What are the recommended haemostasis (hemostasis) agents in gynecology surgery?

Recommended Hemostatic Agents in Gynecologic Surgery

Topical hemostatic agents should be used as adjuncts to conventional surgical techniques (sutures, clips, electrocautery) for venous or moderate arterial bleeding, particularly in areas where traditional methods are inadequate or unsafe, with collagen-based, gelatin-based, and fibrin sealant products being the primary options. 1

When to Use Hemostatic Agents

Topical hemostatic agents are most appropriate in gynecologic surgery for:

• Areas of oozing or slow bleeding where electrocautery or sutures are not ideal or safe 2
• Bleeding near vulnerable structures where thermal injury risk is high 1
• Diffuse bleeding from peritoneal surfaces or cut surfaces of solid organs 1
• After attempting conventional hemostasis first - there is no substitute for meticulous surgical technique with sutures, clips, or electrosurgery 1

Primary Hemostatic Agent Categories

Collagen-Based Agents (e.g., Avitene)

Collagen-based agents directly trigger platelet aggregation and initiate the clotting cascade, making them particularly effective when other hemostatic mechanisms may be compromised 3. These agents:

• Work by entrapping and activating platelets on contact with bleeding surfaces 3
• Are often combined with thrombin to enhance hemostatic effect 4
• Have demonstrated positive hemostatic effects in multiple human studies 4

Gelatin-Based Products

Gelatin-based hemostatic agents function through physical mechanisms:

• Swell when in contact with blood to reduce blood flow 4, 5
• Can be used alone or combined with thrombin for enhanced effect 4
• Show similar or superior hemostatic effect compared to collagen-based agents 4
• Are recommended by the American College of Cardiology for cavity bleeding control, particularly when combined with sutures 3

Fibrin Sealants and Glues

Fibrin-based products have both hemostatic and sealant properties:

• Most effective for prevention of re-bleeding rather than active massive hemorrhage, as the fibrin clot may be washed away by blood flow 6
• Particularly effective in heparinized patients undergoing cardiovascular procedures 6
• Demonstrated significant hemostatic effects in multiple randomized controlled trials involving vascular, bone, skin, and visceral surgery 4
• Require direct application at the bleeding site 6

Cellulose-Based Agents

Oxidized cellulose products:

• Work primarily through physical absorption and creation of an artificial clot 3
• Have less well-studied hemostatic effects with mainly case report support 4
• Can be impregnated with polyethylene glycol or salts for more rapid hemostasis 4

Chitosan-Based Agents (e.g., Axiostat)

Chitosan-based hemostatic agents are recommended for venous and moderate arterial bleeding, particularly when access to the bleeding site is difficult 5:

• Serve as adjuncts to traditional surgical techniques 5
• Should be used in combination with other surgical measures or packing for optimal results 5

Clinical Evidence in Gynecologic Surgery

Recent literature demonstrates specific benefits in gynecologic procedures:

• Reduced bleeding and shorter operating room time in women undergoing hysterectomy for cancer 7
• Decreased reduction in ovarian reserve in women undergoing ovarian cystectomy 7
• Reduced blood loss and operating times in abdominal myomectomy 7

Important Selection Factors

When choosing a hemostatic agent, consider:

• Type and severity of bleeding (venous vs. arterial, oozing vs. active) 4
• Patient's coagulation status 4
• Surgical procedure type and anatomic location 4
• Cost considerations 4, 1
• Each agent's specific characteristics and contraindications 4

Critical Contraindications and Complications

Be aware of potential complications:

• Abscess formation 7
• Small bowel obstruction 7
• Inflammation and allergic reactions 7
• Transmission of blood-borne pathogens (with biologic agents) 7
• Some agents should be avoided when autotransfusion is used 4

Common Pitfalls to Avoid

• Do not use hemostatic agents as a substitute for proper surgical technique - always attempt conventional hemostasis first 1
• Fibrin glues are ineffective for massive active bleeding - use them for prevention of re-bleeding only 6
• Evidence for use in benign minimally invasive gynecologic surgery (MIGS) is lacking - use judiciously in these settings 7
• The use of hemostatic agents has increased rapidly even for surgeries with small bleeding risk - avoid unnecessary use given cost and potential complications 8

Practical Algorithm for Use

1. First-line: Attempt hemostasis with sutures, clips, or electrocautery 1
2. If inadequate: Assess bleeding type (venous/arterial, oozing/active) and location 4
3. For oozing or slow bleeding: Use collagen-based or gelatin-based agents, with or without thrombin 4, 3
4. For difficult-to-access areas: Consider chitosan-based agents (Axiostat) 5
5. For prevention of re-bleeding: Consider fibrin sealants after initial control 6
6. Always combine with packing or other surgical measures for optimal effect 4, 5