Exxcellence pearls: lost pedicle at vaginal hysterectomy

Question 0

What are risk factors for bleeding at vaginal hysterectomy?

Answer 0

Enlarged uterus, lack of descensus, distorted anatomy, narrow suprapubic arch

Question 1

What is the rate of clinically significant bleeding at vaginal hysterectomy?

What is the rate of subclinical hematoma seen on sonography?

Answer 1

1-2%

Up to 15%

Question 2

What is the most common site of clinically significant vaginal bleeding?

Answer 2

Vaginal vault

Question 3

How should a lost pedicle with a major artery such as the uterine or ovarian artery be managed?

Answer 3

Unless immediately adjacent to the surgical field and easily clamped, the best management is to proceed with laparotomy. Tissue and vessels often retract and may allow rapid blood loss. Pressure may be applied vaginally during laparotomy.

Question 4

How should lost pedicle without overt bleeding be managed?

Answer 4

Pedicles such as the uterosacral ligament can be re-clamped however if the tissue has retracted away, care must be taken to avoid bowel or urinary tract injury.

If it pedicle remains lost, laparoscopy should be preformed to ensure hemostasis.

Question 5

How should non-expanding hematoma be managed?

Answer 5

Retroperitoneal hematomas should be surgically repaired. Non-expanding hematomas should not be assumed to be hemostatic.

Question 6

What other options should be considered for control of bleeding that cannot be surgically controlled?

Answer 6

Artery embolization and or pelvic packing.