What are the surgical options to control pelvic bleeding during an abdominoperineal resection (APR)?

Surgical Options to Control Pelvic Bleeding During APR

For pelvic bleeding during abdominoperineal resection (APR), employ direct surgical packing as the primary method, supplemented by topical hemostatic agents (fibrin sealants or thrombin-based products), with preoperative internal iliac artery embolization reserved for high-risk cases and temporary intraoperative packing for uncontrolled hemorrhage.

Primary Surgical Hemorrhage Control Methods

Direct Packing

• Direct surgical packing is the cornerstone technique for controlling venous and diffuse bleeding in the pelvis during APR 1
• Pack the presacral space and paravesical areas systematically, as 80-90% of pelvic bleeding originates from venous plexuses and cancellous bone surfaces 1
• Packing should exert direct pressure on bleeding sources and can be left in place temporarily if needed 1
• In a prospective study of 26 patients undergoing pelvic surgery for locally advanced/recurrent rectal cancer, temporary intraoperative pelvic packing was necessary in 11.5% of cases to control major hemorrhage 2

Topical Hemostatic Agents

• Use fibrin sealants or thrombin-based hemostatic agents as adjuncts to surgical techniques for venous or moderate arterial bleeding from pelvic soft tissues 1, 3
• Fibrin sealants demonstrated 82.8% hemostasis by 4 minutes in soft tissue bleeding during retroperitoneal and pelvic surgical procedures 3
• These agents were utilized in 38.5% of patients undergoing pelvic surgery for advanced rectal cancer 2
• Apply topical agents directly to bleeding surfaces after conventional surgical control attempts 4

Preoperative Adjunctive Measures

Selective Arterial Embolization

• Consider preoperative internal iliac artery embolization for patients with bulky tumors at high risk of intraoperative hemorrhage 2, 5
• Preoperative embolization was performed in 7.7% of high-risk pelvic surgery cases 2
• A case report demonstrated successful bloodless APE following preoperative tumor embolization two days before surgery 5
• This technique is particularly valuable when refusing neoadjuvant therapy or when tumor vascularity is extensive 5

Intraoperative Vascular Control

Aortic Cross-Clamping

• In exsanguinating patients where conventional techniques fail, employ aortic cross-clamping as a temporary adjunct to reduce pelvic bleeding and redistribute blood flow 1
• This technique should be reserved for patients in extremis when proximal vascular control is necessary 1
• Use as a bridge to definitive hemorrhage control, not as a standalone measure 1

Direct Surgical Bleeding Control

• Achieve hemostasis through vessel ligation and electrocautery as first-line measures before employing adjuncts 1
• When bleeding cannot be controlled with standard techniques, proceed systematically through the algorithm rather than persisting with ineffective methods 1

Damage Control Approach

When to Employ Damage Control

• If the patient develops hypothermia (≤34°C), acidosis (pH ≤7.2), or coagulopathy during the procedure, abort definitive repair and employ damage control principles 1, 6
• Pack the pelvis definitively and plan for re-exploration after 48-72 hours once physiologic parameters normalize 1
• This "lethal triad" predicts mortality and mandates abbreviated surgery 1, 6

Damage Control Technique

• Perform abbreviated hemorrhage control with packing rather than time-consuming definitive repairs 1
• Focus on core rewarming, acid-base correction, and coagulopathy reversal in the ICU before returning to the operating room 1
• Remove packs preferably only after 48 hours to lower re-bleeding risk 1

Postoperative Hemorrhage Management

Angiographic Embolization

• For persistent bleeding after surgery, angiographic embolization is highly effective for arterial sources 1, 7
• Selective embolization can achieve hemostasis quickly without reoperation 7
• Consider repeat angiography if bleeding persists after initial embolization 1

Critical Pitfalls and Caveats

High-Risk Population Recognition

• Patients undergoing APR for locally advanced or recurrent rectal cancer have a 53.8% risk of blood loss ≥1,000 mL and 50% transfusion rate 2
• Anticipate the need for multiple hemostatic adjuncts in 50% of cases 2
• Median blood loss in this population is 1,250 mL, requiring proactive hemorrhage control planning 2

Avoiding Common Errors

• Do not rely solely on electrocautery in the presacral space where venous bleeding predominates 1
• Avoid prolonged attempts at individual vessel control when diffuse venous oozing is present—pack early 1
• Do not perform non-therapeutic laparotomy for pelvic bleeding; use targeted approaches 1
• Recognize that arterial bleeding, when present, is almost always accompanied by venous bleeding (100% likelihood), requiring combined management strategies 1