure should be maintained
for 15–20 min. The temptation to re-examine the
area ahead of this interval should be resisted, and
the time should be used to formulate a plan and
obtain necessary equipment. The pressure effects of packing may also be complemented with
commercially available fibrin-based haemostatic
agents [12]. A combination of haemostatic matrices (e.g. FloSeal, Baxter, USA) and absorbable haemostatic products (e.g. Surgicel Fibrillar,
Ethicon, USA) may be used.
It is important to determine whether the bleeding has resulted from an injury to the presacral
402 S. Srinivasa and A. G. Hill
venous plexus or to a basovertebral vein. If the
bleeding point can be controlled by compressing
the surrounding veins, there has been an injury to
the presacral veins. If the bleeding is abated only
by direct compression, it is from an injury to a
fine or large-calibre basivertebral vein.
Injury to the presacral venous plexus can often
be successfully managed with suture ligation ensuring that it is performed over intact presacral
fascia and the bites are deep enough to contain
presacral veins but also surrounding deep connective tissue so that the stitches hold traction
[13].
Injury to the basivertebral veins can be managed with thumbtacks over the sacral foramen
or by breaking the sacral foramen with a bluntended instrument [4]. A number of authors have
reported the successful use of thumbtacks to stop
presacral bleeding [14, 15]. It is inexpensive and
technically straightforward unless the bleeding
arises from veins near S3 or S4 as the curvature
of the distal sacrum can make access difficult.
Thumbtack displacement and chronic pain have
been reported though these are secondary issues
when confronted with life-threatening bleeding
[16, 17].
Lou et al. have also described “welding” an
epiploic appendix to the bleeding point with cautery whilst Saurabh et al. have reported successful management of bleeding with the use of argon
plasma coagulation [2, 18]. Both techniques have
been reported in the context of open surgery but
could be applicable to minimal-access surgery.
Rectus muscle tamponade has also been described as a strategy and is broadly similar to the
use of the epiploic appendix though the former
has been reported to lead to subsequent necrosis
and abscess development [19].
Other strategies that have been successfully
used include the application of bone wax, Teflon pledgets, expandable breast implant sizers or
saline bags and haemostatic agents [16, 17, 20,
21]. Ligation of the internal iliac veins is usually
futile since this will obstruct blood flow in the
pelvic venous plexus, obturator veins and gluteal
veins. As a result, blood flow will be redirected to
the injured veins via the lateral or anterior sacral
veins.
A number of strategies have been described
in the literature. However, practical application
of these techniques in an individual situation is
limited by the surgeon’s familiarity and comfort
and availability of required tools within the institution. The listed strategies cannot be exhaustively worked through due to the rapidity of the
bleeding. Rather, it is up to the individual to decide upon a few which he/she can employ in a
systematic manner.
If the bleeding cannot be controlled despite all
attempts, the pelvis should be packed and the operation abandoned. The patient should be transferred to the intensive care unit with a planned relook laparotomy when the patient has stabilised.
Assistance from interventional radiologists may
also be helpful for angioembolising any vessel
showing extravasation of contrast though this is
unlikely to be helpful due to the bidirectional nature of flow and redundant pathways contributing
to bleeding.
Minimal-Access Surgery
Many of the techniques described above can be
utilised during laparoscopic or robotic resection.
The initial differences upon encountering significant presacral bleeding relate to the view, which
may in fact be superior to open surgery, and identification of the bleeding point (Fig. 38.2). Port
placement may preclude direct pressure over
the sacrum, and extra ports should be inserted
as appropriate to maintain direct pressure in an
ergonomic fashion. Since the view during laparoscopic or robotic surgery may be highly magnified, the bleeding may appear even more voluminous. The other disadvantage is that it may not
be possible to remove the operative specimen as
quickly as during open surgery.
The specific strategies used successfully in
the literature include argon plasma coagulation in
a ‘point and shoot’ manner [18]. Germanos et al.
have described the use of haemostatic agents to
40338 Management of Presacral/Pelvic Bleeding
Fig. 38.2 Presacral bleeding. MSV middle sacral vein,
IIV internal iliac vein, LSV lateral sacral vein, BVV ba-
sivertebral vein, PSVP presacral venous plexus, IVVS in-
control presacral bleeding [16]. Although their
case reports are in the context of open surgery,
a similar strategy of using haemostatic matrixes
and fibrin-based haemostatic gauze may be applicable and technically straightforward in minimal-access surgery.
