By Filippakis, George M Leandros, Manolis; Albanopoulos, Kostas; Genetzakis, Michael; Et al
Bleeding originating from the presacral venous plexus during pelvic operations is difficult to control, constituting a potentially life-threatening complication. Although suture ligatures, packing, and placement of tacks are established hemostatic techniques, they are often proved to be ineffective. We report a simple novel technique using spray diathermy for managing this severe complication. We have applied our method in four patients, two undergoing low anterior resection, and the others undergoing abdominoperineal resection for rectal cancer, that manifested severe presacral bleeding during rectal mobilization. Electrocautery at spray setting was applied slightly above the target bleeders at the presacral fascia, delivering a high- frequency electrical current in combination with drainage suction. In all cases, the method resulted in successful hemostasis. Applying spray electrocautery is a simple and effective method for controlling presacral bleeding. The advantages of using such a method instead of conventional hemostatic techniques include the option of varying the degree of haemostatic effect by altering the frequency and the volume of electric current. presacral bleeding is a troublesome and lifethreatening complication that is encountered during the mobilization of rectal tumors, especially where mesorectal resection cannot be accomplished using sharp dissection. Adjuvant radiation therapy, large tumors, or inadequate surgical training may result in damage to the presacral fascia, causing bleeding from the presacral venous plexus lying on the pelvic surface of the sacrum or from one to several large-caliber foramina of the sacral basivertebral veins.1- 2
Because of the inaccessible location of these vessels, the management of presacral bleeding has always been a challenge for surgeons. Measures of controlling such a hemorrhage mainly include tamponade by packing with or without hemostatic agents and the application of metallic thumbtacks.1-3 The application of clamps or sutures is usually ineffective and inadvisable because further damage with increased bleeding may be caused. Conventional coagulation is usually not recommended because it could also aggravate the previous damage to the fragile walls of a vein. Likewise, blind attempts to clamp the bleeding presacral veins exacerbate the bleeding by extending the tear in the thin-walled veins. Packing over the bleeding site to provide tamponade of the area can sometimes be effective, but often continuous hemorrhage may force surgeons into ligating both hypogastric arteries at their origin, even clamping the aorta for a couple of minutes, especially when profound bleeding is encountered.4^6
Bleeding from the presacral veins tends to be profuse and vigorous for several reasons. The inferior vena cava, the presacral veins, and the internal vertebral venous system, dilated under general anesthesia, act as a large venous “blood pool” in the pelvis because of the lack of functional valves. With the patient at the lithotomy position, hydrostatic pressure of this venous pool can reach two to three times the pressure of inferior vena cava. That means the highest hydrostatic pressure at the site of a distal presacral vein rupture is approximately two to three times the pressure in the inferior vena cava. Thus, rupture of even a small presacral vein may result in copious bleeding, resulting in hemorrhagic shock and even death.1- 3 Experimental studies1 have demonstrated that blood loss from cut ends of presacral veins measuring 2 to 4 mm in diameter can reach up to 1000 milliliters per minute, and an increase of the diameter of the vein by just 1 mm can increase the blood loss almost three-fold.
Materials and Methods
We applied our technique in four patients, two undergoing low anterior resection and the others undergoing abdominoperineal resection for rectal cancer who manifested severe presacral bleeding during rectal mobilization. All patients, two men and two women, underwent elective surgical excision by the same surgical team between 2003 and 2005 in our Department. The mean patient age was 67 (range, 6275) years. Mean intraoperative blood replacement was three (range, 2-6) units.
The type of diathermy we used was the Force FXCTM electrosurgical generator (Valleylab, Boulder, CO) unit, with the Valleylab adaptive REMTM system and Instant Response TM technology. This device operates with 390 kHz damped sinusoidal bursts with a repetition frequency of 30 to 57 kHz into 500 ohms at fulgurate setting and with 390 kHz damped sinusoidal bursts with a randomized repetition centered at 28 kHz at spray setting. For the latter, frequencies range from 21 to 35 kHz and the output is further modulated by a random 250 Hz envelope with variable duty cycle. During the described technique, monopolar diathermy was originally set and operated at Fulgurate-High setting (high crest factor) for initial noncontact coagulation and then on the spray setting.
