Presacral bleeding is a potentially life-threatening complication that can be encountered during pelvic surgery, particularly during sacrocopalpexy. Various techniques exist to achieve hemostasis in the event of uncontrolled bleeding. This video will demonstrate some of the available methods that may be employed in the management of presacral bleeding. Utilization of the following techniques should be based on product availability, surgeon preference, and bleeding severity. We have no relevant financial disclosures. The iliac vessels and ureter compose the lateral borders of the presacral space. The abundant vasculature can be seen in proximity to the sacral promontory. Direct pressure to the site of bleeding can be used both as a temporizing maneuver to limit blood loss as well as for hemostasis. A sponge stick or laparotomy sponge can be used to apply direct pressure. Care must be taken to avoid shearing veins and creating additional bleeding sites. Pelvic packing with the use of multiple laparotomy pads or a large abdominal pack, as shown here, is an effective form of hemostasis. Pelvic packing is most often utilized when all other modalities have failed. The packing may be left in the abdomen for 24 to 48 hours to ensure adequate time to tamponade the areas of bleeding. Gelatin matrix, such as gel foam, can absorb up to 40 times its weight. The desired size is cut from the sheet. The gelatin matrix sponge can conform to an irregular surface like the sacrum. Pressure is held for several minutes and the gelatin is left to absorb. Bone wax is an inexpensive material to use in an attempt to achieve hemostasis. The wax is manipulated and placed at the site of bleeding. A Russian forceps, finger, and periosteal elevator can be used to assist in application of the bone wax to the site. Excess bone wax should be removed if it is to be left in. Sterile thumbtacks have been shown to be effective in the management of presacral bleeding. The thumbtack is seen preloaded on an applicator. The thumbtack is lined up along the site of bleeding and is pressed firmly into the sacrum. The applicator is then removed. When an easily identifiable blood vessel is found to be the source of bleeding, a clip may be placed directly on the vessel for hemostasis. Different sized clips may be used depending on the circumstances of the bleeding. Similarly, when the bleeding vessel can be identified, suture ligation may be attempted. Caution must be exercised as potential exists for worsening bleeding. Oxidized, regenerated cellulose, such as surgicell fibrillar, is an absorbable hemostat mesh. It is most effective when there is oozing from a cut surface. The needed amount is obtained and applied to the site of bleeding. Here the material is placed in between two ends of suture and is tied down. Suture may also be passed through both ends of the material. Here a bare needle passes the suture through the cellulose and then applied directly to the bleeding site and tied down. An omental flap or epiploic flap can be used to control presacral bleeding. Here a piece of omentum is sutured to the site of sacral bleeding. Electrocautory remains an option for bleeding in the presacral space. When identification of a vessel is possible, DeBakey forceps can be used to isolate the offending blood vessel and indirect coagulation is administered. Direct coagulation can be used, but it runs the risk of causing worsening bleeding, which has been documented in the literature. Muscle fragment welding is a technique that requires harvesting a small piece of rectus muscle and applying it to the site of presacral bleeding and then administering electrocautory to the muscle fragment. First the site of rectus muscle harvest is identified. Care is taken to avoid the inferior epigastric vessels. A 2 by 2 centimeter fragment of muscle is harvested. Traction and counter traction helps to facilitate the muscle harvest. The muscle fragment is then placed on the site of presacral bleeding. Indirect coagulation is administered to the muscle. The resulting effect tampers with the muscle fragment. The muscle fragment is then placed on the site of presacral bleeding. Indirect coagulation is administered to the muscle. The resulting effect tampers with the muscle fragment. The resulting effect tamponades the bleeding vessels. Increase in cautery settings may be needed for tissue adherence. Gelatin matrix combined with thrombin such as Flo-Seal is an effective topical hemostatic agent. It may be used alone or in combination with oxidized regenerated cellulose. Here a sponge is used to keep the site of bleeding dry while the thrombin gelatin matrix is administered. Pressure is then placed on the bleeding site. Hemostasis can be achieved as quickly as 20 seconds. Alternatively, it may be administered directly. Microporous polysaccharide spheres such as Arista is made from potato starch. After pressure is applied to make the bleeding sites as dry as possible, powder may be applied liberally. Pressure may be reapplied if needed. Spray electrocautery may be administered to the area just above the bleeding to aid in hemostasis. Presacral bleeding can be encountered during palpation. Presacral bleeding can be encountered during pelvic surgery. We present a variety of modalities to treat presacral bleeding. Familiarity with these techniques and product availability will aid in the management of acute presacral bleeding.

presacral bleeding

pelvic surgery

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