Suture ligation may also be used but will only
be useful if the bleeding arises from the presacral
venous plexus. It also requires advanced laparoscopic skills, and its applicability may be limited
by unfavourable, non-ergonomic working angles
with conventional port placement.
A simple algorithm reported in the literature
involves a trial of local compression with gauze
or an absorbable haemostat followed by attempted sealing of the bleeding point with either an
omentum or an epiploic appendix. The graft is
obtained using bipolar diathermy and then held
in place with grasping forceps with monopolar
diathermy to seal it in place. The third stage of
the authors’ algorithm was to use a bovine pericardial graft and attach it to the source of bleeding with endoscopic tacking devices [22].
Strategies used in minimal-access surgery are
broadly similar to those used in open surgery,
and the principles have been partially derived
from liver bleeding during laparoscopic cholecystectomy. Although presacral bleeding can be
safely managed laparoscopically or robotically,
prolonged periods of time should not be spent
tervertebral venous system. (Reproduced with permission
from [13] © Springer 2013)
attempting to control the bleeding without converting to open surgery.
The Postoperative Period
The patient should remain in a monitored environment, and their ongoing fluid and blood requirements should be managed to prevent the lethal triad of hypothermia, coagulopathy and acidosis. Patients may benefit from ongoing doses
of tranexamic acid and antibiotics (though there
is no evidence for this). Anticoagulation with
heparin or equivalent should be withheld. The
family should be informed.
Lastly, given the rarity of the event, a debriefing session should be held for all members involved. This is particularly valuable for junior
members of staff. The benefit of an even an informal debriefing session is to discuss prevention
and management in detail whilst also potentially
resulting in system improvements as necessary.
Summary
Presacral bleeding is a rare but clinically significant event in open- or minimal-access pelvic
surgery. It usually results from injury to either
the presacral venous plexus or the basivertebral
404 S. Srinivasa and A. G. Hill
veins. Conventional means to stop bleeding are
usually unsuccessful. The management of this
problem requires the active participation of the
whole operating theatre team. Successful technical strategies involve localising the bleeding
point, identifying whether the bleeding has arisen
from the presacral venous plexus or basivertebral
veins and employing appropriate strategies in
a systematic manner in line with the surgeon’s
preference and availability of necessary tools
within the institution.
Key Points
1. Correct identification of the TME plane, especially posteriorly
2. Pack the pelvis and identify source of bleeding
3. Inform operating room staff and get additional
help if possible
4. Differentiate between injury to the presacral
venous plexus and basivertebral veins
5. Follow a structured plan based on injury
type—suture ligation/haemostatic agents/
thumbtacks etc.
References
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Breakdown/Non-healing
ofPerineal Wound
Justin M. Broyles, Jonathan E. Efron
andJustinM.Sacks
39
Introduction
Malignancies of the anorectum, vagina, and other
soft tissues in anogenital region are the most common reason for perineal resection. Commonly
employed procedures include the traditional abdominoperineal resection (APR), intersphincteric
resection, pelvic exenteration, and low anterior
resection (LAR). Although there is a trend toward more sphincter preserving surgery for rectal
cancer, traditional APR is still used in 15–25 % of
patients with rectal cancer [1].
The perineum is one of the more difficult sites
in the human body to reconstruct after surgical
obliteration due to the significant volume of dead
space, close proximity of multiple organs, high
bacterial counts, and the subjection to direct pressure in both the sitting and recumbent positions.
Cancer patients receiving tumor extirpation in
Disclosures: Dr. Justin M. Sacks is a speaker/consultant
for LifeCell Corporation. Branchburg, NJ.
J. M. Sacks () · J. M. Broyles
Department of Plastic and Reconstructive Surgery,
The Johns Hopkins Hospital Outpatient Center, 601N.