Operative Technique and Results
In all four cases, during mobilization of the tumor, blind sharp and blunt dissection was performed because the lesion was densely adhered to the presacral fascia and the visibility was poor, resulting in profuse bleeding from the sacral venous plexus and the sacral foramina area. Rapid removal of the tumor was necessary to improve exposure.
The first temporizing measure in arresting bleeding was direct pressure over the bleeding site with a laparotomy pad. Once accumulated blood was aspirated, the area around the bleeders was swabbed with gauze. Then, while simultaneously withdrawing the laparotomy pad over the bleeding sites, electrocautery at spray setting was applied slightly above the presacral bleeders (Fig. 1). We used a high-frequency electrical current to coagulate all of the bleeding sites, and further packing was applied for 10 minutes.
Excepting one case where we applied the technique three times repeatedly, successful hemostasis was achieved on the first attempt. The mean intraoperative blood replacement need was 3 (range, 2-6) units. Postoperatively, no patient showed any evidence of ongoing blood loss. In addition, postoperatively, all patients manifested low back pain that was successfully managed using opioid analgesics and nonsteroid antiinflammatory drugs. This complication might be explained by the fact that spinal nerve roots in the sacral foramina lie in close proximity to the presacral venous plexus and all of these elements may be affected by heat transmitted via tissues during the appliance of spray electrocautery, causing thermal damage and pain postoperatively.7~12 However, in our study, no case of postoperative back pain proved significantly hard to control. After discharge, three of four patients req^jjred further mild analgesic treatment for 3 to 6 months, orally.
FIG. l. Presacral bleeding is controlled by application of electrocautery at spray setting over the bleeding vessel at a 3 to 5 mm distance, using a 90 degree angle of approach. (A) Drain suction over the bleeding site. (B) Monopolar diathermy at spray stetting. (C) Bleeding site.
Discussion
Surgical dissection of the retrorectal space during mobilization of the rectum shall be done in the plane between the perirectal fascia anteriorly, and the pelvic fascia posteriorly. The latter covers the presacral venous plexus, making it invisible to the surgeon’s eye. The presacral venous plexus is formed from the two lateral sacral veins, the middle sacral vein, and the veins connecting them. These connecting vessels are disposed perpendicular to the middle sacral and lateral sacral veins in a stair-like fashion (Fig. 2). The presacral venous plexus is connected with the internal vertebral venous system through the basivertebral veins that pass through the sacral foramina and is also connected to the internal iliac veins. The presacral venous plexus courses into the pelvic fascia, covering the anterior aspect of the sacrum that is constituted by the presacral fascia, the piriformis and coccygeal muscle fascia, and the sacrospinous ligament.7″9
Mobilization of the rectum is usually performed with minimal bleeding, but occasionally, inadvertent breaching of the presacral fascia may result in hemorrhage from the presacral venous plexus or basivertebral veins.4’13,14 Because of the retrofascial course of the presacral venous plexus and its plexiform disposition,10-12,15, 16 occurrence of such a hemorrhage is always a risk during pelvic operations. Presacral veins lacerate easily because their adventitia is intimately blended with the sacral periosteum at the margins of the sacral foramina.1 Thus, blindly stripping the posterior surface of the rectum from the hollow of the sacrum by blunt dissection, from the abdominal or perineal approach, leads to venous injury from lifting of the presacral fascia together with the periosteum of the sacrum.
FIG. 2. Presacral venous plexus is formed from two lateral sacral veins (1), a middle sacral vein (2), and connecting veins (3). These connecting vessels are disposed perpendicular to the middle sacral and lateral sacral veins in a stair-like fashion. The presacral venous plexus is connected with the internal vertebral venous system through the basivertebral veins that pass through the sacral foramina. Conventional hemostatic techniques can be often ineffective in controlling severe presacral bleeding. Suturing and cauterization usually exacerbate bleeding,15 whereas ligation of internal iliac artery would have no effect on the hydrostatic pressure within the sacral venous system, resulting in persisting hemorrhage. Moreover, internal iliac artery ligation has been reported to result in necrosis of buttock and bladder.17 Additionally, ligation of the internal iliac veins will obstruct venous drainage from the pelvic, gluteal, and obturator veins, and consequently, the blood will be directed to the injured vein through the lateral sacral veins, thus exacerbating the bleeding.
