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Intraoperative emergencies 

Intraoperative emergencies
Chapter:
Intraoperative emergencies
Author(s):

Stergios K. Doumouchtsis

, and S. Arulkumaran

DOI:
10.1093/med/9780199651382.003.0012
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date: 19 November 2019

Intraoperative emergencies Haemorrhage

An unexpected blood loss of >500 mL at any gynaecological operation is considered significant by the RCOG clinical governance standards. When such estimated blood loss has occurred intraoperatively the following measures may be considered:

Treatment

  1. 1. ► Inform your anaesthetist and ask for cross-match of 4–6 units of blood.

  2. 2. Careful ligation of appropriate vessels with sutures. ►► In case of a solitary source of bleeding like lacerated vessel or slipped pedicle, it is vital that the source is identified accurately and secured. Blind suturing should be avoided as it can make matters worse and cause further damage.

  3. 3. Careful use of diathermy and consider using Surgicel.

  4. 4. Apply pressure with a warm pack and ensure adequate blood and/or clotting factors replacement. Inform the on-call haematologist and send a clotting screen.

  5. 5. Rarely the organ bleeding (tube, ovary, or uterus) will require removing surgically to arrest bleeding.

  6. 6. Very rarely consider ligation (but not division) of anterior division of internal iliac artery possibly with vascular surgeon on call.1 A vascular clamp/or bulldog clamp can be used to see if ligation of the iliac artery will be useful or not.

  7. 7. Should there be one available, an interventional radiologist can be involved to locate and occlude the vessels causing the haemorrhage (embolization) when other measures have failed. Cell savers technology should be utilized where available.2

  8. 8. The use of the protease inhibitor aprotinin, arginine vasopressin derivatives (desmopressin), and recombinant factor VII (rfVIIa) can all be considered when blood loss continues despite the above-mentioned measures and have been proven to be useful.3

  9. 9. Very rarely a pack may be left in situ (especially when hypothermia (<35°C), acidosis > 7.2, or coagulopathy (partial thromboplastin time >16 sec) exist4) and removed at second look laparotomy 24 hours later when the patient’s condition has stabilized.

References

1. Oleszczuk D, Cebulak K, Skret A, et al. Long term observation of patients after bilateral ligation of internal iliac arteries. Ginekol Pol 1995; 66(9):533–6.Find this resource:

2. Guo XY, Duan H, Wang JJ, et al. Effect of intraoperative using cell saver on blood sparing and its impact on coagulation function. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2004; 26(2); 188–91, 2004.Find this resource:

3. Paramo JA, Lecumberri R, Hernandez M, et al. Pharmacological alternatives to blood transfusion: what is new about? Med Clin (Barc) 2004; 122(6):231–6.Find this resource:

4. Stagnitti F, Bresadola L, Calderale SM. Abdominal “packing”: indications and method. Ann Ital Chir 2003; 74(5):535–42.Find this resource:

Intraoperative emergencies Perforated uterus

This may occur during D&C, hysteroscopy, insertion of a coil, or at ERPC/suction termination of pregnancy (STOP). It may be noticed at the time by the feeling of ‘lack of resistance’ when probing the uterine cavity or may present postoperatively with signs of acute abdomen. Its incidence is 0.1–0.5% and risk of associated bowel trauma is >0.1%.1

Treatment

  1. 1. Inform the anaesthetist and ensure a large-bore IV cannula is inserted.

  2. 2. Leave instrument in the uterus that you believe has caused perforation and, if this is a suction cannula, then turn off the suction.

  3. 3. Proceed to a laparoscopy, assuming the patient is haemodynamically stable.

  4. 4. Inspect uterus for perforations/bleeding points and if possible inspect as much intestine at the laparoscopy as you can. If in doubt about bowel trauma, especially if fat (which may be part of the omentum) was sucked or removed, patient needs a laparotomy for a good evaluation. Call a colorectal surgeon.

  5. 5. Commonly small perforations that are not bleeding can be managed conservatively with antibiotics (cefuroxime and metronidazole) and admitted overnight for observation.

  6. 6. Should there be bleeding from the uterus then a laparoscopic suture or laparotomy may be needed to repair the perforation and to arrest bleeding.2,3,4

  7. 7. ERPC or STOP can then be completed under laparoscopic control and under US guidance to ensure there are no retained products of conception.5

References

1. Lindell G, Flam F (1995). Management of uterine perforations in connection with legal abortions. Acta Obstet Gynecol Scand 1995; 74(5):373–5.Find this resource:

2. Sharma JB, Malhotra M, Pundir P. Laparoscopic oxidized cellulose (Surgicel) application for small uterine perforations. Int J Gynaecol Obstet 2003; 83(3):271–5.Find this resource:

3. Mustafa MS, Gurab S. Endoscopic management of bleeding uterine perforation occurring during evacuation of retained products of conception. Int J Gynaecol Obstet 1995; 49(1):71–2.Find this resource:

4. Romer T, Lober R. Endoscopic management of uterine perforation with the ENDO-UNIVERSAL surgical stapler. Zentralblatt fur Gynakologie 1998; 120(2), 69–70.Find this resource:

5. Kohlenberg CF, Casper GR. The use of intraoperative ultrasound in the management of a perforated uterus with retained products of conception. Aust N Z J Obstet Gynaecol 1996; 36(4):482–4.Find this resource:

Intraoperative emergencies Damage to urinary tract/blood vessels/bowel

Urinary tract trauma

Damage to the urinary tract should ideally be recognized at the time of surgery. Postoperative vaginal leakage of urine, urine in drainage bottles, or the presence of loin pain should always raise the possibility of inadvertent damage to the urinary tract.