Caroline St., Suite 2114C, Baltimore, MD 21287, USA
e-mail: jmsacks@jhmi.edu
J. E. Efron
Department of Surgery, The Johns Hopkins University,
Baltimore, MD, USA
e-mail: jefron1@jhmi.edu
this anatomic location often have undergone neoadjuvant chemotherapy and/or radiotherapy to
downstage their disease, which further impacts
wound healing. As a result, wound complications
are frequently encountered in these patients, with
rates ranging from 40 to 65 % (Fig. 39.1) [1–4].
Primary closure of large perineal defects can
be associated with unacceptable wound-healing
complications ranging as high as 65 % [2–4].
Other common surgical complications include
hematoma, seroma, abdominal and/or perineal
hernia, fistulization, and nonhealing wounds [1].
Such complications can lengthen hospital stays,
decrease mobility, prolong time to adjuvant therapy, and increase patient morbidity.
In an attempt to mitigate the occurrence of
such complications, many plastic and reconstructive surgeons advocate the use of a pedicled,
vascularized soft-tissue flap coverage to close
large perineal defects [3, 4]. Utilizing a vascularized, soft-tissue flap will assist in obliterating dead space and this has shown to improve
wound-healing outcomes by decreasing incisional tension while increasing vascular supply, oxygenation, and delivery of cytokines and
growth factors. In the current chapter, we aim to
provide a comprehensive overview of the various
reconstructive options for perineal defects to educate the reader on how to prevent as well as treat
perineal wounds in an effort to maximize patient
outcomes in these challenging cases.
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_39,
© Springer Science+Business Media New York 2015
407
408 J. M. Broyles et al.
Fig. 39.1 Large perineal defect demonstrating vast dead
space and exposed viscera
Preoperative Evaluation
The physiologic status of the patient must be considered and balanced with the overall reconstructive plan. The long-term prognosis of the patient
must also be taken into account as well. Reconstruction to improve quality of life should be considered even in a palliative scenario. If possible,
an accurate assessment of the wound or planned
surgical site should be performed in the preoperative setting and may be facilitated by an examination under anesthesia.
Medical Comorbidities
A thorough review of the patient’s past medical
history should be performed to risk-stratify each
patient using conditions that increase the relative
risk of infection and/or wound-healing problems.
Smoking has been shown to affect microcirculatory blood flow and soft-tissue healing and
should be discontinued a minimum of 4 weeks
prior to surgical intervention if possible [5]. Patients undergoing major reconstructive efforts require optimization of nutritional parameters prior
to intervention [6–8]. If enteral feeding is not
possible preoperatively, postoperative enteral or
parenteral nutrition should be administered with
protein supplementation.
Radiation Therapy
Radiation therapy induces tissue injury through
changes in the microcirculation of the defect
and its surrounding areas, leading to decreased
perfusion and impaired wound healing [4]. The
reconstructive surgeon should be cognizant of
the timing, dosage, and location of any prior or
planned radiation and not limit debridement of
radiated tissue. Additionally, the surgeon should
utilize tissue outside the field of radiation for flap
reconstruction.
Chemotherapy
Neoadjuvant chemotherapy can significantly
impair wound healing and should be considered when selecting reconstructive options. The
plastic and reconstructive surgeon should work
closely with the medical oncology team to determine if and when the patient will require adjuvant chemotherapy, as wound-healing complications can potentially delay onset to therapy.
Imaging
Preoperative evaluation with imaging modalities such as computed tomography (CT) and/or
magnetic resonance imaging (MRI) could be obtained to evaluate the integrity of the surrounding soft tissue and vascular anatomy. While these
adjuncts are not essential, they can assist the surgeon in surgical planning.
Timing of Reconstruction
The timing of perineal reconstruction is most
often dictated by the status of the tumor and surgical margins. Certain factors such as advanced
age, multiple comorbidities, or the need for locoregional control with adjuvant radiotherapy must
also be considered in the timing. Primary reconstruction carries a significantly decreased rate of
Table 39.1 Classication of perineal defects by anatomic location
Anatomic structure(s) involved Missing tissue components
Vaginal vault S, MS, ST
Vulvoperineal surface MS, ST
Scrotum S, ST
Penis S, MS, ST
Perineum and pelvic support musculature S, ST (extensive)
Sacrum/pelvic rim S, ST, +/− osseous involvement
S skin, MS mucosal surface, ST soft tissue
40939 Breakdown/Non-healing of Perineal Wound
wound-healing complications and is preferred to
delayed reconstruction in defects located in other
areas of the body [9, 10]. Delayed reconstruction,
while not optimal, is occasionally unavoidable
for defects with extensive soft-tissue deficits or
patient instability. If a patient requires delayed
reconstruction, a negative pressure closure device is the preferred temporizing measure until
definitive reconstruction can be performed at a
later time.