There are two basic approaches in confronting severe presacral bleeding. The first technique involves the use of tamponade, removable after stabilization.4 However, discontinuation of tamponade is associated with the risk for secondary hemorrhage. Moreover, pelvic packing and inflatable balloon devices are established means of arresting hemorrhage.4 Inflatable devices might be left in situ to reinflate. Even an expandable breast implant sizer has been used successfully.18
The second alternative includes various means of bleeder occlusion. Probably the largest reported experience is with occlude pins or thumbtacks.5’16- 19 Using titanium thumbtacks is not always effective10 -5- 20 because of bad conforming to the irregular contour of the sacrum, which may result in detaching of the thumbtacks.21’22 Furthermore, multiple bleeders will require additional pins. A potential pitfall in this technique is that pins cannot be overlapped to control bleeders if the hemorrhage is diffuse or originates from the sacral foramina.5 The use of combined absorbable hemostatic gelatin sponges and cyanoacrylate glue, as well as using hemoclips and microfi&rillar collagen, has been also reported.23 Bone wax13 and electrocautery through a free rectus abdominis muscle fragment24’25 are also reported to be effective. During the latter technique, temperature increases gradually and coagulation is attained because of the larger contact area between the bleeding point and the muscle fragment.
In this study, we described a simple alternative technique using spray electrocautery. This technique has been already successfully applied on four patients in our department. Monopolar electrocautery device at the spray setting has been used as the simplest coagulation electrical system, generating a direct current that operates between 200 kHz and 3.3 MHz, well above the range where neuromuscular stimulation or electrocution could occur. With the coagulation mode on the generator, tissue fulguration is achieved by using electrical arcs (sparks). The sparks jump from the electrode across an air gap to the tissue, which causes clotting of blood and destruction of tissue with no cutting effect. The coagulation current can produce spikes of voltage as high as 9000 volts. The tissue is heated when the waveform spikes, and cools down in between spikes, thus producing coagulation of the cell. The correct method for achieving fulguration when using coagulation is to hold the tip of the active electrode slightly above the target tissue in a 90 degree angle.
The effectiveness of this technique may be related to the fact that a larger contact area between the bleeding area and the electrode is achieved. Moreover, if bleeding originates from the basivertebral veins that pass through the sacral foramina, spray electrocautery can effectively reach and coagulate the nonvisible bleeding points. The advantages of using spray electrocautery instead of conventional hemostatic techniques include the option of varying the degree of hemostatic effect by altering the frequency and the volume of electric current. Additionally, spray electrocautery is by far more cost-effective than all of the other hemostatic agents or techniques, and is readily available in all operating rooms. The only complication of this technique was sacral pain, which required oral analgesics for 3 to 6 months postoperatively.
REFERENCES
1. Wang QY, Shi WJ, Zhao YR, et al. New concepts in severe presacral hemorrhage during proctectomy. Arch Surg 1985; 120: 1013- 20.
2. Barras JP, Fellmann T. Massive hemorrhage from presacral veins during resection of the rectum. HeIv Chir Acta 1992;59: 335-9.
3. Hill AD, Menzies-Gov N, Darzi A. Methods of controlling presacral bleeding. J Am Coll Surg 1994; 178:183^t.
4. Zama N, Fazio VW, Jagelman DG, et al. Efficacy of pelvic packing in maintaining hemostasis after rectal excision for cancer. Dis Colon Rectum 1988;31:923-8.
5. Stolfi VM, Milsom JW, Lavery IC, et al. Newly designed occluder pin for presacral hemorrhage. Dis Colon Rectum 1992; 35:166- 9.
6. Khan FA, Fang DT, Nivatvongs S. Management of presacral bleeding during rectal resection. Surg Gynecol Obstet 1987;165: 275- 6.
7. Diop M, Parratte B, Tatu L, et al. Mesorectum: The surgical value of an anatomical approach. Surg Radiol Anat 2003;25: 290-304.
