Logothetopolis, control of intraoperative hemorrhage with pelvic pressure pack. We have no financial disclosures. The day-to-day life of an obstetrician-gynecologist includes bleeding. Many gynecologic surgeries and pathologies have the potential to generate a large and sometimes unexpected amount of bleeding. We will review intraoperative hemorrhage and discuss initial and salvage techniques to address bleeding. And finally, to discuss the technique of abdominal packing known as the pack-and-go-back strategy to control massive intra-abdominal hemorrhage when conservative measures have failed. Specifically for OBGYN, packing is useful with bleeding from gynecologic cancer surgery, retroperitoneal hematoma, peripartum hysterectomy, and pelvic trauma. ACOG practice bulletin number 76 describes packing as a treatment for postpartum hemorrhage following a peripartum hysterectomy with continued bleeding and or disseminated intravascular coagulation. The packing technique is rarely needed in one's career and there are no pictures or instructions on this practice. The incidence of major intraoperative hemorrhage at the time of hysterectomy is noted to be 2.7% in the literature. This percentage varies based on the route of hysterectomy. After more conservative and more aggressive operative measures have failed to control bleeding, it is likely that the patient is experiencing disseminated intravascular coagulation. We will now begin our discussion on salvage interventions using packing that can be used when all other interventions have failed. Triad of death refers to the risk of developing potentially fatal exsanguinating hemorrhage. The triad of death is described in the trauma literature as coagulopathy with an INR of greater than 1.5, acidosis with a pH less than or equal to 7.2, and hypothermia with a temperature less than 35 degrees Celsius. First, we will discuss the pack and then we will discuss the go-back strategy. Pelvic pressure packs control hemorrhage from large raw surfaces, venous plexuses, and inaccessible areas by exerting well-distributed pressure. This compresses bleeding areas against the bony pelvis and the connective tissue of the pelvis. Indications for pelvic pressure packing include post-hysterectomy bleeding from the vaginal vault, uncontrolled bleeding from the pelvic sidewall and inaccessible areas of the pelvis, and non-expanding broad ligament or retroperitoneal hematoma and disseminated intravascular coagulation. Packing is a last resort that usually succeeds in controlling low-pressure or microvascular bleeding confined to the pelvis. Large arterial bleeding, as seen here, will not be stopped by packing. Therefore, if the latter is suspected, other techniques must be considered such as arterial embolization or bilateral internal iliac artery ligation. Items previously described for packing include bed sheets and sterile gowns. These items are either placed directly against the raw surfaces that are bleeding or inside a bag such as a sterile x-ray cassette drape, gastroschisis bag, or infant warming bag. You can see a fully formed pack here. Next, we will describe the logothetopolis tampon, which is pelvic packing removed through the vagina. In 1926, Dr. Logothetopolis described a pack for the management of uncontrolled post-hysterectomy pelvic bleeding. He proved the efficacy of sustained pelvic pressure in arresting bleeding by performing a hysterectomy without ligating any vessels and inserting a pack into the pelvis for hemostasis. While we do not advocate the use of a no-tie hysterectomy, we utilize this technique following peripartum hysterectomy with large oozing surfaces. The technique has subsequently been called the mushroom, parachute, umbrella, or logothetopolis pack. The pack is made using a sterile x-ray cassette drape filled with around five rolls of 11 by 3 centimeter curlex tied together, although the amount of curlex or other packing material is based on how large the pack needs to be to fill the surface area of the true pelvis in a mushroom shape. The pack is placed abdominally and the neck of the pack is pulled through the vagina. Care is made not to compress the small bowel behind the pack during placement. We also place an intraperitoneal, large-gauge, closed-system drain to monitor for post-operative bleeding. Traction is applied to the pack by tying an IV tubing around the neck of the pack and suspending it to a 1-liter fluid bag off the foot of the bed with an orthopedic pulley. To hold the pack in place against the perineum, an 80-millimeter donut pessary can be used with a large clamp. We believe the technique we have described has several advantages. One, it is simple and easy to perform. Two, the sterile cassette drape or bowel bag is inert and in our experience is not associated with adhesion formation so that removal of the pack is less likely to disturb recently formed thrombi. Three, although loose abdominal packing and temporary abdominal closure with surgical clips does provide some degree of tamponade, this effect is not sustained in the same way as the logothetopolis tampon due to the pack being placed on constant tension by suspension of the fluid bag off the end of the bed. It should be noted, however, that continuous transabdominal tamponade for pelvic hemorrhage has been described by Feenan et al. Four, it is not necessary to open the abdomen to remove the pack and there is a high success rate in controlling hemorrhage, although the numbers for these outcomes are quite limited. Potential disadvantages to this method surround the idea that transvaginal removal of the pack leaves the possibility for concealed hemorrhage, although this is not supported in the literature. The pack is optimally removed 48 hours following placement. Literature from abdominal packing and liver trauma notes that removal prior to 48 hours is associated with re-bleeding while retaining the pack for greater than 72 hours is associated with sepsis. Intraoperative hemorrhage can be safely and effectively addressed using pelvic packing. There are several approaches to addressing hemorrhage and the logothetopolis tampon has distinct advantages to abdominal packing that should be considered in pelvic hemorrhage.

pelvic pressure packs

Logothetopolis tampon

intraoperative hemorrhage

obstetrics and gynecology

pack-and-go-back strategy