Classification of Defect
Acquired perineal defects should be classified
according to what structures are missing and/or
compromised. This will allow the reconstructive
surgeon to employ the correct reconstructive modality in an effort to replace damaged tissue with
tissue that is most similar to that which is missing. The classification of perineal defects is listed
in Table 39.1.
The size of the defect and types of missing tissue should be assessed for viability. Potential flap
donor sites should be evaluated for adequate rotational length. If there is a potential for microvascular free tissue transfer, recipient donor vessels
should be evaluated for patency. If these vessels
are unavailable or greater length is required, arteriovenous loop can be created if needed. However, most perineal defects can be reconstructed
with the use of local flaps typically from the abdominal wall, thigh, or buttock region.
Reconstructive Surgical Tenants
The core principles underlying reconstructive
algorithms used by plastic and reconstructive
surgeons are to progress from simple to more
complex reconstructions on the basis of the specific wound requirements. The goal for each reconstruction is to provide a tension-free closure
that obliterates all dead space which replaces the
defect with tissue that is most similar to what is
missing. The adage is “like with like.”
Local tissue flaps enable surgeons to reconstruct soft-tissue defects with similar tissue from
an adjacent location. Axial pattern flaps are based
on named blood vessels and are the mainstay of
perineal reconstruction. Axial pattern flaps can be
fasciocutaneous (deep muscle fascia with overlying skin), myocutaneous (muscle with skin), and
myofasciocutaneous (muscle with deep fascia
and overlying skin), which will enable reconstructive surgeons to repair defects with tissue
that is similar to the resected tissue.
Microvascular free tissue transfer involves
harvesting a tissue construct and its named blood
supply from a distant region of the body and
placing it into a defect using microvascular anastomosis between the flap’s donor vessels and the
patient’s recipient vessels. Most cases are performed under magnification provided by a surgical microscope. The decision to use a particular
flap is based on the requirements for replacing
missing skin, adipose tissue, fascia, and muscle.
The primary advantage of microvascular free
410 J. M. Broyles et al.
tissue transfer is that tissue of a quality similar to
that of the resected tissue can be moved from a
remote part of the body, thereby enabling optimal
aesthetic and functional outcomes. This also allows irradiated or infected tissue to be removed
and replaced with soft, pliable, and vascularized
tissue from a different part of the body, outside
of the field of injury. Drawbacks of free tissue
transfer are related to donor site morbidity and
the potential for longer operative times.
Adjuncts to Flap Surgery
Negative Pressure Wound Therapy
Negative pressure-assisted closure can provide
for temporary coverage in soft-tissue perineal defects when definitive reconstruction is either delayed or not required. When utilized appropriately, this device can promote neo-vascularization,
decrease edema, and increase local granulation
tissue as well as providing contractile force at
wound edges [11]. This modality is often used to
prepare the wound bed for definitive reconstruction with soft-tissue flaps in a delayed fashion if
immediate surgical intervention is not possible.
Additionally, it can also be used to promote healing by secondary intention in partial-thickness
defects.
hollow viscous or neurovascular structures. Risks
of tissue expansion include infection, extrusion,
and rupture of the implant [12]. Additionally, the
sequential expansion of the prosthesis can be uncomfortable to the patient and requires multiple
office visits to obtain satisfactory expansion.
Biologic Tissue Matrices
Commercially available biologic tissue matrices (BTMs) currently come from five different
sources: human dermis, porcine dermis, porcine
small intestinal submucosa, bovine dermis, and
bovine pericardium [13]. BTMs claim to induce
early revascularization capacity in an effort to
provide soft-tissue coverage and resist infection.
For perineal reconstruction, BTMs can be used in
a multitude of capacities including the creation of
pelvic diaphragms to prevent visceral herniation
into low perineal defects. Additionally, BTMs
can be used to reinforce abdominal site donor
defects in an effort to decrease bulge and hernia
formation in the face or prior irradiation or concurrent ostomy placement.