8. Muntean V. The surgical anatomy of the fasciae and the fascial spaces related to the rectum. Surg Radiol Anat 1999;21: 319-24.
9. Sato K, Sato T. The vascular and neuronal composition of the lateral ligament of the rectum and the rectosacral fascia. Surg Radiol Anat 1991; 13:17-22.
10. Arnaud JP, Tuech JJ, Pessaux P. Management of presacral venous bleeding with the use of thumbtacks. Dig Surg 2000; 17: 651- 2.
11. Harrison JL, Hooks VH, Pearl RK. Muscle fragment welding for control of massive presacral bleeding during rectal mobilization. Dis Colon Rectum 2003;46:1115-7.
12. Pastner B, Orr JWJ. Intractable venous sacral hemorrhage: Use of stainless steel thumbtacks to obtain hemostasis. Am J Obstet Gynecol 1990; 162:452.
13. Qinao W, Weijin S, Youren Z, et al. New concepts in severe pre-sacral hemorrhage during proctectomy. Arch Surg 1985;120: 1013- 20.
14. Bacon HE, Gutierrez RR. Cancer of the rectum and colon: Review of 2,402 personal cases. Dis Colon Rectum 1967;10:61-4.
15. Rotondano G, Romano G. The use of thumbtacks in massive presacral bleeding. Am J Gastroenterol 2000;95:1102.
16. Nivatvongs S, Fang DT. The use of thumbtacks to stop massive presacral hemorrhage. Dis Colon Rectum 1986;29: 589-90.
17. Tajes RV. Ligation of the hypogastric arteries and its complications in resection of cancer of the rectum. Am J Gastroenterol 1956;26:612-8.
18. Braley SC, Schneider PD, Bold RJ, et al. Controlled tamponade of severe presacral venous hemorrhage: Use of a breast implant sizer. Dis Colon Rectum 2002;45:140-2.
19. Timmons MC, Kohler MF, Addison WA. Thumbtack use for control of pre-sacral bleeding, with description of an instrument for thumbtack application. Obstet Gynecol 1991;78:313-5.
20. Patsner B, Ore JW Jr. Intractable venous hemorrha^: use of steel thumbtacks to obtain hemostasis. Am J Obstet Gynecol 1990;162:452.
21. Cosman BC, Lackides GA, Fisher DP, Eskenazi LB. Use of tissue expander for tamponade of presacral hemorrhage: report of a case. Dis Colon Rectum 1994;37:723-6.
22. Suh M, Shaikh JR, Dixon AM, Smialek JE. Failure of thumbtacks used in control of presacral hemorrhage. Am J Forensic Med Pathol 1992;13:324-5.
23. Losanoff JE, Richman BW, Jones JW. Cyanoacrylate adhesive in management of severe presacral bleeding. Dis Colon Rectum 2002;45:1118-9.
24. Xu J, Lin J. Control of presacral hemorrhage with electrocautery through a muscle fragment pressed on the bleeding vein. J Am Coll Surg 1994;179:351-2.
25. Remzi FH, Oncel M, Fazio VW. Muscle tamponade to control pre- sacral venous bleeding: Report of two cases. Dis Colon Rectum 2002;45:1109-11.
GEORGE M. FILIPPAKIS, M.D., PH.D., MANOLIS LEANDROS, M.D., ph.d., KOSTAS ALBANOPOULOS, M.D., ph.d., MICHAEL GENETZAKIS, M.D., EMMANUEL LAGOUDIANAKIS, M.D., NIKOS PARARAS, M.D., ph.d., MANOUSOS M. KONSTANDOULAKIS, M.D., PH.D.
From the First Department of Propaedeutic General Surgery, Athens University Medical School,
Hippocrateion Hospital, Q. Sophia 114, 11527, Athens, Greece
Address correspondence and reprint requests to Michael Genetzakis, M.D., Resident in General Surgery, Kononos 31 Strasse P.C., 11634, Athens, Greece.
Copyright Southeastern Surgical Congress Apr 2007
(c) 2007 American Surgeon, The. Provided by ProQuest Information and Learning. All rights Reserved.
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