Prevention and management of acute intraoperative bleeding

The hemostatic techniques used to control acute intraoperative bleeding must be selected in such a way that tissue necrosis, thrombosis, fistula formation, and nerve dysfunction are minimized and, in turn, the incidence of postoperative untoward sequelae is limited. Avoiding excessive incorporation of tissue in ligated pedicles and excessive dissection, cautery, clamping, and suturing, which compromise small vessels, minimizes the degree of tissue necrosis, release of pyrogens, and postoperative febrile morbidity. Also, the meticulous handling of the major arteries in the pelvis and use of steep Trendelenburg positioning, which limits the need for packing at the pelvic brim, minimize the risk of arterial and venous thromboses, respectively. Furthermore, careful identification and mobilization of the bladder, ureters, and bowel close to the bleeding site avoid injury to these organs and the risk of fistula formation. In addition, the surgeon must rely on three-dimensional anatomy when attempting to secure hemostasis along the pelvic sidewall to avert entrapment of or trauma to the adjacent nerves. Finally, evacuation of residual blood and generous irrigation before closure minimize the culture media and bacterial load, thereby reducing the potential for post-operative infection.