Characterization of Axial Pattern
Flaps (Table39.2)
Rectus Abdominis Muscle
Tissue Expansion
Tissue expansion is a process in which an inflatable prosthetic implant with a silicone shell is
used to expand local and regional tissues so that
they can eventually be advanced into the wound
in a delayed fashion. The inflatable implant is inserted at the time of tumor extirpation or during
a second procedure. At subsequent office visits,
saline is injected through an integrated or remote
port to gradually expand the implant. Once the
tissue has been sufficiently expanded, it can be
advanced into the defect in a second surgical procedure. Because tissue expansion takes time, the
method is not feasible for immediate perineal reconstruction that requires immediate coverage of
The pedicled vertical rectus abdominis (VRAM)
flap is a versatile flap based on the deep inferior
epigastric system. The flap can be harvested as
a muscle-only, myocutaneous flap, or perforator
flap with a large skin paddle. All but the largest
of myocutaneous flaps can still allow for primary
closure of the donor site. However, as previously
mentioned, synthetic or BTM reinforcement may
be required to prevent subsequent complications.
The flap has a robust vascularity and abundant
soft-tissue bulk that can be used to obliterate the
vast amounts of dead space seen with large APR
defects [14–17]. Butler et al. demonstrated that
despite the overall complication rate not being
significantly different between primary closure
and VRAM flap reconstruction, patients who
Table 39.2 Commonly employed pedicled ap options for perineal reconstruction
Flap name Blood supply Area of use
Rectus abdominis Inferior epigastric artery Total perineal reconstruction/poste-
rior vaginal wall
Gracilis Medial circumflex femoral artery Smaller perineal defects
Gluteus maximus Superior gluteal artery Posterior/inferior perineal defects
Pudendal Posterior labial artery Vaginal vault defects
Anteriolateral thigh Descending branch of lateral circumflex femoral artery Total perineal reconstruction
41139 Breakdown/Non-healing of Perineal Wound
underwent VRAM reconstruction experienced
significantly lower incidences of perineal abscesses (9 vs. 37
(9 vs. 30 %) (Fig. 39.2) [
%) and major wound dehiscence
17].
Advantages of the VRAM are seen in the ability to provide robust, vascularized tissue into the
defect that is outside of the field of radiation. The
large, vertical skin paddle is particularly useful
when reconstructing the contour of the posterior
vaginal wall. Alternatively, this flap can be tubed
to create a neovagina if the entire vaginal vault
has been obliterated. In many cases, the donor
site is already exposed during tumor extirpation
Fig. 39.2 Surface anatomy of VRAM (vertical rectus ab-
dominis) flap displaying arterial pedicle
negating the need for a second incision and donor
site (Fig. 39.3).
Disadvantages of this flap are inherently related to the anatomic location of the donor site.
If the patient is not undergoing a concurrent midline laparotomy, flap harvest obligates the patient
to undergo an anterior approach, which can lead
to herniation, bulge formation, wound-healing
complications, and/or injury to the surrounding
viscera. Furthermore, this flap should not be harvested at the site of planned ostomy placement
to allow the new stoma to be anchored into the
rectus abdominis muscle. Finally, the vascularity
of the VRAM is questionable in the presence of
prior ostomy placement through the rectus abdominis muscle and should be avoided if at all
possible.
Gracilis Muscle Flap
The pedicled gracilis muscle flap is a versatile
flap based on the medial circumflex femoral artery in the proximal thigh. The flap can be harvested as a muscle-only or a myocutaneous flap
with a small skin paddle. The flap has minimal
donor site morbidity and can be harvested bilaterally if additional soft-tissue bulk is required.
Advantages of the gracilis flap include a relative ease of dissection with minimal donor site
morbidity. The ample pedicle length coupled
with a relatively linear muscle design allows for
the flap to be tailored fitting a variety of defects.
It is particularly useful for obliterating fistulous
tracts between the rectum and vagina or urethra
with an excellent success record [18, 19].
Disadvantages of the gracilis muscle flap are
related to flap size and dimension. Often times,
even when harvested bilaterally, the gracilis flap