If there is trauma to the ureter or base of the bladder during surgery, the on-call consultant urologist should be called to theatre. For trauma to the bladder dome, a two-layer closure using 2/0 Vicryl® should be performed followed by methylene blue dye to check for leakage.

If the ureter is damaged and noted during surgery then, depending on the site of damage to the ureter, the following may be considered: ureteric reimplantation, Boari flap, or ileal conduit. These procedures should be carried out by a consultant urologist.

Should the urinary tract trauma be diagnosed in the postoperative period, then:

  • For suspected bladder trauma: a speculum examination may reveal the point of leakage. If not identifiable, a catheter is inserted and methylene blue dye instilled and a swab test performed. Non-colouration, but soaking of the swab will indicate ureteric fistula and swabs soaked with blue indicate vesicovaginal fistula. Alternatively, a cystogram with radio-opaque material can be performed which will reveal the point of leakage.

  • For suspected ureteric trauma: an IV urogram can be performed and hydronephrosis and delayed emptying or even complete renal obstruction can be seen. Usually in such cases loin pain is evident within 6–12 hours after surgery and a percutaneous nephrostomy should be performed as a primary procedure to avoid damage to that kidney. U&Es may not be abnormal if the damage is only on one side.

Trauma to blood vessels

These can occur during laparotomy or laparoscopic procedures.

Trauma to large vessels (aorta, vena cava, iliac vein/artery)

This is usually during laparoscopy by either the Veress needle or the trocar. Should trauma be suspected (blood returning up needle/trocar) the following management should ensue:

  • Leave the trocar/needle in situ and ensure no gas is running in.

  • Place patient in steep Trendelenburg position.

  • Cross-match 6 units and ask for 2 units of O-negative blood/maintain adequate fluid replacement.

  • Perform a midline laparotomy and apply considerable pressure proximal to the vessel injury to slow down blood loss.

  • Call for vascular surgeon to attend immediately to the emergency.

Trauma to pelvic side wall vessels/venous oozing

This can be encountered especially when performing laparoscopy and dividing adhesions.

  • Indiscriminate use of diathermy should be avoided as this can lead to further bleeding and retroperitoneal haemorrhage.

  • Pressure with a sucker or tonsil swab should be maintained for at least 2–3 min and careful lavage performed to ensure haemostasis.

  • A redivac drain should be left in situ postoperatively.

Inferior epigastric injury

This should be avoided by careful inspection of the course of the epigastric vessels when inserting laparoscopic ports, but should the epigastric vessel be damaged then the following can be instituted:

  • Pass a Foley catheter down the port site and inflate the balloon and pull back to apply pressure.

  • Diathermy to the bleeding point via a contralateral port.

  • Pass a suture around the vessel using a Grice or Bonney–Reverdin needle.

  • Enlarge the port skin site and place a Vicryl® suture directly through the sheath under laparoscopic vision.

Trauma to bowel

If perforation occurred during laparoscopy with the Veress needle, one may notice feculent fluid during Palmer’s test or high inflation pressures and gas escaping from the patient’s anus.

  • Veress needle should be left in situ.

  • A laparotomy or alternatively another site for entry (e.g. Palmer’s point entry using a 5 mm laparoscope) could be performed to confirm the diagnosis.

  • Should the diagnosis be confirmed then a general surgeon should be called for assistance.

  • A suture should be placed laparoscopically or via laparotomy. If it involved large bowel then copious peritoneal lavage should be performed.

  • Broad-spectrum antibiotics should be given and the patient admitted for observation.

If noticed from the trocar insertion, one may notice feculent smell or feculent fluid via side port.

  • Again trocar should be left in situ.

  • A laparotomy or alternatively another site for entry (e.g. Palmer’s point entry using a 5 mm laparoscope) could be performed to confirm the diagnosis.

  • Should laparotomy be performed then the umbilical port site can be extended along the length of the port to guide to the area of perforation. Should the diagnosis be confirmed then a general surgeon should be called for assistance.

  • A suture placed laparoscopically or via laparotomy should be considered. If it involves large bowel, copious peritoneal lavage should be performed.

  • Broad-spectrum antibiotics should be given and the patient admitted for observation.

  • Consideration of defunctioning of the bowel should be considered, although is rarely required.